Healthcare and the American Public

Dear Friends and Colleagues;

Americans say that high costs and the lack of insurance and access to care are the most pressing health care problems for government to address, Robert Blendon and coauthors report in an article published October 17 as a Health Affairs Web Exclusive.
Writing a month before the 2006 congressional election, the researchers also say that health care overall is a "second-tier issue" for the American public, ranking behind Iraq, the economy, and gasoline prices as a priority for government action. However, health care still ranks higher today than issues such as education, the environment (including global warming), Social Security, poverty, and crime.


Understanding The American Public’s Health Priorities: A 2006 Perspective

Health issues are on Americans’ minds,but they are not the top priority in 2006.


by Robert J. Blendon, Kelly Hunt, John M. Benson, Channtal Fleischfresser, and Tami Buhr


ABSTRACT:

Opinion surveys conducted in 2006 show that health care is an important but second-tier issue in terms of priorities for government action. Americans’ top health care concerns are mostly related to economic insecurity: rising costs and the problems of the uninsured. The biggest perceived health threats are cancer, HIV/AIDS, and avian flu. Although most Americans do not think that the health system is in crisis, the public remains dissatisfied with both the country’s health care and public health systems. These attitudes are likely to create a climate that is supportive of increased health spending and substantial policy changes. [Health Affairs 25 (2006): w508–w515 (published online 17 October 2006; 10.1377/hlthaff.25.w508)]

This is the fifth in a series of essays published by Health Affairs examining Americans’ health and health care priorities.1 As in our earlier reviews of this subject, findings show that the American public has a clear set of priorities for the country, which have changed over time in response to specific events and the emergence of new health concerns. Public priorities typically emerge either when an issue is high on policymakers’ agendas and written up regularly in the popular press or when it represents a serious, real-life problem that people experience. Immigration, for example, rose to become one of the top three public priorities in April 2006, while it was high on policymakers’ agenda and written about daily in the newspapers.2 On the other hand, some issues, such as health care, that are part of people’s everyday lives remain much more enduring concerns in poll findings.

The Role Of Public Opinion

Over the past thirty-five years, there has been a huge jump in the number of polls conducted by decisionmakers in U.S. society, to monitor public opinion on a variety of topics.3 These include polls paid for by the media, political parties and leaders, interest groups, and foundations.4 Studies have shown that politicians continually monitor public opinion, attempt to shape it, and enlist it to gain leverage over other political actors. For example, research shows that polling done for U.S. presidents has gone from a relatively rare activity to a continuous information-gathering effort.5 Public opinion surveys provide politicians with information about what their constituents want across a wide variety of issues. This might lead them to be more responsive to general public opinion or to some subset such as members of their own political party or so-called swing voters.

Notwithstanding this substantial increase in monitoring of public opinion by decisionmakers, the role that public opinion actually plays in leaders’ ultimate policy decisions is not completely clear. There is general but not complete consensus among political scientists that public opinion plays a role in government decision making in certain circumstances and on certain issues, but not in all. But there is no agreement among all scholars about the particular circumstances and issues where decisionmakers pay attention to or ignore public opinion.6 What the research does show is that if an issue is salient to the public (a subject we examine in this paper), decisionmakers are more likely to pay attention to public opinion than they are for issues that are not very salient to the public.7

Research has shown that both the president and Congress respond to public opinion on issues that rank high in public concern or that people confront in their day-to-day lives.8 Health care is one such issue. Decisionmakers show greater responsiveness to public opinion when determining government spending on health care than in policy areas that are more remote from people’s daily lives, such as foreign aid.

In this paper we examine Americans’ health priorities along six dimensions: (1) the relative importance of health care as an issue for government to address, (2) the top health care issues for government, (3) views on national health spending and health care costs, (4) current ratings of the health care system and personal experiences with health care, (5) top general health concerns for future government action, and (6) ratings of the nation’s public health system and the general health conditions in their communities.

Study Data And Methods

To present a comprehensive picture of the public’s health priorities in 2006 and the changes that have taken place over time, this paper analyzes polling results from nineteen national opinion surveys conducted between 1940 and 2006. We pay particular attention to trends since the time of the Clinton health reform plan (early 1990s).

The survey data are from two main sources. The first consists of two Harvard School of Public Health/Robert Wood Johnson Foundation polls. International Communications Research (ICR) conducted fieldwork for both polls via telephone. For “Americans’ Views of the Healthcare System,” ICR conducted interviews 5–9 April 2006 with a nationally representative sample of 1,108 adults (age eighteen and older). For “Americans’ Views of Public Health,” ICR conducted interviews 31 March–4 April 2006 with a nationally representative sample of 1,107 adults. The margin of error for the total samples in each survey was plus or minus three percentage points at the 95 percent confidence level.9

The second source consists of seventeen other national opinion surveys that contain current and historical data. The criteria for inclusion in the paper are that the poll questions (1) reflect the public’s current priorities and the salience of the issues; (2) are the most current on a particular issue; or (3) represent trends that shed light on the public’s views and priorities over time. A number of organizations conducted these polls: Harris Interactive, Gallup, ABC News/Washington Post, the Pew Research Center, and the National Opinion Research Center/General Social Survey. All of the surveys were conducted by telephone, except for a 1940 Gallup poll and the General Social Survey, which were conducted in person. The sample sizes range from 1,000 to 1,500. The margin of error (at the 95 percent confidence level) for a sample of 1,000 is plus or minus three percentage points; for a sample of 1,500, it is plus or minus 2.5 points.

Survey Findings

Relative importance of health care as an issue for government to address. Elected officials can work on only a limited number of major issues at one time. To ascertain what the public thinks the priorities for government action should be, respondents were asked in August 2006 to say in their own words what they considered the top two issues for government to address. The results suggest that in terms of priority for government action, health care is a second-tier issue (Exhibit 1). Today it ranks as the fourth most important issue for government to address, behind the war, the economy, and gasoline/oil prices/energy. This is a lower ranking for health care than in 1993, a time of major national debate about health care reform. In the 2006 survey, health care was one of the top two issues for 13 percent of the population. This compares to 31 percent in 1993, when it was ranked second, and 9 percent in 2002, when it also ranked fourth.10
The list of the most important issues for government to address often corresponds the public’s ranking of issues that they say will be most important in their voting choices. In August 2006, health care ranked fourth when respondents were asked which of six issues would be most important in their vote for Congress. Once again, health care ranked behind Iraq, the economy, and gasoline prices, but ahead of terrorism and education.11

Of note, although health care is not among the top-priority issues for government action, it ranks higher today than many other national problems often identified as being very important. Health care issues rank higher than terrorism, the top issue in late 2001, as well as education, the environment (including global warming), Social Security, poverty, crime, and problems in the developing world.12 This consistent rating of health care among the top four concerns signifies that it is an issue of ongoing concern for the public, regardless of how high a priority policymakers make it.

Top health care issues. More specifically, respondents were asked to say, again in their own words, what they thought were the two most important health care problems that government should address. Health care costs and the lack of insurance/access to care were the most frequently cited (Exhibit 2). Medicare and the prescription drug benefit, the subject of current national attention, ranked third but well behind these other two. Quality of care, an issue of considerable concern to many national health policy leaders, ranked fourth.13

These priorities correspond with the public’s assessment of the state of health care in the country. In November 2005, only 20 percent of Americans were satisfied with the cost of health care, and only 21 percent rated health care coverage in this country as excellent or good.14 In April 2006, about four in ten Americans (41 percent) approved of the Medicare prescription drug program.15 And in November 2005, just over half (53 percent) rated the quality of health care in the United States as excellent or good.16

Views on national health spending and health care costs. Multiple survey results show that the public favors increased health spending in the years ahead but is concerned about the impact of rising health care costs on the financial situation of American families. In 2004, 78 percent of the public thought that national spending to improve health was too low; only 4 percent said that it was too high.17 Similarly, in 2006 a survey asked specifically about overall national spending on health care and national health care spending by government. The majority of respondents (57 percent) thought that the United States as a country was spending too little on health care in the aggregate, and 70 percent said that government health care spending was too low. Only 26 percent thought that the country as a whole was spending too much, and 11 percent thought that the government was spending too much. Around one-tenth of Americans thought that these spending levels were “about right” (9 percent, nation as a whole; 11 percent, government).18

What concerns Americans is not aggregate spending, but the perceived negative impact on American families of their direct health care outlays (insurance premiums, copayments, deductibles, and direct payments for services and products). When asked about spending for health care by average Americans in 2006, 65 percent of respondents said that the average American spends too much, while only 17 percent said too little.19 (Twelve percent felt that the level of spending was “about right.”) This is what Americans mean when they list health care costs as the top health care priority for government action.

Ratings of the health care system and their own care. As of spring 2006, most Americans were dissatisfied with the state of the U.S. health care system. About seven in ten respondents (69 percent) rated the nation’s system for providing medical care as fair or poor (Exhibit 3).20 Furthermore, in August 2006, only about four in ten respondents expressed “a great deal” or “quite a lot” of confidence in the health care system, a level that has remained relatively constant for more than ten years.21

Although the public is critical of the health system, only 22 percent think that it is in a state of crisis. However, this is a much higher proportion than in 2002 (11 percent). Most people think that the system has major problems, a view that has remained relatively stable since 1994 (Exhibit 4).22

In contrast to their views on the health system, most Americans are satisfied with their own most recent medical care experiences. Three-fourths of respondents had received medical care in the past year. Of those who received care, more than four in five people said that the services (84 percent) and physician care (85 percent) they received were excellent or good.23 This pattern has appeared in multiple surveys in previous years.24

A likely reason for the difference in opinions about the overall health system versus personal health care experiences could be that general health system questions tend to measure broader public concerns about the insecurity of health insurance coverage, high prices, bureaucracy, waste, and disparities in access to care in the United States. Measures of personal experiences are narrower and reflect individuals’ mostly positive recent experiences with care received from doctors and nurses; they do not take into account these other perceived societal problems.

Top general health concerns for government action. Respondents were also asked to state in their own words what they thought were the two most important diseases or health conditions for government to address. Cancer (51 percent) and HIV/AIDS (41 percent) were the top two health priorities stated.25 Smaller percentages also identified avian flu (21 percent), heart disease (16 percent), and diabetes (11 percent) as top priorities. Of interest, a parallel question asked respondents about the diseases and health conditions that posed the greatest threats to the American public. On this question, the rankings were essentially identical to the findings about priorities for government action, except that obesity tied with diabetes for fifth place. This suggests that a share of the public sees obesity as a serious national health concern but not as a current top priority for government action (3 percent), even though almost half (47 percent) see obesity as a major problem in their communities.26

Of historical note, these health priorities can change markedly over long periods of time. In 1940, Americans were asked to name the most serious health problem from a list of diseases considered very important at the time. Syphilis was the public’s top concern (46 percent), followed by cancer (29 percent), tuberculosis (16 percent), and polio (9 percent).27

Ratings of the public health system and health conditions in their communities. The country faces a number of public health threats that have emerged since 2001, such as severe acute respiratory syndrome (SARS), anthrax, smallpox, avian flu, and obesity. These threats have raised concerns about the adequacy of the U.S. public health system. When asked their assessment, the majority of respondents reported that they were not satisfied with the nation’s current system for protecting the public from these threats and preventing illness. Just over half of respondents rated the public health system as fair or poor, while fewer than half rated it as excellent or good (Exhibit 3).28

More Americans report satisfaction with the public health conditions in their own communities than with the overall public health system. About three-quarters of respondents gave excellent or good ratings to the quality of life in their communities (76 percent). The majority gave excellent or good ratings to the quality of emergency services such as police, fire, and ambulance (78 percent), as well as to air quality (69 percent), the availability of preventive health services (69 percent), the quality of drinking water (67 percent), and the availability of recreational facilities (65 percent). In addition, respondents were asked about whether health conditions in their community had changed during the last two years. Almost seven out of ten (69 percent) reported no change. Relatively small percentages thought that conditions had gotten better (14 percent) or worse (13 percent).29

Discussion And Conclusions

Most U.S. news coverage about medical care issues during the past year has concentrated on Medicare’s new prescription drug benefit, while many in the research and professional community have focused on the nation’s quality-of-care problems. What is important to recognize is that these are not the American public’s top health care priorities today. Americans want their government to do something about their rising health care costs and the problems of the uninsured. When Americans talk about health care costs, however, their concern is not for the share of the nation’s gross domestic product (GDP) going toward health care, but rather the financial impact on their own families.

Also important to recognize is that cancer and HIV/AIDS are the public’s top priorities as health threats that they want government to address. Even though there have been no human cases of avian flu in the United States, that emerging disease has now joined this list. Cancer has remained a major health concern to the American public for more than sixty years. Although there have been major medical advances in cancer care, it is still an issue that worries many Americans.

Another issue that could become more important to the public in the future is obesity. Although it has emerged as a major concern for the public in general and in their communities, the government role in obesity prevention is unclear for many Americans. This could change over time, as obesity receives more attention from the media and health professionals.

The public considers the wars in Iraq and Afghanistan to be the top issues for government. But the survey findings also indicate that from a public perspective, health issues are very likely to remain prominent on the national agenda. Although health care is not the top issue for Americans, it consistently ranks among the top five issues for government to address. In addition, contrary to the concerns of many experts, the public continues to favor more rather than less health spending in the aggregate.

Moreover, although most Americans do not think that the health system is in crisis, the public remains dissatisfied with the country’s health care and public health systems. These attitudes are likely to create a climate supportive of both increased health spending and substantial change in the years ahead.

This work was supported by a grant from the Robert Wood Johnson Foundation. The views expressed are solely those of the authors, and no official endorsement by the sponsor is intended or should be inferred.

NOTES

1. R.J. Blendon et al., “Americans’ Health Priorities: Curing Cancer and Controlling Costs,” Health Affairs 20, no. 6 (2001): 222–232; R.J. Blendon et al., “Americans’ Health Priorities Revisited after September 11,” Health Affairs 20 (2001): w96–w99 (published online 13 November 2001; 10.1377/ hlthaff.w1.96); R.J. Blendon et al., “The Impact of Terrorism and the Recession on Americans’ Health Priorities,” Health Affairs 21 (2002): w420–w425 (published online 17 January 2002; 10.1377/ hlthaff.w2.420); and R.J. Blendon et al., “The Continuing Legacy of September 11 for Americans’ Health Priorities,” Health Affairs 21 (2002): w269–w275 (published online 14 August 2002; 10.1377/hlthaff.w2.269).
2. Harris Interactive, “President Bush’s Job Approval Ratings Remain Low,” Harris Poll no. 30, 19 April 2006, http://www.harrisinteractive.com/harris_poll/index.asp?PID=654 (accessed 13 September 2006).
3. J.G. Geer, From Tea Leaves to Opinion Polls: A Theory of Democratic Leadership (New York: Columbia University Press, 1996).
4. Our search of the iPOLL database at the Roper Center for Public Opinion Research, the country’s largest archive of public opinion data, found a steady growth in the number of polling questions asked during each successive election cycle: from 8,752 questions in 1980, to 14,132 in 1988, to 19,458 in 1996, to 22,448 in 2004. See also E.C. Ladd and J.M. Benson, “The Growth of News Polls in American Politics,” in Media Polls in American Politics, ed. T.E. Mann and G.R. Orren (Washington: Brookings Institution, 1992), 19–31.
5. R.M. Eisinger, The Evolution of Presidential Polling (Cambridge: Cambridge University Press, 2003).
6. J. Manza, F.L. Cook, and B.I. Page, eds., Navigating Public Opinion: Polls, Policy, and the Future of American Democracy (Oxford: Oxford University Press, 2002); R.S. Erikson, G.C. Wright, and J.P. McIver, Statehouse Democracy: Public Opinion and Democracy in American States (New York: Cambridge University Press, 1993); L.R. Jacobs and R.Y. Shapiro, Politicians Don’t Pander: Political Manipulation and the Loss of Democratic Responsiveness (Chicago: University of Chicago Press, 2000); A.D. Monroe, “Public Opinion and Public Policy: 1980–1993,” Public Opinion Quarterly 62, no. 1 (1998): 6–28; and J.A. Stimson, M.B. MacKuen, and R. Erikson, “Dynamic Representation,” American Political Science Review 89, no. 3 (1995): 543–565.
7. B. Canes-Wrone and K.W. Shotts, “The Conditional Nature of Presidential Responsiveness to Public Opinion,” American Journal of Political Science 48, no. 4 (2004): 690–706; J. Manza and F.L. Cook, “A Democratic Polity: Three Views of Policy Responsiveness to Public Opinion in the United States,” American Politics Research 30, no. 6 (2002): 630–667; and C. Wlezien, “Patterns of Responsiveness: Dynamics of Public Preferences and Policy,” Journal of Politics 66, no. 1 (2004): 1–24.
8. B. Canes-Wrone, Who Leads Whom? Presidents, Policy, and the Public (Chicago: University of Chicago Press, 2006); Canes-Wrone and Shotts, “The Conditional Nature”; and Wlezien, “Patterns of Responsiveness.”
9. Harvard School of Public Health/Robert Wood Johnson Foundation, “Americans’ Views of Public Health” poll (Storrs, Conn.: Roper Center for Public Opinion Research, 31 March–4 April 2006); and HSPH/RWJF, “Americans’ Views of the Healthcare System” poll (Storrs, Conn.: Roper Center, 5–9 April 2006).
10. For 1993 and 2002, Harris Interactive, “The National Mood Changes as Ratings of Bush, Cabinet Members and the Congress Fall Sharply—TABLES,” Harris Poll no. 34, 24 July 2002,
http://www.harrisinteractive.com/harris_poll/tables/ 2002/july_24_2002.htm (accessed 13 September 2006); for 2006, Harris Interactive, “Democrats Continue to Hold Substantial Lead over Republicans in Race for Congress,” Harris Poll no. 63, 11 August 2006,
http://www.harrisinteractive.com/harris_poll/index.asp?PID=689 (accessed 13 September 2006).
11. ABC News/Washington Post poll (Storrs, Conn.: Roper Center, 3–6 August 2006).
12. Harris Interactive, “President Bush’s Job Approval Ratings Remain Low”; for 2001 results, see Blendon et al., “The Continuing Legacy,” w270.
13. HSPH/RWJF, “Americans’ Views of the Healthcare System” poll.
14. Gallup poll (Storrs, Conn.: Roper Center, 7–10 November 2005).
15. ABC News/Washington Post poll (Storrs, Conn.: Roper Center, 6–9 April 2006).
16. Gallup poll, 7–10 November 2005.
17. J.A. Davis and T.W. Smith, General Social Survey (Chicago: National Opinion Research Center, 2004).
18. Pew Research Center for the People and the Press poll, “March 2006 News Interest Index, Final Topline,” 8–12 March 2006, http://people-press.org/reports/questionnaires/273.pdf (accessed 13 September 2006).
19. Ibid.
20. HSPH/RWJF, “Americans’ Views of the Healthcare System” poll.
21. Gallup Poll, “Confidence in Institutions” (Princeton, N.J.: Gallup Organization, 14 August 2006).
22. Gallup polls (Storrs, Conn.: Roper Center, 6–7 September 1994, 11–13 September 2000, 11–14 November 2002, 3–5 November 2003, 7–10 November 2005); and HSPH/RWJF poll (Storrs, Conn.: Roper Center, 10–15 August 2006).
23. HSPH/RWJF, “Americans’ Views of the Healthcare System” poll.
24. R.J. Blendon, M. Brodie, and J.M. Benson, “Health Policy,” in Polling America: An Encyclopedia of Public Opinion, ed. S.J. Best and B. Radcliff (Westport, Conn.: Greenwood Press, 2005), 289–291.
25. HSPH/RWJF, “Americans’ Views of Public Health” poll.
26. Ibid.
27. Gallup poll (Storrs, Conn.: Roper Center, 8–13 March 1940).
28. HSPH/RWJF, “Americans’ Views of Public Health” poll; and HSPH/RWJF, “Americans’ Views of the Healthcare System” poll.
29. HSPH/RWJF, “Americans’ Views of Public Health” poll.

Robert Blendon (rblendon@hsph.harvard.edu) is a professor of health policy and political analysis at the Harvard School of Public Health (HSPH) in Boston, Massachusetts. Kelly Hunt is senior program director at the New York State Health Foundation, in New York City. At the time the study was conducted, she was a research officer at the Robert Wood Johnson Foundation in Princeton, New Jersey. John Benson is managing director, Channtal Fleischfresser is a research assistant, and Tami Buhr is assistant director at the Harvard Opinion Research Program, HSPH.

DOI: 10.1377/hlthaff.25.w508