Presents results of a survey on the healthcare system, priorities for reform, and views on the uninsured, a public insurance plan, and individual mandates, compared with other surveys. Analyzes how the way reform elements are described affects responses

John M. Benson

Kathleen J. Weldon

Robert J. Blendon

English

IssueLab

        HARVARD SCHOOL OF PUBLIC HEALTH       Robert Wood Johnson Foundation Health Priorities Survey Report  THE MEDICAL SYSTEM AND THE UNINSURED  June 2009      SUMMARY AND TOPLINE RESULTS             Robert J. Blendon, Harvard School of Public Health, Project Director John M. Benson, Harvard School of Public Health Kathleen J. Weldon, Harvard School of Public Health          HARVARD SCHOOL OF PUBLIC HEALTH 2  Americans’ overall priorities for the nation Health care is near the top of the American public's priorities for government action. Health care is considered one of the two most important issues for the government to address by 31% of the population, making it the public’s second highest priority. Health care is substantially behind the highest priority, the economy.   The ranking of health care as a priority is the same now as it was in 1993, when there was a large national debate about health care reform. What is different now is the even greater emphasis the public gives to the economy (Tables 1a and 1b).   Americans rate the medical care system In 2009, most Americans remain dissatisfied with the state of the U.S. medical care system. Sixty-nine percent of Americans rate the nation’s system for providing medical care as “fair” or “poor” (Table 2). While 20% currently believe the system is “good,” only 8% see it as “excellent.”   Although most Americans do not rate the nation’s health care system highly, only about one in five believe it is in crisis. A majority see it as having major problems (Table 3).  About the same proportion (34%) of Americans today as in 1993 believe that the health care system has so much wrong with it that it should be completely rebuilt (CBS New/New York Times poll, June 2009 and Kaiser Family Foundation/Commonwealth Fund/Harris poll, August 1993) (Table 4).  Most important problems with the medical care system When respondents are asked about the most important problems with the medical care system, about six in ten Americans cite health care costs as one of the top two problems, while about four in ten name lack of insurance or access to care. These rankings are unchanged since 2008, but the percentage naming each of these issues as important problems is significantly higher this year than last year (Table 5).  However, when the public is asked to choose only between keeping health care costs down for average Americans and providing health insurance for Americans who do not have any, a majority says that the uninsured is a more serious problem (CBS News/New York Times poll, June 2009).  A national health insurance plan As one measure of Americans’ desire for change, we ask about their support for a generic national health insurance plan, financed by tax money, paying for most forms of health care. A majority (55%) say they favor such a plan, the same proportion as in 2008. The level of support for a national health insurance plan was nearly the same in 1993 (59%) (Table 6).    Individual mandate The idea of an individual mandate is relatively new in the U.S. Currently, such a system exists only in Massachusetts. The answers to polling questions about an individual mandate vary widely depending on whether they mention subsidies for people who cannot afford to buy insurance or penalties for those who do not comply. The Robert Wood Johnson Foundation survey uses a question similar to one asked in Massachusetts before the health reform act was passed in that state. Nearly six in ten Americans favor a law that requires everyone to have health insurance they buy themselves or get through an employer, similar to the law that requires drivers to have auto insurance. People who cannot afford to buy health insurance would get help from the government (Table 7).   HARVARD SCHOOL OF PUBLIC HEALTH 3  In an ABC News/Washington Post poll, about half of the public initially supports an individual mandate in a question that does not mention either subsidies or penalties. When asked if they would support such a law if it included a tax credit or other aid to help low-income people pay for health insurance, support goes up to 70%. However, when penalties for not getting or buying health insurance are mentioned (and subsidies are not), support drops to 44% (Table 8).  The lack of familiarity with the concept of an individual mandate is apparent in a recent CBS News/New York Times poll. After being read a description of an individual mandate with both subsidies and penalties, people were asked if they thought it was a good or bad idea, or if they were unsure. More than four in ten said they were unsure (Table 9).  Paying for health care  In this year's survey, nearly half of Americans who do not have health insurance report having had problems paying medical bills during the past year. However, most Americans who have insurance have not had problems paying. Overall, about one in four Americans report having had problems paying medical bills in the last 12 months (Tables 10 and 11).   About one in five people say that at some point over the last 12 months, they or a family member needed health care but did not get it; four in five of these respondents did not get care for financial reasons (Table 12).  Views about the uninsured Nearly two-thirds of Americans think that Americans not having health insurance is a bigger problem now than it was five years ago. This is a substantially larger proportion than in 2000 (Table 13).  On other views about the uninsured, however, little has changed since 2000. Most Americans still think the uninsured can get medical care, but they believe that the uninsured have problems getting it.   Nearly six in ten still believe that the uninsured in their community can get the medical care they need from doctors and hospitals. Only about one-third believe that the uninsured are unable to get medical treatment (Table 14). Among those who believe the uninsured can get medical care, six in ten believe that getting such care is difficult to do (Table 15). Just as in 2003, nearly two-thirds of the public believe that the care most uninsured people in their community get is not as good as the care the average insured person gets (Table 16). Among those who believe that uninsured people in their community cannot get medical care, nine in ten believe that most of those the uninsured who do not get care suffer health consequences, including half who believe they suffer serious consequences (Table 17).  Worries about the future This year's survey finds that significantly more insured people than last year are worried about losing their health insurance. Among Americans who have health insurance, about three in ten (29%) are worried that they will lose their health insurance coverage in the next six months. This is a significantly higher proportion than in 2008, when 21% were worried (Table 18). Hispanics are twice as likely as whites to be worried that they will lose their health insurance coverage (Table 19).   Most of those who are worried about losing their health insurance do so because of some financial concern. About two-thirds say that the possibility that their insurance might become too expensive  HARVARD SCHOOL OF PUBLIC HEALTH 4  (68%) or that they or a family member might lose their job (64%) are reasons they are worried about losing coverage. More than half (54%) say that the possibility they or a family member's employer might drop their coverage is a reason. Only about one-third mention a medical problem that could lead to their losing coverage (Table 20).   Methodology This study was prepared by the Harvard School of Public Health and the Robert Wood Johnson Foundation. This study was designed and analyzed by researchers at the Harvard School of Public Health. The project director is Robert J. Blendon of the Harvard School of Public Health. The research team also includes John M. Benson and Kathleen J. Weldon of the Harvard School of Public Health and Melissa J. Herrmann of ICR/International Communications Research.  Fieldwork was conducted via telephone by ICR/International Communications Research (Media, PA), June 17-20, 2009, with a nationally representative sample of 1,098 adults age 18 and over. Of those, a total of 116 were African American respondents and a total of 109 were Hispanic American respondents. The margin of error for the total sample was plus or minus 3.5 percentage points at the 95% confidence level.  Possible sources of nonsampling error include nonresponse bias, as well as question wording and ordering effects. Nonresponse in telephone surveys produces some known biases in survey-derived estimates because participation tends to vary for different subgroups of the population. To compensate for these known biases, sample data are weighted to the most recent U.S. Census data available from the Current Population Survey for gender, age, race, and education, as well as number of adults in the household. Other techniques, including random-digit dialing, replicate subsamples, callbacks staggered over times of day and days of the week, and systematic respondent selection within households, are used.    HARVARD SCHOOL OF PUBLIC HEALTH 5  Harvard School of Public Health/Robert Wood Johnson Foundation Health Priorities Survey 2009-1 Overall Results The Medical System and the Uninsured  June 17-21, 2009   The study was conducted for Harvard School of Public Health/Robert Wood Johnson Foundation via telephone by ICR, an independent research company.  Interviews were conducted from June 17-21, 2009, among a nationally representative sample of 1,098 respondents 18 years of age or older.  Of those, 116 are African American and 109 are Hispanic.  The margin of error is +/-3.5 percentage points at the 95% confidence level.   Now I'm going to ask you some questions about the nation's system for providing medical care to Americans.   MC-1 How would you rate the nation’s system for providing medical care to Americans?  Would you say excellent, good, fair or poor?    (ENTER ONE ONLY)   Excellent Good Fair Poor Don’t know Refused 6/21/09 8 20 34 35 2 * 3/30/08 7 22 30 39 2 * 4/18/07 8 25 31 32 4 *   HARVARD SCHOOL OF PUBLIC HEALTH 6   MC-2 What do you think are the TOP TWO problems with the nation’s MEDICAL CARE SYSTEM?   6/21/09 3/30/08 4/18/07 Health Care Costs (NET) 54 46 43  Cost/High cost (unspec) 26 27 23  Cost of prescription drugs 6 6 7  High cost of health care/services 16 7 8  High cost of insurance 12 9 8  Other health care costs 1 1 1 Insurance (NET) 35 23 23  Lack of benefits/medical coverage (poor coverage) 10 8 6  People who don’t have insurance 13 8 8  Insurance companies have too much control choosing drs./procedures, etc) 4 2 2  Medicare issues 3 1 2  Medicare/Medicaid * 1 *  Should have national health care plan 2 2 1  Health insurance (non spec) 1 2 2  Other insurance 5 3 4 Accessibility (NET) 16 16 12  Accessibility to health care for all 13 12 9  Accessibility to health care for poor  2 3 3  Accessibility to health care for elderly 1 1 1  Other accessibility * * -- Lack of Quality Health Care (NET) 13 13 16  Poor service from health care providers (too slow/rude, etc) 3 4 5  Lack of quality health care 6 5 9  Lack of medical professionals 3 4 2  Other lack of quality health care 1 1 1 Government Role in Health Care (NET) 4 4 5  Government (mismanagement/they should pay, etc) 1 * *  Government shouldn’t be in healthcare 3 1 2  Other government role in health care 1 3 3 Law suits 2 1 2 Organization of the system 1 2 1 Greed 3 2 2 Misallocated money/lack of funding 2 2 3 Prescription drug program -- 1 2 Illegal immigrants getting health care 2 2 3 Other 10 8 19 None 5 8 8 Don’t know 6 10 10 Refused -- 1 --   HARVARD SCHOOL OF PUBLIC HEALTH 7   MC-3 Which of these statements do you think best describes the U.S. health care system today—it is in a state of crisis, it has major problems, it has minor problems, or it does not have any problems?   In a state of crisis Has major problems Has minor problems It does not have any problems Don’t know  Refused 6/21/09 18 52 24 4 2 * 3/30/08 18 51 26 4 2 *   MC-4 Do you favor or oppose national health insurance, which would be financed by tax money, paying for most forms of health care?   Favor Oppose Don’t know Refused 6/21/09 55 38 7 * 3/30/08 55 35 9 1 4/18/07 61 30 9 *   MC-5 Do you favor or oppose having a law that requires everyone to have health insurance that they buy themselves or get through an employer?  This would be similar to the law that requires people who drive cars to have auto insurance.  People who cannot afford to buy health insurance would get help from the government to pay their health insurance premiums.   Favor Oppose Don’t know Refused 6/21/09 58 38 4 *   MC-6 In the past 12 months, have you had problems paying medical bills, or not?   Yes No Don’t know Refused 6/21/09 24 76 -- * 3/30/08 22 77 1 * 4/18/07 22 78 * --   MC-7 Was there a time over the past 12 months when you or another family member living in your household needed medical care, but did not get it?   Yes No Don’t know Refused 6/21/09 18 82 * * 3/30/08 17 82 1 * 4/18/07 17 83 * *   (Asked of total respondents who needed or had a family member who needed medical   care in the past 12 months but did not get it; n = 169)   MC-8 Was it mainly for financial reasons, or for some other reasons?   Financial Reasons Some other reasons Don’t know Refused 6/21/09 89 11 -- -- 3/30/08 85 12 2 -- 4/18/07 80 20 * --  HARVARD SCHOOL OF PUBLIC HEALTH 8  MC-7/MC-8 Combination Table   NO MEDICAL CARE Received Medical Care Don’t know Refused  NET Financial Reasons Some other reasons 6/21/09 18 16 2 82 * * 3/30/08 17 14 2 82 1 * 4/18/07 17 13 3 83 * *   READ TO EVERYONE:  Now I have some questions about the uninsured, that is, people without any health insurance at all.    MC-9 Compared to five years ago, do you think the problem of Americans not having health insurance is a bigger problem, less of a problem, or about the same?   Bigger Less About the same Don’t know Refused 6/21/09 63 4 31 2 * 8/30/00 47 10 37 7 *   MC-10 Do you think most people in your community without health insurance are unable to get medical treatment, or that these uninsured people are still able to get medical care they need from doctors and hospitals?   Unable to get medical treatment Still able to get medical care  Don’t know  Refused 6/21/09 34 58 7 * 8/30/00 31 57 11 *   (Asked of total who think people in community who are uninsured are still able to get medical   care; n = 661)   MC-11 Do you think it is very difficult, somewhat difficult, not very difficult, or not difficult at all for most people in your community who do not have health insurance to get the medical care they need?   Very Somewhat Not very Not at all Don’t know Refused 6/21/09 10 49 23 16 2 * 8/30/00 17 48 21 12 3 0   MC-10/11. Combo Table   ------------------------ABLE TO GET CARE----------------------- Unable to get care Don’t know  Refused  NET Very Somewhat Not too Not at all 6/21/09 58 6 28 13 9 34 7 * 8/30/00 57 9 27 12 7 31 11 *   HARVARD SCHOOL OF PUBLIC HEALTH 9   (Asked of total who think people in community who are uninsured are unable to get medical   treatment; n = 332)  MC-12 Do you think that MOST of those who are unable to get the medical care they need suffer serious health consequences, some health consequences, or do you think that it doesn't matter very much?   Serious health consequence Some health consequence Doesn’t matter very much Don’t know  Refused 6/21/09 50 41 10 * -- 8/30/00 60 34 4 2 0   MC-10/12. Combo Table   Able to get care -------------------UNABLE TO GET CARE--------------------- Don’t know  Refused  NET Serious Some Doesn’t matter much 6/21/09 58 34 17 14 3 7 * 8/30/00 57 31 19 11 1 11 *   MC-13 Do you think that the care that most uninsured people in your community get is as good as the care that the average person with insurance would get, or do you think that their care would not be as good?   As good Not as good Don’t know Refused 6/21/09 31 64 5 -- 12/9/03 28 65 7 1     (Asked of total insured; n = 958)  MC-15 Thinking about the next six months, how worried are you that you will lose your health insurance coverage?  Are you very worried, somewhat worried, not too worried, or not at all worried?   Very Somewhat Not too Not at all Don’t know Refused 6/21/09 11 18 24 47 * * 3/30/08 7 14 22 56 1 -- 4/18/07 6 15 20 59 1 *   HARVARD SCHOOL OF PUBLIC HEALTH 10   (Asked of total worried will lose health insurance in the next 6 months; n = 258)  MC-16 I'm going to read a list of reasons why someone might be worried about losing their health insurance coverage.  For each one, please tell me if it is a reason you are worried.   Yes, reason No, not reason Don’t know  Refused a. You or someone in your family might lose their job 64 35 * * b. Your health insurance might become too expensive 68 30 1 -- c. You or someone in your family has a medical problem that could   lead to losing coverage 31 67 2 -- d. Your employer or a family member’s employer might drop your   insurance 54 45 1 --   (Asked of total who are worried might lose health care for more than one reason)  MC-17 You said you were worried about losing your health insurance coverage because (READ THE ITEMS ANSWERED "YES" IN MC-16).  Which of those is the MOST IMPORTANT reason you are worried?   MC-16/17. Most Important Reason Summary   Base = total who are worried might lose health insurance in next 6 months; n = 258   6/21/09 You or someone in your family might lose their job 39 Your health insurance might become too expensive 32 You or someone in your family has a medical problem that could lead to losing coverage 6 Your employer or a family member’s employer might drop your insurance 10 None of these are most important 13       

Robert Wood Johnson Foundation Health Priorities Survey Report: The Medical System and the Uninsured

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Robert Wood Johnson Foundation Health Priorities Survey Report: The Medical System and the Uninsured

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