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Americans’ Health Priorities: Curing Cancer And Controlling Costs
In this paper we provide a comprehensive examination of Americans’ priorities within both health and health care. We find that Americans do have a clear set of priorities in each of these areas. Americans rated cancer, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), and heart disease, and medical research to address these conditions, as top priorities among eighty health problems. However, they did not rank many leading causes of death very high as serious problems. On the issue of health care, problems of costs, prescription drugs, and the uninsured top the list. Americans are very concerned about emerging international infectious diseases that they believe threaten their health.
For nearly thirty years national surveys have asked Americans to report their level of support for spending more money to improve and protect the nation’s health. Each time the question has been asked, a majority of Americans have favored more spending. Moreover, since 1987 at least 65 percent of the public has taken that position.1 However, during this period Americans have not been asked their health priorities across a wide range of public health and health care issues. In this paper, which was written prior to the 11 September 2001 attacks on New York City and Washington, D.C., we examine priorities within both areas along three dimensions, to answer the following questions: (1) What do Americans think are the major health issues, and how do these compare with leading causes of death? (2) What do Americans think are the major health care system problems? (3) What are Americans’ priorities for government action in each of these areas? We also asked Americans how they rated the seriousness of chronic diseases, the subject of this special issue of Health Affairs. It is too early to tell how the recent tragic events may alter these priorities.
Our survey data are derived from four sources. The first is a series of eleven surveys designed by researchers at the Harvard School of Public Health for the Robert Wood Johnson Foundation as part of a larger ongoing tracking study, begun in 1999, to assess health issues among Americans.2 The surveys were conducted via telephone by International Communications Research with randomly selected samples of 1,000–1,200 adults nationwide. The first survey was conducted between 22 April and 15 May 1999.3 The second survey was conducted between 31 July and 14 August 2000. The other nine surveys were conducted between 6 May and 31 July 2001. Since asking about many of these issues together is complicated by their interrelations, and to minimize respondent burden, the authors designed specific modules of questions for each survey.4 Data also were drawn from three other sources.5 The Harvard School of Public Health surveys asked Americans about their health priorities in three stages.6 First, they were asked to say, in their own words, what they thought were the two or three most important health and health care problems facing the country. Second, they were asked to rate the seriousness of seventy-nine health problems. This list of health problems was drawn from Centers for Disease Control and Prevention (CDC) reports, the National Institutes of Health’s list of Research Initiatives and Programs of Interest, World Health Organization reports, a number of articles written by health professionals concerning the underlying causes of disease, and issues described by the media as important health problems.7 Third, we asked respondents to rate twenty-eight issues now before Congress in terms of their priority for government action in the next year. This focus was used because prior research has shown that public policymakers pay more attention to those issues that the public thinks are very salient.8
When asked to say in their own words what they thought were the two or three most important health problems facing the nation, respondents identified cancer, heart disease, and human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) as the top three (Exhibit 1  ).9 These findings are similar to two other recent surveys: One asked Americans which diseases they feared most, and the other asked the public to name the most urgent health problem facing the United States.10 Then, too, these three diseases topped the list.
Rankings of comprehensive lists. In the second phase of the surveys, the public was given comprehensive lists of health problems and asked to rate their relative seriousness.11 This approach provides a perspective that our first survey did not capture. While the first measure portrays the public’s top few concerns, it does not provide a picture of relative concerns that are not immediately identified by the public but about whose importance they may have opinions. The same three conditions ranked at the top of the public’s list on both measures (Exhibits 1  and 2).
Examination of these responses revealed that certain issues often named by some health policy and public health researchers as major health problems, such as poverty, infant deaths, substandard housing, and racial discrimination, were not seen as very serious health problems by a majority of the public. In addition, although cancer was the top-rated item, there was a variation among types of cancer. Breast cancer was at the top of the "very serious concern" list, while prostate cancer did not rank as highly, even among men.
Chronic diseases.
A wide range of chronic diseases appear in the list shown in Exhibit 2 We also examined whether the public understood the term chronic and if they were able to identify specific diseases correctly as being chronic. We found that the majority knew what the term meant. When asked to choose between two definitions, three-fourths of the public chose the description of chronic diseases as "illnesses that are rarely cured completely and last a long time" over "illnesses that last a short time, are cured or go away on their own or the patient dies." When asked if particular diseases were chronic or not, seven out of ten said that heart disease, cancer, arthritis, and diabetes were chronic diseases. A third or fewer said that meningitis or appendicitis, both acute illnesses, were chronic.12
Ratings by demographic group.
Exhibit 3
African Americans, but not white Americans, included deaths from guns, stress, diabetes, and poor water quality in their top-ten list but did not include smoking, child abuse, drunk driving, and drug abuse, listed among the top ten health problems by whites.
Leading causes of death versus public perceptions.
Exhibit 4
Public health legislative priorities. When asked how important each of fourteen public health issues being considered by Congress were as their own priorities for government action, the public said that a majority of these issues were important priorities. However, when we examined the responses of those who said that it was an extremely important priority to pass legislation within the next year, differences in ratings emerged. As shown in Exhibit 5 , the top three issues at the time were requiring background checks of anyone purchasing a gun at a gun show, doing more to prevent the spread of infectious diseases, and increasing inspections of imported meat. Of interest is the low ranking for funding more research about how to help people change their habits so they can be healthier in the future. Only one item, background checks at gun shows, was ranked as "extremely important" by half of the public.14
Respondents were asked to say in their own words what they thought were the two or three most important health care problems. As shown in Exhibit 6 , the top three issues named were cost of health care services, the lack of or inadequate health insurance coverage, and the cost of prescription drugs. In combination, costs were the top issue for approximately half of respondents.
Also, respondents were asked how satisfied or dissatisfied they are with the availability and affordability of health care and with the nation’s system for protecting and improving the public’s health. Many more Americans are dissatisfied with health care (63 percent said that they were not too or not at all satisfied) than are dissatisfied with the nation’s public health system (47 percent).15
Priorities for legislative action.
To determine Americans’ priorities for legislative action, we asked how much priority they would give to fourteen health care issues that have been discussed by Congress. Passing a law to increase spending on medical research on diseases such as cancer, AIDS, and heart disease was the top priority (Exhibit 7
At the time of the 2001 surveys, the patients’ bill of rights was being actively debated in Congress. Although poll results showed substantial support (81 percent in favor) for its passage, this legislation was not seen as the top priority for action in either our open-ended questions or our list of legislative priorities.17
Our findings suggest that Americans do have a clear set of health priorities. We also found that some of the top killers did not rank very highly, but other problems that were not leading causes of death did. These findings correspond to other research showing that the public rates the seriousness of health problems using criteria other than the relative numbers of people who die from a particular condition. They focus on other attributes, such as its potential to harm large numbers of people at once; whether it is voluntary or involuntary; whether it is caused by human actions or failures; if these are conditions that lead to terrible deaths or involve immense suffering; a condition’s disproportionate effect on children; and its spread to and effect on the next generation of Americans.18 The public also evaluates some health problems as to their potential for leading to crime or moral decline.19 Media coverage can also influence the public’s perception of these issues.20 This study cannot determine which of these factors affects Americans’ health priorities, but it is clear that some of these are playing a role. A possible example is drunk driving, which is seen as an involuntary way that people are harmed by the actions of others. Another example is cancer versus heart disease, where the latter is the leading cause of death but the former ranks higher, because having cancer is more dreaded by the public. Drug abuse is seen as a major problem because of its moral and crime dimensions as well as its effects on health.21 Also, we find that most people are not broad and conceptual in their thinking about health priorities. They are more likely to be concerned about a specific and concrete problem rather than a general issue. For example, when asked about infectious diseases, the majority of respondents did not rate this as a very serious problem. However, when asked specifically about ebola, mad cow disease, and West Nile virus, respondents exhibited a high level of concern, with a significant proportion rating these problems as extremely important priorities for government action. The same holds true for meat inspections. Only a minority of Americans think overall food contamination is a very serious problem; however, inspections of imported meat ranked second on our legislative health priorities list. Americans also have a clear set of health care priorities. Cost is the top issue, but with the exception of prescription drugs, reducing the cost of health care for most Americans is not an issue on the current congressional agenda. It is important to note that when Americans say that their primary concern is the cost of health care, they appear to mean their own costs, rather than society’s overall health spending. When Americans think about aggregate spending, they may believe that public and private monies are available to cover these expenditures. Other surveys suggest that when people say they are concerned about high costs, they mean their own out-of-pocket spending and what they perceive to be unfair charges. Thus, we see public support both for more aggregate spending, which is seen as more services and research, and for efforts to control costs, which are seen as putting limits on industry charges and their own out-of-pocket costs.22 Another significant health care finding is the importance that Americans place on the issue of uninsured people. In a period when relatively more attention has been paid to the patients’ bill of rights and a Medicare outpatient drug benefit, it is interesting that the issue of the uninsured ranks as a high concern, even though it has been receiving relatively little media or congressional attention. Taken together, these findings suggest that in the absence of a perception of crisis or large-scale efforts to raise the salience of other health and health care problems, the public’s agenda will be dominated on the one hand by concerns with cancer, HIV/AIDS, and heart disease and on the other hand by cost, prescription drugs, and the uninsured. However, one set of issues that may be growing in public concern is the threat of emerging international infectious diseases that may affect health in the United States. After September 11, concerns about this in regard to biological terrorism are likely to grow.23
Robert Blendon is a professor of health policy and political analysis, Kimberly Scoles is a research manager, and Catherine DesRoches and John T. Young are project directors at the Harvard School of Public Health. Melissa Herrmann is vice-president/social science research and Jennifer Schmidt is a project director/social science research at International Communications Research. Minah Kim is a doctoral candidate in health policy at Harvard University. This work was supported by a grant from the Robert Wood Johnson Foundation. The views expressed are solely those of the authors, and no official endorsement by the sponsor is intended or should be inferred.
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