Question

What in your view is the most important policy issue facing the United States? Why is it important and which specific problem needs to be solved? Choose between Social Security, Medicaid and Medicare.

Answer 1

For more than two decades, polls have shown that Americans are dissatisfied with their current health care system. However, the public's views on how to change the current system are more conflicted than often suggested by individual poll results. At the same time, Americans are both dissatisfied with the current health care system and relatively satisfied with their own health care arrangements.

As a result of the conflict between these views and the public's distrust of government, there often is a wide gap between the public's support for a set of principles concerning what needs to be done about the overall problems facing the nation's health care system and their support for specific policies designed to achieve those goals.

Public opinion, health care costs, medically uninsured, quality of health care

The last attempt at major reform of the U.S. health care system was made more than a decade ago. Since President Bill Clinton's failed reform proposal, the percentage of Americans without health insurance has risen; the proportion of GDP devoted to health care grows larger with every year; and out-of-pocket medical spending makes up an increasing portion of Americans' budgets. Is the public ready for another attempt at system reform? Before Clinton's 1994 effort, the aggregate indicators also revealed that the health care problem was growing and that Americans were becoming increasingly dissatisfied with the health care system. Indeed, at the time, a large review of public opinion on health care suggested that Americans were ready for major reform (Jacobs and Shapiro 1994; Jacobs, Shapiro, and Schulman 1993). Yet when health care moved onto the actual policy agenda and the perceived trade-offs of major reform were better understood, the public had second thoughts and their support dissipated.

Accordingly, as we approach the next presidential campaign and candidates already are discussing the need for major health care reform, it is time to reexamine the state of public opinion regarding health care. Over the decades, the health care issue has come to encompass a broad set of concerns, many of them controversial. In this article, we first consider the role of public opinion both in a democracy in general and in past health care policy debates in particular. Next we draw data from more than eighty opinion surveys dating back to 1980 to examine Americans' views in seven critical areas: (1) health care as a national priority for government action; (2) the state of the U.S. health care system; (3) satisfaction with their own health care; (4) health care spending and costs; (5) the uninsured and national health insurance; (6) the financial viability and future shape of Medicare, its prescription drug program, and the Medicaid program; and (7) the problem of quality health care in the United States. Last we discuss the implications of these findings for the future of the nation's health care system.

A central tenet of our representative democracy is that elected officials should be responsive to the wishes and desires of the public. Although many scholars agree that public opinion plays an important role in the policy process, there is less agreement about the magnitude and circumstance of its actual influence on specific policy outcomes. Because of differences in the methods used, issues studied, and time periods examined, studies have produced varying results regarding the impact of public opinion. Some studies have shown a strong connection between public opinion and policy, with opinion more often leading policy than the reverse (see, for example, Erikson, MacKuen, and Stimson 2002a). Other research has shown public officials to be less responsive to the public, with a growing divide since the 1970s between the public and their representatives (Ansolabehere, Snyder, and Stewart 2001; Jacobs and Shapiro 2000). Finally, some researchers argue for a “contingent model” in which the degree of impact of public opinion on policy varies depending on the issue and circumstance (Manza and Cook 2002; Monroe 1998).Past research has shown that the public's views of health care issues are more complex and conflicted than often suggested by individual poll results (Blendon and Benson 2001; Hetherington 2005; Jacobs and Shapiro 2000; Koch 1998). It therefore is difficult to argue that public opinion either drives or follows health policy. The two most recent attempts at major health care reform were made when the public was in a more liberal “mood” and wanted more from government. Both President Richard Nixon's proposals and Clinton's plan came at high points in policy liberalism in general and in health care liberalism in particular (Erikson, MacKuen, and Stimson 2002b, 84, n. 9; Stimson 2004b, 51). Yet the support for sweeping changes evaporated when the policy trade-offs became clear, and the public moved away from wanting more government involvement in health care. According to Erikson, MacKuen, and Stimson's measure of public mood, the public is once again turning to government for answers to their problems (Stimson 2004a). Our examination of twenty-five years of trends in public opinion regarding health policy will thus give us a better understanding of whether the public is finally ready for major change or will support change only at the margins, as in the past.Although Americans are concerned about many national problems, they expect that at any given time the government will address only a few of them. In regard to what most needs governmental action, this public agenda has tended to vary over the years. Although health care is currently considered an important issue, it is not as high on the nation's agenda as it was in 1993 when Bill Clinton became president. Indeed, in January 1993, 31 percent of those surveyed named health care as one of the two most important issues for government to address, thereby ranking it as second in importance. In contrast, in June 2006, during President George W. Bush's administration, 12 percent named health care, making it the fourth-highest-rated issue (Harris Interactive Poll 1993, 2006d). More recently, health care has been surpassed by a combination of the war in Iraq and the threat of terrorism. Over the past thirteen years, various domestic issues such as Social Security and education have moved up and down the agenda, sometimes surpassing health care as a priority

In a number of opinion surveys, a majority of Americans today express dissatisfaction with the nation's health care system, although their dissatisfaction has not reached the point that they believe the system to be in crisis and that a completely new health care system is needed.

In 2006 about four in ten Americans (38 percent) expressed a great deal or quite a lot of confidence in the nation's medical system (Gallup Poll 2006b). When asked in 2005 about five major systems in the United States, the public rated the health care system as the lowest, behind the tax, Social Security, legal, and education systems (Pew Research Center 2005a).In 2006 only about three in ten Americans (31 percent) reported that they had a great deal of confidence in the leaders of medicine, which is significantly lower than the rate during the early 1970s and late 1990s but higher than the low point of 22 percent in 1992 and 1993.Since 1982, one survey organization has asked Americans whether they think their health care system works pretty well and needs only minor changes, has some good things but needs fundamental changes, or has so much wrong with it that it needs to be rebuilt completely. By this measure, the majority of Americans have never been completely satisfied with the health care system. They were the most positive in 1987, when 29 percent reported that they thought the system was working pretty well. In 1991, often seen as the starting point of the major health care reform debate of the early 1990s, only 6 percent held this favorable view. In that same year, 42 percent of Americans believed that the health care system should be completely rebuilt, the highest level ever recorded

In 2006, one in eight Americans (13 percent) saw the system as working pretty well, while 37 percent thought it should be completely rebuilt. In short, Americans were more dissatisfied than in 1987, but less so than in 1991 (Harris Interactive 2006e).

Americans' attitudes toward the health care system are related to differences between those with secure and comprehensive health coverage and those without it. Using a dataset with a wide range of variables, we conducted a multivariate analysis of opinions about the state of the health care system (NPR/Kaiser/Kennedy School 2002). Controlling for income, education, race, and satisfaction with one's personal medical care, those who are uninsured and worried about their future ability to afford health care are significantly more likely than the rest of the public are to feel that the health care system needs major changes.

Americans are more dissatisfied with their health care system than are citizens of other industrialized countries. Between 2004 and 2006, international public opinion surveys showed that only a minority of Spanish (28 percent), U.K. (26 percent), Canadian (21 percent), and U.S. (13 percent) residents were completely satisfied with their health care system. But of the four countries, Americans expressed the highest level of dissatisfaction: more than one-third (37 percent) believed the U.S. health care system needed to be rebuilt completely. This is nearly three times the proportion of Canadian (14 percent), Spanish (13 percent), and U.K. residents (13 percent) who had this negative view of their own country's health care system. (Harris Interactive Poll 2006c; HSPH/Fundacío Biblioteca Josep Laporte 2006; Schoen et al. 2004).

Americans are far less satisfied with the availability of affordable health care in their country than the Canadians and British are with theirs, but residents of the three countries agree in their assessment of their country's quality of medical care. Nearly three-fourths (72 percent) of Americans in 2003 expressed dissatisfaction with the availability of affordable health care in their country, including about one-third (44 percent) who were very dissatisfied. Only one in four was very or somewhat satisfied, a proportion significantly lower than that in the United Kingdom (43 percent) and Canada (57 percent) (Gallup Poll 2003a).

Similarly, in 2005 only about one in five Americans (21 percent) rated health insurance coverage in the United States as excellent or good, and more than three-fourths (78 percent) rated it as only fair or poor (Gallup Poll 2005b).

However, Americans were about evenly divided about the quality of medical care in the country. In late 2005, about half of U.S. (53 percent), U.K. (55 percent), and Canadian

Similarly, in 2005 only about one in five Americans (21 percent) rated health insurance coverage in the United States as excellent or good, and more than three-fourths (78 percent) rated it as only fair or poor (Gallup Poll 2005b).

However, Americans were about evenly divided about the quality of medical care in the country. In late 2005, about half of U.S. (53 percent), U.K. (55 percent), and Canadian (52 percent) residents rated the quality of health care in their country as excellent or good (Gallup Poll 2006a). Similarly, in 2006, 53 percent of Americans rated the quality of health care in the United States as excellent or good (ABC/WP 2006).

Added to their general concerns about the health care system, a significant proportion of Americans in 2006 believed that insurers and pharmaceutical companies were not doing a good job for those they served. More than four in ten (44 percent) thought that managed care companies were doing a bad job serving their consumers, and more than one-third (36 percent) thought the same about pharmaceutical companies (Harris Interactive Poll 2006b).

Even though a majority of Americans are dissatisfied with their current health care system, most do not see it as being in a state of crisis requiring immediate action. In 2006 only one in five (22 percent) described the health care system as being in a state of crisis, although this is a significantly higher proportion than in 2002 (11 percent). A majority (52 percent) in 2006 said it had major problems, a view that has remained relatively constant since 1994. Also in 2006 about one in four (23 percent) believed their health care system had minor problems.