A Reality Check: The Public’s Changing View’s of our Health Care System

      In December 1996, the National Coalition on Health Care conducted a survey of adult Americans on their attitudes and beliefs about health care. The purpose of that survey, “How Americans Perceive the Health Care System,” was to determine perceptions of health care in three specific categories: cost, coverage and quality. Those findings, released in January 1997 showed:

a lack of trust among Americans in the health care system,

a lack of confidence in the quality of health care,

a fear that because of rising costs, quality medical care is unaffordable to the average American, and

fears about losing health insurance coverage (1).

      These anxieties crossed gender, age, political, economic and regional boundaries.

      Public opinion surveys over the last 12 months since the Coalition’s survey was released indicate that the electorate is even more disgruntled with the health care system than they were a year ago. Anxieties are running high, especially among middle-class working families.

      There is widespread and growing discontent with the health care system. This has been confirmed emphatically in the findings of 22 public opinion research polls (see Table 1) conducted since the Coalition’s survey. These surveys were chosen because of their comprehensive nature in ascertaining the public’s attitudes and perceptions on the health care system as a whole and on three key measures of satisfaction: cost, coverage and quality (as opposed to surveys that ask a single question on health care as part of a general survey). Our review of those surveys shows that the public has serious concerns about the basic structure and operations of our health care system, and that this in turn gives rise to worries about the rising cost, decreasing coverage and the quality of health care. The 22 polls show that consumers are concerned about obtaining timely, affordable, quality health care for their families. The paradox is that this is occurring at the same time there is substantial optimism by the public on the economic front due to a period of unprecedented growth in the economy, coupled with low inflation and low unemployment.

      Our research shows that the public’s most recent concerns with the health care system arose because of the inability of consumers to obtain medical care in the way they had before the proliferation of managed care. Patients were required to “navigate” through the system in ways that they were not asked to do under fee-for-service medicine and indemnity insurance. With the growth of managed care, consumers began to voice concerns about the lack of choice among health care providers and access to a specialist or to an emergency room. Public opinion polls in 1995-1997 revealed widespread dissatisfaction with all types of care including managed care, and that most of this displeasure was grounded in personal experience. However, more recent surveys show new concerns: about the ability to obtain and pay for health insurance and medical care; to access the health care system when coverage is lacking or inadequate; and, to receive appropriate, quality medical care. This finding is significant because for the first time since the defeat of comprehensive health care reform in 1994, the public is expressing concern about overall problems in the health care system. These concerns existed prior to the proliferation of managed care. Moreover, these concerns are clearly growing, and they cut across all types of delivery and financing mechanisms, including fee-for-service and managed care.

      These concerns about cost, access, coverage and quality also are being played out in a much wider public policy arena. Concerns about accessing quality, affordable medical care reflect the findings of key studies issued by several organizations, including the Coalition, that show by all key macro and micro indicators the problems of cost, coverage and quality continue to grow significantly worse, especially for middle-income working families (2).

Concerns About Affordability of Health Insurance and Medical Care: The Coalition survey in December 1996 showed that 40 percent of respondents felt they could not afford medical insurance or afford quality medical care for a serious illness. A more recent survey by the Henry J. Kaiser Family Foundation and The Commonwealth Fund shows that more than half of the adults polled in low and low-middle income categories report that they do not have health insurance because they cannot afford it (3). When they do have health insurance, many consumers are concerned about the out-of-pocket expenses they must incur, including premiums, coinsurance and deductibles. The Kaiser and Commonwealth Fund surveys highlight that almost 20 percent of the uninsured had to change their lives significantly (problems in paying for basic living expenses like housing and food) to pay medical bills. Nearly 40 percent of all respondents said they worried “a great deal” or “quite a lot” about paying for basic living expenses such as food and housing in order to pay medical bills.

Concerns About Access to Medical Care: The December 1996 Coalition survey showed that only 10 percent of respondents agreed strongly that “health insurance companies put the needs of their customers ahead of profits” while 43 percent disagreed strongly with that statement. In recent surveys, a majority of people in managed care plans expressed their belief that if they were sick, their health plan would be more concerned about saving money than with what is the best medical care. One survey showed that one-third of respondents who were in traditional insurance plans felt the same way (4). Another survey conducted in Minnesota, where a high proportion of people are covered in managed care plans, found that only one-third of the chronically ill have a great deal of confidence that they will receive needed medical care, compared with 40 percent of the healthy (5). Many surveys report that respondents believe that managed care plans have made it harder for people who are sick to see medical specialists. One study showed that 25 percent of Americans report that they personally, or someone they knew, had experienced difficulty getting permission to see a medical specialist (6). Regardless of their health insurance status, one survey found that 75 percent of working-age adults reported that they did not get needed medical care in the past year and said their condition was painful or made carrying out normal daily activities difficult. Nearly all of those people said that the consequences of forgoing care were serious and half of those said they still had the untreated medical condition (7).

Concerns About Quality of Care and the Patient/Health Care System Interface: While policymakers have focused on “patient’s bills of rights” and managed care reform, there are other real and significant quality problems plaguing the U.S. health care system. The public’s perceptions on quality show a growing lack of confidence in the health care delivery system overall and the quality of the care being received regardless of whether they are in a fee-for-service or managed care plan. Surveys conducted in Minnesota and California show widespread problems with denial or delays in getting medical treatment or referrals to specialists, and with receiving inappropriate care (8). Seriously ill patients in these polls (and in earlier polls) have expressed their lack of confidence that they will receive care when they need it. However, healthy individuals are now expressing the same lack of confidence that the “system” will provide them the care they need. These concerns are represented as being grounded in personal experience.

      In the Coalition study conducted in December 1996, 75 percent agreed with the statement that “there are serious problems with the quality of medical care.” Specifically, four in ten Americans had a bad experience with medical treatment or care. In a recent survey conducted by the American Medical Association, nearly half of the respondents said they personally or a friend or relative had been in a situation where a medical error was made (9). One out of three adults indicated that the medical error had a permanent, negative impact on the patient’s health. Another survey commissioned by the American Hospital Association showed significant concern by patients in the way decisions were being made about the care being received, and growing doubts about the quality of the care they were receiving (10).

      New surveys also show a shift in public opinion regarding Americans’ views of for-profit health care. Two surveys conducted by Kaiser revealed that fewer Americans believe for-profit health plans and hospitals offer better quality care, are more responsive, or are more efficient than their nonprofit counterparts. Both surveys also found that Americans believe two to one that the trend to for-profit health care is “bad” for the country (11).

      The surveys that are referenced in this report show a lack of confidence by consumers in our health care system and serious concerns about cost, coverage, and quality. Further, Americans are increasingly concerned about the transformation of the health care system from a non-profit industry to a for-profit enterprise and the effect of this change on cost, coverage and quality. These concerns need to be addressed through the development of a system in which consumers can have confidence — and which deserves that confidence.

Hard copies of “A Reality Check: The Public’s Changing Views of our Health Care System” are available by contacting the National Coalition on Health Care at (202) 637-6850.

Press Release: Public Concern About Health Care on the Rise

Full Report: “A Reality Check: The Public’s Changing Views of our Health Care System“