HOW PUBLIC OPINION REALLY WORKS The public's thinking on issues progresses through seven predictable stages, the dean of American pollsters finds. Politicians make a big mistake just looking at raw numbers.
By Daniel Yankelovich REPORTER ASSOCIATE Suneel Ratan

(FORTUNE Magazine) – SOMETIMES a truth is so simple and obvious that it eludes detection for years. So it is with public opinion. We have grown so accustomed to seeing public opinion quantified in polls (77% say they support ''national health insurance,'' for example) that we make an unwitting -- and, as it happens, false -- assumption. We assume that public opinion is some kind of phenomenon like wind velocity, whose variations can be measured, and that the measurement is valid. Public opinion is in fact less like a physical process than a biological one, evolving in seven stages. Unless one knows opinion's stage of development on an issue, poll numbers will usually mislead. Any political leader who really thinks 77% of voters support national health insurance is deluding himself. As I demonstrate in my book Coming to Public Judgment, once one sees public opinion in this light, one can never go back to the old way of looking at it. Public opinion on any issue develops slowly over a long period -- at least ten years for a complex issue. It evolves from incoherent globs of opinion toward fully integrated, thoughtful, and considered public judgment. On issues in early stages of development, the quality of public opinion is raw and unformed. Many people express strong feelings, but vehemence does not mean settled views. Opinions at this stage are unstable, flip-flopping at the slightest provocation. People have not thought through the consequences of their views. Today, for example, most of the public remains mired in wishful thinking on protectionism and health care, resisting any attempt to confront with realistic information the costs and trade-offs each entails. Political candidates who act on the results of opinion polls on these issues will soon feel the ground give way under their feet. At the opposite end of the developmental spectrum are issues on which public opinion has had a chance to mature. When public opinion has progressed through all seven stages, its quality is impressive. People's views are solid and stable, not mushy. They hold them consistently and coherently, accepting responsibility for the trade-offs involved. Many issues have reached this stage, but I want to cite one that may seem surprising. Many policymakers fear that the American public, under pressure from the recent recession, is reverting to a pre-World War II form of isolationism. But the American people have actually thought through the isolationism vs. internationalism issue. Having gone through all seven stages, they agree with those who urge that with the end of the Cold War, the nation should give greater priority to our domestic concerns -- without, however, abdicating our responsibility as leader of the free world. Unfortunately, opinion polls as presently reported don't indicate which stage a particular issue has reached. Leaders attempting to communicate with the public without this information risk gridlock and frustration. Why? Because to communicate with the populace, a leader has to know where people are coming from, where they stand in their thinking now, and where they are headed. Let me illustrate the seven stages with a critical issue of the 1992 presidential campaign: the rising cost of health care.

-- STAGE 1: DAWNING AWARENESS. Here people become aware of an issue or some aspect of it. Budding awareness launches the long and tortuous journey toward public judgment. On health care a number of messages have reached Stage 1. A majority of the public is aware that health care costs are skyrocketing, that millions of Americans have no health insurance coverage, and that their own coverage is at risk of being lost or whittled away. The public's current view is that greed and waste are at fault -- too many people with their hands in the health care till. Everyone has an anecdote to tell: The hospital that charges $40 for a $3.95 bottle of aspirin, the $1,000 surgeon's fee for a ten-minute procedure, the millions of dollars that stick to the hands of malpractice lawyers, and so on. At this stage in the debate most people remain largely unaware of the more specific drivers of rising health care costs: advances in technology, the high cost of caring for increasing numbers of elderly people and AIDS patients, and rising administrative expenses, among others. Nor is there much awareness of specific proposals being floated to address the problem. People glibly refer to the Canadian system but don't know what it is.

-- STAGE 2: GREATER URGENCY. The second stage is a move beyond awareness to a sense of urgency about an issue. Health care has moved squarely into this second stage. The recession has many people terrified about job security, and much of this anxiety gets channeled into worry about health care. Typically someone will say, ''If I lost my job we could manage for a while, but what happens if I get sick and no longer have health insurance?'' This concern is why almost four out of five Americans (79%) believe the health care system is in crisis. For now this sense of urgency is global and diffuse. The dominant sentiment is a panicky appeal to ''Do something!'' These first two stages are parts of a necessary ''consciousness raising.'' The term, borrowed from the women's movement, is apt for describing how the public learns about an issue. One can be aware of a problem without feeling it is important or that anything needs to be done about it. Although the health care issue has been kicking around for years, the public's consciousness of its importance and active readiness to do something about it has risen only in the past year or so.

-- STAGE 3: DISCOVERING THE CHOICES. In the third stage the public begins to focus on alternatives for dealing with issues. The timing of Stage 3 varies by issue. On some, choices become clear almost immediately. But on most they do not. Some issues can fester for years before concrete, feasible choices appear. The public comes to focus on choices that leaders offer without insisting upon alternatives to consider. Often the proffered options are not the best choices and certainly not the only ones. Stage 3 represents progress, however, because it begins the process of converting the public's free-floating concern about the need to do something into proposals for action. Health care is a particularly vivid example of the disorderly manner by which the public comes to focus on choices. Among leaders and experts hardly a day passes without a new idea for coping with the crisis. But the public remains oblivious to most choices. Four choices have begun to swim into focus for the public, indicating the issue's progress to the third stage of public opinion. The first relates to malpractice: People are learning about the debate to limit damages in malpractice suits. They are coming to see the links between multimillion- dollar damage settlements, rising insurance rates for physicians, and the pressure on doctors to practice defensive (and unnecessarily expensive) medicine. This understanding neatly fits their preconceptions about greed as the driver of costs: The idea that lawyers are enriching themselves at the expense of the system is inherently credible. A second choice coming into focus is incentives for prevention. People are aware of the benefits of not smoking, adopting more nutritious diets, exercising, and reducing stress. This doesn't mean that their behavior has changed drastically. It does mean that they are focusing on prevention as a choice. For some groups of employees the use of health maintenance organizations (HMOs) has become a third choice. Typically this choice is forced by employers. The growth of managed health care plans is making prepaid alternatives to fee-for-service health care increasingly familiar to some segments of the population. A fourth choice, less sharply focused, is the idea that individuals should become more cost conscious and begin to bring their well-honed consumer skills to the purchase of health care. It rarely occurs to people to shop actively for quality and price in the health care arena; the idea of evaluating hospitals for elective surgery, for example, is unfamiliar and confusing. Still, the idea that one should approach health care as a knowledgeable, cost- conscious consumer is gradually coming into focus.

-- STAGE 4: WISHFUL THINKING. This is where the public's resistance to facing trade-offs kicks in. Most of the time on most issues, the public raises a barricade of wishful thinking that must be overcome before people come to grips with issues realistically. In opinion polls it is easy to get people to express approval for a cornucopia of improved services and even to claim that they would accept modest increases in taxes for them. But saying this in a survey and accepting it in reality are wholly different matters. It is difficult to know whether the public's tendency toward wishful thinking is stronger now than in earlier periods of American life. I suspect it is. The public's ritualistic incantation of ''waste, fraud, and abuse'' may be a rationalization to avoid the need to confront societal problems, even though it has grounding in reality. Mainly, though, the public erects its wishful-thinking barricade to public- policy proposals because people feel excluded from decision-making on matters that affect their lives. It is a truism that people act most responsibly when they are personally engaged. To make sacrifices ungrudgingly, people must understand why these are needed, and they must have some say in the types, forms, and conditions of sacrifice they are asked to make. A significant part of the public's resistance to facing reality reflects the perception that a serious disconnect separates today's leaders from the voters.

No issue illustrates this resistance better than health care. People start with the assumption that complete health care is a right, such that ''everyone should have the right to get the best possible care -- as good as the treatment a millionaire gets''; 91% agreed to this proposition in a Harris poll. They think ''health insurance should pay for any treatment that will save lives even if it costs $1 million to save a life'' (71%). Reinforcing this outlook is a gross misunderstanding of who bears the costs. People assume that they pay directly for 70% to 80% of their health care insurance, as they do for auto insurance, while in reality they pay for only about 20% to 30%. The present outlook, in sum: People feel a sense of urgency about changing the health care system but haven't even begun to confront realistically the hard choices that need to be made. Unfortunately, policymakers are largely unaware of the depth and intensity of the public's resistance, for the simple reason that the bulk of it has not yet made itself felt -- voters have not yet focused on the hard choices. The situation is analogous to what happened in 1988 to legislation on catastrophic health care insurance for the elderly. In July of that year, Congress passed a bill putting a $2,000 cap on out-of-pocket costs for catastrophic health care in hospitals. Legislators had badly misinterpreted public opinion. They had learned from polling data that two-thirds of older Americans (69%) were deeply concerned about catastrophic care and supported a program to address it. But they went on to infer that older Americans were prepared to accept the higher Medicare premiums needed to defray the costs of the cap -- a disastrously false inference. Humiliating itself, Congress was obliged a year and a half later to repeal the bill. We are in danger of repeating the same mistake on a larger scale. Policymakers know Americans are deeply concerned about the adequacy, safety, and affordability of health care coverage. But they incorrectly infer that this means voters are ready to accept the consequences -- including the costs -- of changing the existing system. The health care issue hasn't yet reached Stage 4 among the broad public.

-- STAGE 5: WEIGHING THE CHOICES. Here the public does what we call choice work: weighing the pros and cons of alternatives for dealing with an issue. In practice Stages 4 and 5 overlap, with people thinking through how they feel at the same time that they continue to resist coming to grips with the hard choices. Wrestling with complex issues -- abortion, the death penalty, immigration, censorship, environmental protection, homelessness, as well as health care -- requires getting in touch with one's deepest values and often realizing that these may conflict with one another on a particular question. People naturally resist having to compromise or abandon cherished values. Stage 5 is hard work, and work that the public must do for itself; there are no shortcuts. In earlier stages the media and experts do most of the work. The media specialize in consciousness raising, and they do it well. Leaders and experts formulate the policy choices. But the public must invest the effort to grasp the choices, understand their consequences, and wrestle with the conflicts of values these choices entail. Virtually none of the choices on health care have made it to Stage 5. Stretching a bit, one choice may be edging into this stage for one group in the population. Older Americans are just beginning to weigh the pros and cons of the so-called heroic measures physicians often take to keep elderly people alive for a few more days, weeks, or months. My firm's surveys show that over the past five years the percentage of older Americans having doubts about whether anything and everything should be done on this front for as long as possible has grown from 40% to 64%. Stages 3, 4, and 5 can be grouped under the general heading ''working through,'' a term borrowed from psychology. I find it apt because it has several connotations that ''thinking through'' doesn't have. It encompasses thought but also feelings and ethical concerns. And it signifies the hard work of struggling with change.

-- STAGE 6: TAKING A STAND INTELLECTUALLY and STAGE 7: MAKING A RESPONSIBLE JUDGMENT MORALLY AND EMOTIONALLY. As the two stages of resolution, these can be considered together. These stages are linked, but different. People are quicker to accept change in their minds than in their hearts. Most Americans, for example, accept in their minds the idea of equal opportunity for minorities in the workplace, but they haven't quite taken the final critical step toward accepting it wholeheartedly. The same is true for First Amendment guarantees of freedom of expression. In their minds, Americans support freedom of expression unreservedly, recognizing how essential it is to preserving America's priceless heritage of political freedom. But the reason that laws and courts are indispensable to First Amendment protection is that offensive speech, flag burning, and pornography create such intense emotional and moral revulsion that, in the heat of the moment, the public can easily disregard its intellectual commitment. Intellectual resolution requires people to clarify fuzzy thinking, reconcile inconsistencies, consider relevant facts and new realities, and grasp the full consequences of choices. Emotional resolution requires people to confront their own ambivalent feelings, accommodate themselves to unwelcome realities, and overcome an urge to procrastinate. In arriving at moral resolution, people's first impulse is to put their own needs and desires ahead of ethical commitments. But once they have time to reflect on their choices, especially if the larger society provides moral support, the ethical dimension asserts itself, and people struggle to do the right thing, often successfully. NO FACET of the health care issue has arrived at either stage of resolution. But polls suggest that, under the impetus of a national debate, health care will move forward in virtually every stage. The public will learn that more than waste and greed are involved in driving costs higher (Stage 1). People's sense of urgency will grow less panicky and more tightly concentrated on controlling and reducing costs (Stage 2). Voters will focus particularly on choices entailing a larger role for government (Stage 3). Resistance will grow as people learn more about the options and the extent to which each involves higher costs and less choice for the individual. Resistance will focus particularly on options requiring employees to pay more, limiting technology, rationing health care, and otherwise restricting choice and access (Stage 4). If the debate genuinely engages the voters, then the public, in Stage 5, should be ready to consider on their merits proposals for some degree of federal regulation of costs, for extending coverage to those who lack it, for curbing heroic measures in the last months of life. Even proposals for modest tax increases may receive a fair hearing. A few choices may even make their way to Stage 6. If the national debate is productive, Americans will support -- at least intellectually -- proposals for drastically reducing the incentives for malpractice lawyers to drive up settlement costs. They will also support proposals that emphasize prevention and that give incentives to individuals to take greater responsibility for their own health. It is too much, I suspect, to think that Americans can reach Stage 7 -- the public judgment stage -- on such a vexing issue in so short a time. But there may be some preliminary movement toward it. If so, it will take the form of an agonizing rethinking of complete health care as an inalienable right. People still support this right unqualifiedly, without thinking through its implications. Odds are that many years and many crises will have to pass before the American public fully accepts the need to ration, regulate, reform, and even revolutionize health care in America so that it preserves some semblance of a right rather than a consumer good, without bankrupting the nation.