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Exploring The Public’s Views On The Health Care System: A National Survey On The Issues And Options
Instead of assessing support for specific health reform initiatives, this study examines fundamental attitudes that shape views about the provision and financing of health insurance. We find strong support for equity and expansion of coverage, with few differences across sociodemographic groups, but some support for holding individuals responsible for health-related behavior. Consumers want to retain choice of plans and coverage for routine expense yet not bear additional financial burden. Compared with the rest of the United States, Californians’ views exhibit more reliance on individuals and provide additional caution about the difficulty of identifying acceptable trade-offs and reaching consensus.
OPINION POLLS CONTINUE TO SHOW that the American public has major concerns about the health care system, particularly access to care and the uninsured.1 Yet a long history of survey research reveals no clear consensus on the merits of specific initiatives to reform the way in which health insurance is provided or financed. It thus is useful to explore key views that shape Americans’ perceptions about health care.2 Some values put forward by others are lack of self-blame, reasoned self-interest, distrust of government, moral commitment to the uninsured, empathy with others, and equality and social justice.3 In this study we used a national sample (and California subsample) from July 2006 to explore fundamental attitudes that shape Americans’ views about health insurance. Should we continue to build on a system of employer-based insurance? What are the appropriate roles for government, the private sector, and the individual? To what extent should the consequences of individual behavior be spread across the general public rather than borne by the individual? What are the key attitudes that should determine our approach to expanding coverage and controlling rising health care costs? In developing this approach, we have borrowed from the framework offered by the Coverage Expansion Resource Center sponsored by the California HealthCare Foundation (CHCF), which asked questions concerning core beliefs about cost and efficiency, fairness and equity, and choice and autonomy, to explore potential support for alternative proposals related to expanding health insurance coverage. After completing the center’s online assessment tool, participants were told which specific policy initiatives were most consistent with the attitudes they had expressed. The assessment was designed for the educated and health policy–literate audience that is most likely to visit the CHCF Web site. Because our purpose is to use a national survey to ensure representation across all educational and economic levels, we did not use this tool’s precise questions. However, we adapted many of its questions and built off its key premise that an understanding of underlying attitudes about health policy alternatives is a prerequisite to the creation of policy initiatives that will be acceptable to the public. Despite the appeal of this approach, it is important to note that when surveying public opinion on complex policy options, it is notoriously difficult to construct effective survey questions and to interpret the data that these questions generate.4 Accordingly, in some cases we offer alternative interpretations of the results, in an effort to fully explore their possible policy implications.
The survey field work was implemented by International Communications Research (ICR) as part of a larger survey that asks a core set of demographic questions and then adds questions from various sponsors. The survey was conducted by telephone 14–19 July 2006. Using a random-digit-dialing approach, researchers interviewed 1,517 respondents nationally age eighteen and older. Because California accounts for approximately 12 percent of the U.S. population, the sample yielded 148 California residents without any oversampling. Respondents were asked a series of questions generally focused on their views of how health insurance should be provided.5 Interviewers made four attempts to reach a respondent at each phone number. The calls were made at different times and on both weekdays and weekends. The survey randomly selected a single respondent within each selected household. The data were weighted to ensure a survey that is nationally representative with respect to key demographic variables. Weighting, however, cannot adjust for the differences in opinions that might be correlated with a decision to participate; thus, this survey—like all surveys—could be subject to nonresponse bias. All results discussed below were based on the weighted data. The weighting process took into account the disproportionate probabilities of household selection resulting from the number of separate telephone lines and the probability associated with the random selection of an individual household member. Following application of these weights, the sample was poststratified and balanced by key demographics. In comparing results between different subgroups (including comparisons between California respondents and those from the rest of the country), we tested for statistical significance using a chi-square test (5 percent level of significance). Multivariate regression models were estimated to explore the degree to which key demographic variables might influence the basic two-variable relationships that constitute the main findings from this study. Except as noted, the key results from this study are fully captured by the two-variable relationships presented below.
Mandatory versus voluntary coverage. We asked three basic questions to elicit views on the provision of health insurance (Exhibits 1  –3). We asked respondents whether they believe that "everyone should be required to have basic health insurance for medical care, just as they are required to have auto insurance" or that individuals should be allowed to decide whether or not they want coverage. Fifty-two percent of respondents stated their belief that basic health insurance should be mandatory; 48 percent said that each individual should decide on his or her own. People age sixty-five and older mirrored the overall population; however, in the under-age-sixty-five groups, there was a marked difference between the youngest adults, who slightly favored individuals’ making their own decisions, and those ages 55–64, who showed the strongest support of mandatory coverage (62 percent). Mandatory coverage was supported by 69 percent of blacks and 55 percent of Hispanics but only 46 percent of whites. There were no significant differences by education or income. Those with private insurance, Medicaid, or other insurance (including Medicare) supported mandatory coverage, with support strongest among Medicaid enrollees. The key exception was the uninsured, 24 percent of whom believe in mandatory coverage compared with 76 percent who support individual choice.
How well is the current system working? There was strong consensus that the current system is not working well. When asked whether or not they agreed with the statement that the current system has lots of problems and needs to be improved, 80 percent of respondents agreed, compared with only 20 percent who said that the employer-based system combined with current government programs is working well. There was modest variation in this result by education and income. How to pay for coverage fairly? The survey also asked about the fairest way to pay for health insurance. Respondents were asked whether they believed that everyone should pay the same regardless of health status or that less healthy and older people should pay more. Here again there was strong consensus. Fully 87 percent of respondents stated the belief that health insurance premiums should not vary with health status. Differences were essentially uniform regardless of age, race, or income, and there were relatively small differences by education. Individual responsibility. When people were asked more detailed questions, however, it became clear that this belief in equity has conditions. Specifically, respondents indicated support for the concept of making individuals bear responsibility for certain types of behavior. We asked whether or not people should pay more if they smoked, if they were obese, or if they had a family history of heart disease or cancer. These characteristics were chosen to vary in terms of the amount of control the individual has; smoking is generally seen as behavior over which individuals have substantial control, obesity tends to be viewed as a characteristic over which individuals have some control but which also has a genetic component, and heart disease and cancer are most likely viewed as genetic conditions over which individuals have only modest influence. A clear majority of respondents (60 percent) believed that people who smoke should pay more; a sizable minority (29 percent) thought that higher health insurance premiums are appropriate for people who are obese; and only very few (12 percent) felt that it is appropriate for people with family histories of heart disease or cancer to pay more.
Employer coverage.
A set of four questions were asked specifically about existing or potential features of employer-based health insurance (Exhibit 4
Changes to the U.S. system. A series of questions explored Americans’ views on how we might change the way health insurance is provided (Exhibit 5 ). Although Americans clearly believe that the system needs to be improved, we found considerable ambiguity in their views on how such improvements should be accomplished. We asked respondents to indicate their level of agreement with six different approaches to changing the way health insurance is provided. A majority supported five of the six approaches, although to varying degrees, despite the fact that several of the approaches are in direct conflict with each other. We found the strongest support for expanding coverage by working with employers to cover more working people and families. At the same time, nearly two-thirds favored fundamentally changing the health care system from the employer-based system to one in which government would provide universal health care. And a majority also agreed with the notion that government’s role should be limited to paying for the population that is low-income, unemployed, or unable to get insurance.
Most people do not embrace the idea of making health insurance more like other types of insurance by having it cover predominantly catastrophic events. Fewer than half of respondents agreed that individuals should pay more of the costs of routine care and insurance should be for catastrophic events. Setting priorities, curbing rising costs. Two additional questions explored views on what should be the highest priority when expanding coverage and how rising health care prices should be controlled. With respect to the former, respondents favored limiting the impact on themselves: 64 percent indicated that the highest priority should be to not increase costs facing individuals and families, 20 percent supported not adding to government spending, and 16 percent were most concerned about not increasing the burden on employers. Concern about protecting the individual from the impact of health care costs was also apparent when respondents were asked about who should be responsible for controlling rising costs. Just over half of respondents (53 percent) believed that it is government’s responsibility to establish price limits, compared with only 27 percent who felt that consumers should pay part of costs so that they will shop around more, and 20 percent who indicated that employers should use their bargaining power to get good deals. Differences among respondents. Differences by political party were among the most consistent subgroup differences observed and did not vary across sociodemographic variables. Thus, differences by party are likely real philosophical differences between Democrats’ and Republicans’ views on health insurance, not surrogate effects related to income, education, or race.6 Perhaps more importantly, although many of the differences observed between Republicans and Democrats are not surprising, others reflect greater commonality in values than might be expected. For example, the majority of Republicans (53 percent) were most concerned about not increasing costs facing families, and members of both parties placed a similar priority on not increasing the burden on employers (it was a priority for 19 percent of Republicans and 15 percent of Democrats). Also notable is that sizable numbers of Democrats (63 percent) and Republicans (48 percent) favored mandatory health insurance. Similarly, the vast majority in both parties believed that the current system needs to be improved.
Californians.
Our study also included a sufficient sample of people living in California to assess how their views might be similar to or different from the rest of those held by other Americans. In terms of the most basic views of how health insurance should be provided, California residents were less likely than other respondents to believe that people should be required to have basic health coverage (Exhibit 6
Californians also differed from the rest of the country in their views about the role of government, the private sector, and the individual with respect to health insurance. Two-thirds of Californians agreed with the statement that the role of government should be limited to paying for insurance for low-income, unemployed, and others who are unable to buy coverage, compared with 54 percent of non-Californian respondents. Similarly, Californians were more likely than non-Californians to put the responsibility for controlling health care costs on either consumers (38 percent versus 26 percent) or employers (25 percent versus 20 percent) and less willing to support government establishment of price limits (37 percent versus 54 percent; data not shown).
Our finding that four-fifths of Americans are dissatisfied with the U.S. health care system and think that it needs to be improved is consistent with other surveys.7 This dissatisfaction, however, has seldom led to consensus about particular policy options. In the early 1990s, Marc Berk noted that "the public is confused. While Americans believe our health care system needs repair, there is no consensus on how to fix it."8 Close to a decade later, Robert Blendon reiterated that "there is no public consensus on any single approach."9 Instead of attempting to use our survey instrument to force possibly false consensus on policy options, we focused on Americans’ views on alternative health insurance options. Indeed, as indicated by our findings, there is a higher level of consensus on these dimensions; this is supported by the relatively small differences we observed among sociodemographic groups. There is general belief in equality with respect to paying for health insurance: Almost 90 percent of respondents believed in equal premiums, regardless of health status or use. This basic perspective holds across age, race/ethnicity, education, income, and party. But the public’s belief in equity does have some limitations. Although views concerning equity extended to those subject to genetic predispositions to poor health, there is moderately strong support behind making people bear responsibility for the health risks that result from their own behavior. Americans clearly want to see coverage expanded, but their beliefs about the relative roles of government, employers, and consumers vary. A majority of respondents approved of several approaches. Although it appears that some of these positions are contradictory, an alternative explanation is that people are expressing different degrees of preference for different forms of change; perhaps they realize that they will have to compromise to get reform, and they are acknowledging that there is a range of acceptable alternatives. Americans are relatively evenly divided regarding mandatory health insurance, with the exception of the uninsured, who are largely against it. This might suggest that a sizable proportion of the uninsured have made a conscious choice not to obtain coverage and want the right to make that choice. On the other hand, the uninsured might want that right because they do not feel able to afford the expense associated with mandatory health insurance. Overall, Americans seem to be hoping for a better deal: There is little evidence of self-sacrifice. They want employers and the government to do more to help pay for coverage, but they still want the right to choose from different policies. They do not want to see insurance more focused on catastrophic coverage but want routine costs to be covered. Support for government to subsidize employment-based insurance to make it more affordable for more people is generally strong, but it declines with age, with much lower support among those of retirement age. These results suggest that people who are retired are less willing to see their tax dollars directed at subsidizing health insurance costs for working people—an interesting result considering that retirees get a large government subsidy for health insurance in the form of Medicare. Or it might simply be that elderly Americans are generally more cautious than others in their approach to government spending. With respect to these two points, there is a clear message that is relatively invariant to personal demographics and socioeconomic position. Of particular interest, views are more similar between Democrats and Republicans than might be expected. The vast majority of members of both parties agreed that the current system needs to be improved. In addition, when asked to select the highest priority when expanding coverage, the majority in each party chose not increasing costs facing individuals and families. Increasingly, health care reform has been taking place on a state rather than national level, and our results offer a warning against using national data to examine state initiatives. Our sample was a national probability sample; like most other surveys of this type, it cannot support state estimates. The one exception is California: With one in five Americans residing in California, we used the subsample of California residents to present their perspectives on many of these issues. We found that Californians had somewhat different views than those residing elsewhere, as stated earlier. Some of the differences might be attributable to a stronger emphasis among California residents on health, fitness, and diet, which when coupled with rapidly rising levels of obesity among the California population could represent a backlash based on belief in personal responsibility for health.10 It is reasonable to infer that if fifty statewide surveys were conducted, California would not be the only state to depart from the national estimates. Thus, although our results offer a useful national perspective, they cannot be used to predict the views of residents of any particular state. This reinforces the view that forging consensus for specific policy options is likely to be difficult. Of interest in this context is the recent Massachusetts reform, which combines individual responsibility with government assistance for low-income people and (required) employer participation. This hybrid approach—by including features that might strengthen support among certain groups and mute opposition from others—could be one model for building consensus in a population with conflicting views. However, Massachusetts has an unusually strong employer-based system, a vigorous and well-funded Medicaid program, and a well-integrated safety net. Thus, although its initiative offers intriguing possibilities for covering the uninsured, its generalizability to other states is uncertain. THIS STUDY REVEALS AMERICANS' VIEWS on some of the important issues and options surrounding national health policy debates. But the ambiguity of the public’s attitudes in key areas suggests that delivering acceptable reform is still an elusive goal. Americans want a system that expands coverage and maintains choice and yet does not increase individuals’ out-of-pocket costs. It might be possible to devise an optimal solution given these apparent contradictions, as shown with the early favorable response to the Massachusetts initiative. However, the potential for differences across states, as evidenced by our results from California, reinforces the importance of understanding the unique features that each state or region might bring to reform plans.
Marc Berk (berk-marc{at}norc.org) is senior vice president and a senior fellow, NORC at the University of Chicago, in Bethesda, Maryland. Dan Gaylin is executive vice president of NORC at the University of Chicago in Washington, D.C. Claudia Schur is a principal research scientist, NORC at the University of Chicago, in Bethesda. This study is one of a series of household surveys designed for Health Affairs that NORC has conducted on health policy–related topics. Funding was provided by the California HealthCare Foundation (CHCF). The views presented are those of the authors and do not reflect the opinions of the CHCF or NORC. The authors thank Norman Bradburn of NORC for his valuable contributions in laying the conceptual framework and crafting the question wording. They also thank Jyoti Gupta of NORC for her programming support and research assistance.
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