During the 1993-1994 debate on health care reform, the major national pollsters covered health care intensively. We learned a great deal about how Americans assessed their own care and the health care system. In 1995, 1996, and 1997, the issue seemed to disappear from most of the pollsters’ radar screens.

Reduced poll coverage was to be expected in part because of the way many polling firms operate today. Many pollsters have media partners, and when the media moves on to other issues (as it did after the exhausting 1993-1994 health care debate), the pollsters do, too. The 1993-1994 health care debate also lent itself to a kind of coverage that has become all too familiar in public polls. The emphasis is on who’s winning and who’s losing--i.e.,President Clinton vs. opponents of his health care plan, Clinton vs. the GOP Congress on the government shutdown, Clinton vs. Ken Starr on scandal investigation. Absent a "campaign" with winners and losers, many issues seem to hold little interest for most of the media pollsters. Fortunately, many survey organizations continue to conduct surveys on health care. Organizations such as Roper Starch Worldwide, Louis Harris and Associates, and Gallup have tracked attitudes on health care for decades, and they continue to provide updates of questions. More recently, Robert Blendon at Harvard University with the support of the Kaiser Family Foundation has been conducting regular inquiries about public assessments in this area. ABC News did substantial health care surveys in 1995 and 1997.

What follows is a summary of current polling on health care. "Is the trend toward managed care unpopular?" as a New York Times headline in 1997 suggested. Are "managed care companies trusted less," as a Washington Post article put it? Is there a backlash against managed care? What do Americans want to do to address concerns they have about the health care system?

Many survey organizations conduct polls for private clients in areas such as employee, patient, and physician satisfaction. Gallup, for example, reports that its database contains proprietary data from more than 500 hospitals. Thirty percent of all Louis Harris and Associates research is in health care. Despite this volume of activity, most of these studies are not released publicly. This report uses only data in the public domain.

Some Preliminaries

Understanding how people are thinking about health care issues today needs to be viewed in a broader context. Americans are a pretty satisfied lot these days. The University of Michigan and the Conference Board continue to report record levels of consumer confidence. Other survey questions show that more people think the country is on the right track (and not headed off in the wrong direction) than have thought so for a very long time. This benign climate has had an effect on public perceptions of the problems the country needs to address. When Americans are asked about the most important problem facing the nation, crime tops the list in Gallup’s most recent survey. Anxiety about the economy is considerably lower than it was in 1992 and 1993. Concern about health care has receded from the time of peak attention in January 1994, when 31 percent of those surveyed told Gallup it was the country’s most important issue. Today, just 6 percent feel this is the case ( Table 1). A finding from the August-September 1997 Kaiser Family Foundation-Harvard University Program on the Public and Health/Social Policy (hereafter referred to as Kaiser/Harvard) reflects in some measure the generally upbeat mood. When asked by Princeton Survey Research Associates to compare their situation to that of a few years ago, just 14 percent said that they and their families were worse off in terms of their ability to get good health care. Fifty-three percent said their situation was about the same, and 31 percent said they were better off.

Add to this the fortunate circumstance that most Americans are healthy. Since 1973, the National Opinion Research Center (NORC) at the University of Chicago has asked people to rate their health as excellent, good, fair, or poor. As  Table 2 shows, the proportion rating their health as excellent or good has increased since 1973. In 1996 (the latest year for which data are available from NORC), 31 percent rated their health as excellent, 49 percent as good, 16 percent as fair, and only 4 percent as poor. Not surprisingly, younger people were more likely to report excellent or good health than older ones. But older people were more positive about their health in 1996 than they were a quarter of a century ago. In 1973, 53 percent of those over sixty years of age said their health was excellent or good; in 1996 that figure was 67 percent. In 1973, 14 percent of those over age sixty described their health as poor; in 1996, just 9 percent did so ( Table 2). Asking people about their health in comparison to other things, as Louis Harris and Associates did in April 1997, provides additional evidence of widespread satisfaction with health. Eighty-eight percent reported feeling good about their health. This was exceeded only by the percentage who felt good about quality of life overall (91 percent), their homes (92 percent), and relations with their family (95 percent). In the poll, 61 percent felt good about the quality of the environment where they lived, and 55 percent about their financial security.

Although slightly more than 60 percent in a 1996 Roper Starch Worldwide survey said they or someone in their household had visited a doctor for a specific problem in the past year, just 12 percent said they had been admitted to a hospital as an inpatient. Twenty percent said they had been to a hospital or clinic as an outpatient. Eighteen percent said they or someone in their family had been to an emergency room for treatment. (A survey conducted in August-September 1997 by Princeton Survey Research Associates for the Kaiser/Harvard team put the number at 27 percent; a survey Louis Harris and Associates for the Kaiser Family Foundation and the Commonwealth Fund in 1997 found that 29 percent had personally or had someone in their family go to an emergency room in the past 12 months for care.) Fewer than 10 percent in the Roper Starch Worldwide poll reported that they or someone in their household had had either planned minor or planned major surgery. Four percent said they had had unplanned emergency surgery in the past year.

Survey data continue to show that large numbers of Americans have some kind of health care coverage, although the number without coverage has edged up unevenly. In 1973, when Roper Starch Worldwide asked for the first time whether "you and your family have any type of health care plan or hospital insurance," 89 percent of those surveyed said they had. The survey organization has asked the question eight times since then, and the number has declined slightly. In December 1997, the last time the question was asked, 83 percent reported that they had health insurance, but 16 percent said they did not have it. The Louis Harris/Kaiser/Commonwealth Fund survey reported in 1997 that over eight in ten adults reported that they had some form of health insurance coverage. (Of the insured, 13 percent reported that they had been completely without health insurance at some time during the past two years.) Roper also asks whether respondents had a personal or family doctor "you or your family can call on." Eighty-five percent gave that response in 1973, and it edged downward to 75 percent in October 1996 ( Table 3). Roughly three quarters in the 1993 and 1997 Louis Harris/Kaiser/ Commonwealth Fund surveys reported that they had a regular doctor they usually go to when sick or in need of medical advice.

Levels of Knowledge

In evaluating public opinion on health care, some caveats are in order. Most Americans are not familiar with the health care terminology that Washington policy makers use routinely. In the August-September 1997 Kaiser/Harvard poll, slightly more than three quarters (78 percent) of those surveyed said they knew what the term "Medicare" meant, and 71 percent, "Medicaid." Seven in ten said they knew what a primary care doctor was. The term "HMO, or health maintenance organization," was familiar to 62 percent, with 24 percent responding that they had heard the term but didn’t know what it meant, and 14 percent that they had never heard the term.

Familiarity with the terms "managed care" and "fee for service" was considerably lower. Just 45 and 41 percent respectively knew what these terms meant. About a quarter said they had heard of managed care but were unsure of its meaning, and 28 percent said they had never heard of it. Fifteen percent said they had heard of fee for service but were unsure of what it meant, and a substantial 43 percent said they had never heard the term ( Table 4).

Another question in the August-September 1997 survey underscores lack of familiarity with terms used by the experts. When asked whether certain groups were doing a good or a bad job in serving the needs of health care consumers, nearly everyone had an opinion about doctors, and separately, about nurses. But a third said they "didn’t know" about managed-care plans, and 27 percent gave that response about HMOs.

To judge from responses to a survey taken in December 1997, not much is known about the consumer bill of rights President Clinton endorsed, either. In the survey, the Kaiser/Harvard team asked people to compare the consumer bill of rights President Clinton endorsed with the health care reform plan that he tried to get passed by Congress a few years ago. Seven percent said the consumer bill of rights was a "comprehensive health care reform proposal very similar to Clinton’s previous plan," 27 percent said "a scaled-down version of Clinton’s previous plan," and 24 percent "a different proposal that calls for more modest changes in the health care system." But 42 percent said they didn’t know. In another question, a third were unable to choose among four responses about what the consumer bill of rights would do. [A personal observation: I confess to being completely stumped by many of the questions I came across in this review of current attitudes about health care, and I suspect many other Americans would have a hard time answering them, too.]

Another pattern common among many public opinion surveys shows up in surveys about health care, too. People are generally more positive about things that are closer to them than about things that are farthur away. And they are also more favorably disposed toward individuals than toward bureaucracies or professions. In an April 1997 survey by Louis Harris and Associates, 79 percent said they felt good about life in their communities. Far fewer--52 percent--felt good about the state of the nation. In a CBS News poll from June 1997, 72 percent were satisfied with race relations in their community. Just 38 percent felt that way about race relations in the nation. In a survey taken in the early 1990s, 50 percent had a high opinion of lawyers they had dealt with, but only 16 percent had a high opinion of lawyers in general. People rate their own doctor higher than they do doctors in general or the medical profession at large.

The Kaiser/Harvard team asked people in August-September 1997 whether they trusted their primary care or family doctor to do the right thing for their care, and separately whether they felt that way about their current health insurance plan. A majority (52 percent) said they trusted their doctor just about always; 41 percent felt that way about their health care plan. In December 1997, Roper Starch Worldwide asked people to agree or disagree with statements about their health care. Fifty-seven percent strongly agreed with the statement that "my doctor is someone I can trust," but just 35 percent strongly agreed that "my health insurer is an organization I can trust."

Another question in the Roper survey showed that 57 percent strongly agreed that their doctor gave them straight answers to their questions; just 33 percent felt that way about their health insurance organization. (When the "just about always" and "most of the time" responses from the Kaiser/Harvard question and the "strongly" and "mostly agree" responses from Roper Starch question are combined, trust in doctors and health insurers look similar. Eighty-three percent of those surveyed by Kaiser/Harvard trusted their family doctor to do the right thing just about always or most of the time, and 80 percent felt that way about their current health insurance plan. Ninety-five percent in the Roper Starch data agreed strongly or mostly with the statement that their doctor was someone they could trust, and 89 percent, their health insurance organization. The pattern of high general satisfaction appeared on the other Roper question mentioned above about giving straight answers, too.)

Questions that ask people about their experience with the health care system, the courts, and the IRS are generally more reliable than abstract questions that ask people about how most Americans are faring under managed care or the criminal justice or tax systems. Questions about large institutions or bureaucracies often echo media coverage of those institutions and bureaucracies.

Another thing to keep in mind is that many buzz words, used in polls about health care or about anything else, almost guarantee a certain response . "For-profit" organizations are seen as less compassionate that "non-profits," in medicine and elsewhere. They are usually seen as more efficient, in medicine and elsewhere. And, finally, many of the survey questions that are asked about health care today are hypothetical ones. "If you had a serious medical problem, how likely do you think it is that. . . . If you were sick, would your health plan do x, y, or z . . ." Some pollsters argue that these kinds of questions are necessary to probe underlying anxiety and to explore paths that policy makers might want to take. But responses to hypothetical questions often vary greatly from survey to survey. This is because most people think in concrete and not hypothetical terms, and they find hypothetical questions difficult to answer. When a pollster asks a hypothetical question, people often inadvertently respond to other cues in the survey such as question wording and question placement, or to the general tenor of the questionnaire, or to things they have heard on the news.

Assessing Personal Care

What are people saying about their own care? Although very little trend data is available in the public domain, some patterns are beginning to emerge for those who have health care coverage.

• First, people in traditional fee-for-service care are generally more satisfied than are those in managed-care arrangements. Still, there is little evidence of widespread dissatisaction among either group. One indication of this is the number who would recommend their plan to others. When people with coverage were asked by ABC News in 1997 whether they would recommend their plan to others, 78 percent of those in traditional plans said they would, as did 79 percent of those in managed-care arrangements.

• Second, the cost of health care, long a concern for Americans, remains a worry. A January 1998 survey by Charlton Research for the Congressional Institute asked people about the most important problem facing health care today. Concern about the cost of health care (60 percent) and about the affordability of health insurance (60 percent) far surpassed other concerns such as lack of choice in insurance plans (cited by 35 percent), restrictions on the choice of doctors (32 percent), and the quality of care (26 percent). Cost is one area in the surveys where those in managed care are usually more satisfied than are those in traditional care.

• Third, the data I have reviewed in the public domain do not support the notion that managed care is good for those who are healthy, but not for those who are sick.

• Fourth, Americans continue to believe that the federal government has an important role to play in regulating health care. This sentiment is tempered by real concern that any federal involvement will increase costs and by widespread skepticism about the federal government’s performance today. In one exercise by the Kaiser/Harvard team, people were asked how important it was to have a hotline telephone number they could call to get help when they had problems with their health plan. Seventy percent thought this was very important. In the next question, people were asked how important it was for the government to set up a hotline telephone number they could call to get help when they have problems with their health plan. The proportion saying this was very important dropped to 43 percent.

• Finally, a compassionate and generous public has not given up on the goal of providing health care for those who do not have it. This is a goal Americans want policy makers to work toward; it is not a demand that overwhelms other considerations.

Trust is important in any relationship, and in an area as vital to most people as their health care, it is key. As pointed out above, when people were asked how often they trust their primary- care or family doctor to do the right thing for their care, 52 percent in the AugustÿSeptember Kaiser/Harvard survey said they trusted that individual just about always. Another 31 percent trusted that person most of the time, for a combined response of 83 percent. The responses to the same question about their current health insurance plan were 41 and 39 percent, respectively, for a total of 80 percent. Fewer than 20 percent indicated low ("only some of the time" or "none of the time") trust in either their doctor or their health insurance plan. If these ratings were applied to a politician, they would be considered very strong. The same question has been asked about the federal government, and trust in the federal government is much lower than trust in health care plans. In a February 1998 Gallup survey, 39 percent trusted the federal government in Washington to do what was right just about always or most of the time.

The survey did reveal a sharp difference between those in managed care and those in traditional arrangements, in terms of high trust in their health insurance plan. Fifty percent of those in traditional arrangments and 32 percent of those in managed care (an 18-percentage-point difference) said they trusted their plan to do the right thing just about always. Once again, when the categories "just about always" and "most of the time" were combined, the differences in responses between the two groups were much reduced. Eighty-four percent of those with traditional plans expressed high trust, 77 percent of those with managed-care arrangements did (a 7-point difference). When asked about their primary care or family doctor, 60 percent of those in traditional plans and 52 percent of those in managed care voiced high trust.

In August-September 1997 and again in December, the Kaiser/Harvard team asked people to "grade" their health insurance. The responses were similar. In December, 30 percent gave their health plan an "A" or excellent grade, 42 percent a B or good grade, 19 percent a C or average grade, 4 percent a D or poor grade, and 2 percent an F. Seventy-four percent of those with traditional care and 69 percent of those in managed care gave their plan an A or B grade. The grading exercise is used in many other areas of survey research, and so a question that asks people to grade the school their oldest child attends, the schools in their community, and the schools in the nation is also included here. The responses about health care are similar to the generally favorable attitudes people have toward the school their oldest child attends, and they are much more favorable than views about local schools and schools nationally ( Table 5).

In a poll taken in 1997, ABC News probed public views on different aspects of care including the quality of health care, health care costs, ability to get a doctor’s appointment, ability to see a specialist, and ability to get the latest, most sophisticated treatment. They also asked those who had personally experienced or had had in their family a serious illness whether they were satisfied with the care received and, separately, with the insurance coverage during that time. Finally, they asked about overall impressions. In most cases, the new findings update work done in 1995.1

 Table 6 shows that those in traditional plans were more satisfied than were those in HMOs in terms of the quality of health care received, the ability to get a doctor’s appointment when they wanted one, the ability to see top-quality specialists, and the ability to get the latest treatment. When it came to cost, however, those in HMOs were more satisfied than were those in traditional plans ( Table 6).

In 1973, Roper Starch Worldwide began asking whether people were satisfied or dissatisfied with four aspects of care: quality, availability, arrangements for paying, and costs. The wording and the response categories people could choose in the Roper Starch questions were different from the ones ABC used, and that is one explanation for the differences in response. So, too, is the fact that Roper surveys are done in person; ABC’s are conducted by phone.  Table 6 shows those results for national samples on the eight occasions when the question has been asked. For the whole population, satisfaction with quality is down 10 percentage points from 1973; with availability of medical care it is down 4 points in the same period. Satisfaction with arrangements for paying is down 12 points among the national adult sample. The belief that costs are reasonable has actually improved, from 42 percent who gave that response in 1973 to 52 percent in 1996 ( Table 7). Eighty-three percent of adults in the 1997 Louis Harris/Kaiser/Commonwealth Fund surveys were satisfied (45 percent of this group were very satisfied) about the health care services that they and their families have used in the last few years. Eight percent were somewhat dissatisfied, and 5 percent very dissatisfied. Of the currently insured, 79 percent in 1993 and 83 percent in 1997 reported satisfaction with their health insurance (49 percent in 1997 were very satisfied). In 1997, 10 percent were somewhat dissatisfied, and 4 percent very dissatisfied.

The 1996 Roper survey showed that those in managed care were just about as satisfied with those in traditional plans with the quality and availability of medical care. More than 70 percent of both groups reported satisfaction in these areas.2 Like the ABC poll, those with managed care felt better about costs than did those with traditional arrangements ( Table 8).

The cost of health care has long been a concern, and, not surprisingly, polls pick this up. In a Kaiser/Harvard survey of people who said they had voted in the 1996 election, 68 percent said the cost of health care for families was a bigger problem than it was five years ago, 27 percent said it was about the same, and just 3 percent said it was less of a problem. Majorities of Democrats, Republicans, and independents agreed that it was more of a problem. The surveyors did not ask whether it was a bigger problem for them personally.

In the August-September Kaiser/Harvard survey, people were asked how likely they thought it would be that their health plan would pay for an emergency room visit. Sixty-four percent of the total sample said very likely and 24 percent said somewhat likely. Five percent of the insured said it was not too likely that their plan would pay for the visit, and 5 percent said it was not at all likely. Those in traditional plans were considerably more likely than those in managed care arrangements to say that it was very likely that their plan would pay for the visit (70 to 59 percent). When the "very" and "somewhat" likely responses were combined, 91 percent of those with traditional care as compared with 86 percent of those with managed care said their plans would pay for the care.

The next question asked "if you had a serious medical problem requiring costly treatment, how likely do you think it is that your health plan would pay most of the cost?" Again, in the national sample, 55 percent said this was very likely, and 34 percent somewhat likely. Five percent said not too likely, and 2 percent not at all likely. Once again, those with traditional care were considerably more likely to say that it was very likely that their plan would pay most of the cost (62 to 49 percent); when the "very" and "somewhat" likely responses were combined, the differences washed out (90 percent of those with traditional care said it was likely that their plans would pay most of the cost; 89 percent of those with managed care felt that way).

Concern about cost could be seen in a question Kaiser/Harvard asked in its AugustÿSeptember poll. Of those who had used emergency room care (27 percent of those surveyed), 23 percent reported problems in having the bill paid by their health insurance company, and 74 percent did not.

 Table 9, with December 1997 data from Roper Starch Worldwide, reminds again that Americans want a lot in the area of health care. The survey also shows high general satisfaction in those areas.

ABC News did something many other public polls haven’t done, by asking people whether they or anyone in their immediate family had had a serious illness or injury under their current health insurance plan. A third of those with coverage said this description applied. Ninety-three percent of those with traditional care reported that they were satisfied with the medical care they or their families received, but so, too, were 88 percent of those with HMO coverage. Eighty-six percent of those with traditional care and 84 percent of those with HMO coverage reported being satisfied with their insurance coverage at the time of serious illness. The ABC poll does not support the idea that managed care is good only when people are healthy ( Table 6). A survey done by Louis Harris and Associates and the Harvard University Program on the Public and Health/Social Policy and supported by the Robert Wood Johnson Foundation3 looked at the experiences of those with a "higher burden of illness." They reported that "the vast majority of these persons are satisfied with many aspects of their health care, regardless of the type of health plan they have. In all, fifteen items (out of sixty-six) revealed significant differences between limited-choice managed care and fee-for-service plans. For all but two (needing to fill out forms and out-of-pocket costs), the finding was more favorable to fee-for-service plans than to managed care plans." These are among the findings these analysts found significant. Twenty-two percent of the sick, non-elderly in managed care reported major or minor problems with not getting treatment which they or their doctor thought was necessary compared to 13 percent of the sick, non-elderly in fee-for-service care. Twenty-one percent of the sick, non-elderly in managed care reported being unable to see a specialist when they thought they had needed one in the past year, compared to 15 percent of this group in fee-for-service care. Seventeen percent of this population in managed care reported having the wait a long time to get a doctor’s appointment compared to 7 percent in fee-for-service care.

Louis Harris and Associates, in its 1997 survey for the Kaiser Family Foundation and the Commonwealth Fund, asked about an issue much in the news in the last year. Among adults who had been hospitalized in the past year (12 percent of those surveyed), 72 percent said the time they spent in the hospital was about right, whereas 18 percent said it was too short. Six percent said the time was too long.

Asking those with health insurance whether they would recommend their plan is an important bottom-line assessment. ABC News asked that question in a straightforward way and found that 78 percent of those with traditional arrangements would recommend their coverage, compared with 79 percent of those in HMOs. Around one in five said they would not. In 1995, those responses were 82 and 80 percent, respectively (table 6).

The Kaiser/Harvard team asked people in December 1997 whether they or someone they knew had experienced different kinds of problems with an HMO, managed-care plan, or health insurance company in the past few years. Fewer than one in five had, or knew someone who had, "had difficulty getting permission from a health plan or regular doctor to see a medical specialist, such as a doctor specializing in cancer" (18 percent), "had difficulty getting a health plan to pay an emergency room bill" (19 percent), "wanted to file an appeal to an independent reviewer when a health plan denied coverage for a particular medical treatment" (17 percent). Fewer than one in ten had, or knew a woman who had "had difficulty getting permission from a health plan or regular doctor to see a gynecologist" (6 percent), and "wanted to sue a health plan for malpractice" (9 percent).

The Louis Harris/Kaiser/Commonwealth Fund asked about different kinds of problems or irritants in its 1997 survey. Twenty-four percent of the insured said they had had major (6 percent) or minor (18 percent) problems having to deal with rules that were confusing or complex, 54 percent said they had had no such problems, and 22 percent no experience of this kind. Nineteen percent of the insured said they had had problems with their plan delaying payment for services (5 percent major problems, 14 percent minor problems), but 60 percent reported no such problems. Seventeen percent of the insured said they had had problems with their plan not covering treatment they or their doctor thought was necessary (5 percent major, 12 percent minor), but 61 percent had had no such problems. Finally, 10 percent had had problems with their plan delaying care while waiting for approval, and 64 percent had had no such problems.

 Table 10, from the December 1997 Kaiser/Harvard survey, shows a different kind of general assessment. Twenty percent of those surveyed said people like themselves were better off because of the trend toward managed care, and 28 percent said worse off, but a strong plurality (45 percent) said they had not been affected much either way. Those in managed care were more likely than those with traditional arrangements to say that people like themselves were better off because of the trend (27 to 18 percent), and virtually identical numbers said that people like themselves were worse off (25 and 26 percent, respectively).

The System as a Whole;
The As Good as It Gets Effect

In the movie As Good as It Gets, Helen Hunt plays a working mother whose son is severely asthmatic. One of the elements of the story is her struggle to get good care for the boy. At one point, after Jack Nicholson’s character finds a doctor to care for her son, the doctor asks if the standard scratch test for allergies has been done. To the doctor’s amazement, Hunt’s character says she was told that the test was not covered by her plan. The exasperated Hunt utters the line "F---ing HMO, b------ pieces of s---. I’m sorry... forgive me," to which the new doctor responds, "No. Actually, I think that’s their technical name." News reports have suggested that many audiences have broken into spontaneous applause during that scene.

Are things this bad? What exactly are people saying about managed care? The August-September Kaiser/Harvard asked people to evaluate the job performance of some different kind of groups in serving the needs of health care consumers. Here again, significant numbers did not have opinions about HMOs (27 percent said they didn’t know or refused to answer) or managed care health plans (32 percent).

Those surveyed thought that nurses (83 percent), doctors (69 percent), pharmaceutical or drug companies (62 percent), and hospitals (61 percent) were doing a good job in serving health care consumers. Fewer, 44 percent, felt that way about health insurance companies (32 percent said they were doing a bad job). Slightly more than a third of those surveyed, 36 percent, reported that HMOs were doing a good job (25 percent said they were doing a bad job) and 34 percent felt that way about managed-care health plans (21 percent reported they were doing a bad job). More people in managed care than in traditional care said HMOs were doing a good job (46 to 29 percent,) and roughly equal numbers of those in managed care and traditional care said HMOs were doing a bad job (25 and 27 percent) ( Table 11).

 Table 12 shows the responses to a question that asks people to put aside their own health care and talk generally about HMOs. Fifty-nine percent in the August-September Kaiser/Harvard survey said that during the past few years, HMOs and other managed care plans have made it harder for people who are sick to see medical specialists (25 percent said it was easier). Fifty-one percent said that HMOs decreased the quality of health care for people who are sick (32 percent said they increased it). Forty-five percent said that HMOs decreased the quality of care (32 percent increased). Sixty-one percent said that HMOs had decreased the amount of time spent with patients and only 16 percent felt that the time had increased. The one plus for HMOs in the survey came on the issue of preventive care. Forty-six percent said HMOs and other managed-care plans had made it easier to get preventive services, but 31 percent said that was harder, too. In only one instance in this battery of questions did Kaiser/Harvard offer a category "hasn’t made much difference." Twenty-eight percent said that HMOs had helped keep costs down, but 55 percent said they hadn’t made much difference ( Table 12). Most people in managed care in the ABC and Roper polls, however, report being generally satisfied with their health care services, quality, and availability.

Once in 1995, twice in 1996, and once in 1997, Louis Harris and Associates asked whether, on the whole, people thought that the trend away from traditional fee-for-service coverage and toward more managed care was a good or a bad thing. In 1997, those surveyed split evenly, 44 percent responding good, 44 percent bad. In 1995, 59 percent had thought this was a good thing, and 28 percent a bad thing ( Table 13).

Harris went on to inquire whether people thought that the trend toward managed care would help contain costs, would improve or harm the quality of care, and would make health care plans more responsive to consumers.  Table 14 shows the results. A bare majority in 1997 (51 percent) felt that the trend would help to contain health care costs, but 42 percent said the changes would not help. The proportions in 1995 were 59 and 31 percent. A majority (54 percent), up from 39 percent in 1995, said that the trend would harm the quality of medical care for people like themselves. In March 1996 and in August 1997, 52 and 55 percent, respectively, said that the trend would not make their health care plan more responsive to them as the customer.

To understand current attitudes about how the health care system is performing, it’s also useful to consider how people’s views of institutions with responsibility in the area have changed over time. For several decades, three major survey organizations have asked about confidence in central institutions such as the military, the educational system, Congress, and the scientific community. In 1966, Louis Harris and Associates began asking whether people had a great deal, only some or hardly any confidence in those running "medicine." Twenty-five years ago, 60 percent had a great deal of confidence in medicine, 33 percent had only some, and just 6 percent had hardly any. Twenty years ago, in 1978, those numbers were 39, 47, and 11 percent. Ten years ago, in 1988, 40 percent had a great deal of confidence, 48 percent only some, and 11 percent hardly any. In early 1998, the numbers were 36, 48, and 15 percent, respectively. The number having hardly any confidence in medicine, then, has more than doubled in twenty-five years, but still only 15 percent feel that way.

The National Opinion Research Center’s question about medicine has been asked for twenty-five years. In 1973, 54 percent had a great deal of confidence, 39 percent only some, and 6 percent hardly any. In 1996, the last time the question was asked, the numbers were 45, 45, and 9.

From 1993 to 1997, Gallup inquired about "the medical system." At a time of substantial press coverage of health care in 1993, 34 percent said that they had a great deal or quite a lot of confidence in the medical system, 34 percent said they had some, and 31 percent, very little or none. In 1997, those percentages were 38, 38, and 23 percent, respectively.

In NORC’s 1996 ranking, more people expressed a great deal of confidence in medicine than expressed that level of confidence in any other of the thirteen major institutions surveyed. For the Harris, medicine ranked third among fourteen institutions surveyed in terms of a "great deal of confidence" in 1998. The Gallup picture was quite different. In terms of a great deal or quite a lot of confidence, the medical system ranked ninth of fifteen institutions, behind small business, the military, the police, the church, the Supreme Court, the presidency, banks, and the public schools. All three organizations show small upturns in confidence in this area since 1993 ( Table 15).

The Media’s Message

Where do people get their information about managed care? In the Kaiser/Harvard August-September survey, those who said that HMOs did a good job in serving health care customers (36 percent of the sample) were asked to identify the main reason why they felt that way. A near majority chose the response of "their own experience," and 29 percent cited the experience of friends and family. Just 17 percent reported getting their news from television, newspapers, or other media. Of those who thought HMOs did a bad job (25 percent of the sample), the results were not much different. Asked the main reason why they felt HMOs did a bad job serving consumers, 42 percent cited their own experience, 32 percent the experience of friends and family, 18 percent the media.

Many public opinion surveys have documented that Americans get most of their news from television. In a March 1997 Roper Starch Worldwide survey for ABC, CBS, and NBC, 69 percent said they got most of their news about what’s happening from television, 37 percent said newspapers, 14 percent radio, and 5 percent magazines. A survey by Roper Starch Worldwide for the National Health Council taken between August and October of 1997 asked people about their "primary sources of medical and health news, that is, the ones from which you most often get medical and health news." Many people mentioned more than one source, but in terms of net responses, 40 percent mentioned television, 39 percent health care professionals, 35 percent magazines or journals, 16 percent daily local and national newspapers, and 7 percent friends, family, and colleagues. In this regard it is interesting to look at how managed care is generally covered by television.

The Kaiser Family Foundation commissioned a comprehensive study of media coverage of managed care for the period 1990 to 1997 (Princeton Survey Research Associates did the content analysis) and found that even though the tone of coverage had become more negative over time, "the vast majority of media coverage [of managed care] is neutral." Eleven percent of it was positive in tone, 64 percent neutral, and 25 percent critical. But the picture was much different for broadcast news (defined by the authors as stories broadcast on the ABC , CBS, and NBC evening news programs). Nineteen percent of stories had a positive tone, just 26 percent a neutral tone, and a full 55 percent adopted a critical tone. Sixty-two percent of broadcast pieces were 2.5 minutes or longer. As the authors of the study point out, "any story that is more than 2.5 minutes long represents 10 percent or more of the news presented in a half-hour network broadcast, excluding commercials." Special series coverage in newspapers conveyed negative coverage more than half of the time, too.

What Do People Want?

In its December survey, Kaiser/Harvard asked people how much regulation they thought was necessary to protect consumers’ interests in five areas. All involved health or safety, and not surprisingly, people wanted a strong role for government. Sixty-four percent said that a lot of regulation was necessary in food safety, 61 percent in airline safety, 57 percent for environmental hazards, 46 percent for health plans and health insurance, and 44 percent auto safety. For all of the areas, no more than 14 percent responded that very little or no regulation was needed ( Table 16).

In a separate question, 41 percent said they felt that current government regulation of health insurance and health plans was very or somewhat effective in protecting consumers interests. Larger proportions felt that government regulation was effective in food safety (76 percent), environmental safety (64 percent), auto safety (82 percent), and airline safety (66 percent).

But these views of the importance of government’s role collide with contemporary skepticism about the federal government. Americans want a lot from government as surveys about health care and other areas show, but the weight of survey evidence today shows that people think of government as a problem causer, not a problem solver. A poll from CBS News and the New York Times illustrates. In January 1998, 87 percent of those surveyed said that the government can have a positive impact on people’s lives. But in the same poll, in response to another question, just 31 percent thought that it was having a positive impact on most people’s lives today. Other surveys underscore increased skepticism about government. In 1958, 43 percent of those surveyed by the University of Michigan said that people in government waste a lot of the money we pay in taxes. In 1996 that response was 60 percent. In 1958, 73 percent said that they thought they could trust the government in Washington to do the right thing most of the time or just about always. When Gallup repeated that question in February 1998, just 39 percent gave that response.

In its August-September survey, when people were asked by the Kaiser/Harvard team which of several entities they would most like to see regulate the operations of HMOs and other managed care plans, 34 percent chose an independent non-profit organization, 19 percent chose the federal government, and 18 percent the state government. Sixteen percent did not want them regulated at all ( Table 17).

In its December survey, 57 percent thought that a non-government independent organization should have the main responsibility for protecting consumers in managed care, and 23 percent thought that the government should do it. Just 15 percent thought that the managed care industry itself should have this responsibility ( Table 18). In a follow-up question, 50 percent said that self-monitoring by the managed-care industry would be very or somewhat effective in making sure consumers in HMOs and other managed-care plans were treated fairly and got proper care, but 46 percent said that this would be not too effective or not at all effective. Fifty-five percent thought that "government, which would develop and enforce regulations that managed care must follow" would be effective, but 41 percent said that this kind of government involvement would not be effective. Sixty-nine percent felt that "non-government, independent organizations which would develop and enforce standards that managed-care plans must follow" would be effective, and only 26 percent thought this would not be effective.

Three times in the past three years, Kaiser/Harvard has asked people to respond to this statement: "Some people say that new government regulation is needed to protect consumers from being treated unfairly and not getting the care they should from managed care plans. Others say this additional regulation isn’t worth the cost because it would raise the cost of health insurance too much for everyone. Which position comes closer to your own view?" In December 1997, the public split pretty evenly, with 44 percent choosing the first statement, and 47 percent the second ( Table 19). The hesitation people have about new government regulation in this question and others is driven in part by people’s concerns about cost, but it also speaks to powerful reservations people have today about the federal government’s performance.

The Kaiser/Harvard team also probed people’s reactions to a number of elements in the president’s consumer bill of rights. They began by asking about the measures in the abstract, and not surprisingly, as  Table 20 shows, they found very substantial support for them. But they followed up the questions by asking people if they would still favor each proposal if it resulted in an increase in insurance premium costs, and separately, if the measure would get the government too involved in health care, and finally, if it would result in employers dropping coverage for employees. The change in responses was dramatic. Eighty-eight percent in the initial question supported a law requiring health plans to allow those whose claims had been denied to appeal them to an independent reviewer. But far fewer--63 percent--still supported the legislation if it might result in increased costs, 51 percent if it would get the government more involved in health care, and 49 percent if it would result in employers’ dropping coverage. The exercise reveals deep reservations about what the federal government can do successfully in this area, and it also reinforces the argument presented above about widespread concern with cost.

Another question in the Kaiser/Harvard survey showed that 72 percent of those surveyed supported the President’s consumer bill of rights legislation. But an additional question showed that 43 percent would still favor the consumer bill of rights if their premium increase was in the range of $1-$5 a month. Only 28 percent would still support the legislation if the premium increase were larger ($15-$20 a month). Additional everyday expenditures of other kinds could dampen enthusiasm for increased cost even more.

Louis Harris and Associates in its 1997 survey for the Kaiser Family Foundation and the Commonwealth Fund asked this question about cost: "New funds may be needed to pay for improved health care coverage. Would you support an increase in income taxes or not?" Just 37 percent of the national sample (35 percent of the insured) said they would, while 60 percent of the national sample said they would not. In another question, 42 percent nationally said they would support an increase in sales taxes, but 55 percent would not. Forty-five percent would support an increase in insurance premiums paid by employers and employees, but 49 percent would not. Forty-one percent would support an increase in the payroll tax, but 55 percent would not.

Conclusion

Change is always unsettling, but in an area such as health care, where many people consider themselves medically illiterate or unsophisticated, it can be downright frightening. The horror stories of botched care reported by the news media add to the fear factor and the emotionalism surrounding the issue. In an area as sensitive as this one, then, it is hardly surprising that these stories as well as tales of irritation and frustration resonate in the White House, Congress, and statehouses.

Still, the early survey findings suggest that there is little evidence of widespread or serious dissatisfaction with health care arrangements among those who have coverage. Large majorities of those in managed care would recommend their plans to others. Although Americans favor many reforms in the abstract, they are considerably less enthusiastic about changes that would raise the cost of their health insurance premiums, get the government more involved in the area, or cause employers to cut back on coverage. They aren’t confident about managed-care operations’ ability or willingness to police themselves, but they aren’t confident about the federal government’s responsiveness or effectiveness either. Americans are generally averse to big bureaucracies, whether they be in the form many expected the original Clinton plan to take or in the form of private managed-care regimes.

None of this is to say some reforms aren’t necessary and desirable. But if we get the diagnosis wrong, the cure won’t work.

Karlyn Bowman is a resident fellow at the American Enterprise Institute. This paper was written for AEI’s Program in Health Policy Studies.

Notes

1. Many people are not familiar with health care terminology, and many people do not know what kind of coverage they have. So, most pollsters provide descriptions of various kinds of care. ABC News describes the kind of care people who have private coverage might have this way: "There are three main types of private health insurance. There are traditional fee-for-service plans where you can go to any doctor you want and the insurance company pays part of the cost. There are Preferred Provider Organizations which pay higher reimbursement if you go to a doctor on the insurance company’s list. And there are Health Maintenance Organizations, or HMOs where you can only go to HMO doctors and nearly all costs are covered. Which type of plan do you have?"

2. In 1988, Roper began asking those with health insurance whether they had an "HMO, Preferred Provider Organization (PPO), POS [Point of Service], or other managed care plan where you have a limited choice of doctors." Twelve percent said they did in 1988, and 42 percent gave that response in December 1997. In April 1993, Roper added several new categories including "traditional health insurance plan where you can choose any doctor you want." The number with traditional fee-for-service care declined from 42 percent in 1993 to 26 percent in 1997.

3. The data come from Harris surveys conducted in 1994 and 1995. The data were pooled to allow comparisons of sick persons in managed care and in fee-for-service plans. The quote is from an article in Health Affairs (Volume 15, Number 2) that summarized the findings.