Policy Research Paper
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publicopinion_download.pptxClaudia Deane Associate Director Public Opinion & Survey Research Henry J. Kaiser Family Foundation May 2011
Public Opinion and Health Care Policy
SLIDE ‹#›
Hi. My name is Claudia Deane and I’m Associate Director of Public Opinion and Survey Research at the Kaiser Family Foundation. I’m tasked with giving you a basic overview of public opinion on health policy, which I’m limiting today to topics related to the delivery and financing of health care. As you can imagine, given the complexity and breadth of health care policy, as well as the diversity of the American public, this is a talk that could last for hours if not days. But here we’re going to settle for hitting some of the high points of the field, and giving you some basic principles to apply when thinking about the public’s reaction to any given health policy issue.
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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?
Looking at the System as a Whole, Most See Problems
Note: Does not have a problem and Don’t know/Refused answers not shown.
Source: 1994-2007, Gallup Poll trend data.; 2008-2009, Harvard School of Public Health/Robert Wood Johnson Foundation Polls .
State of crisis
Major problems
Minor problems
SLIDE ‹#›
When Americans are asked to rate the health care system as a whole, their reactions over the past fifteen years have consistently been less than enthusiastic. While relatively few people report the system is in crisis – a response represented by the bottom line on this chart-- a majority have consistently said the U.S. health care system has major problems, as you can see in the line stretching across the top.
Unlike many other public policy issues, however, health care is a topic on which every American also has personal experience … nearly all of us have health issues at one time or another, go to the doctor, take prescription drugs, and if we’re fortunate enough to have insurance coverage, deal with insurance companies. So another consistent public opinion finding is that Americans’ views about their own health care are much more positive than their views about health care more broadly.
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For The Insured, High Levels of Personal Satisfaction
Among those with health care coverage, percent who…
Sources: ABC News Polls (Jul. 1994, Nov. 1995, Aug. 1997), ABC News/Washington Post Poll (Oct. 2003), ABC News/Kaiser Family Foundation/USA Today Poll (Sept. 2006), Kaiser Family Foundation Polls (June 2008, March 2011)
Are satisfied with quality of care
Are satisfied with ability to get latest treatments
Rate health insurance coverage “excellent” or “good”
SLIDE ‹#›
Currently, about eight in ten of the non-elderly, and nearly all the elderly, have health insurance coverage, and among these insured there is a great deal of satisfaction with most aspects of that coverage. In March 2011, for example, we found that fully nine in ten of the insured would rate their coverage as “excellent” or “good”, and that nearly as many are satisfied with the quality of medical care they receive and their ability to get the latest treatments. And as you can see, these findings have been consistent over nearly two decades.
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Half Put Off Care Due to Cost
Percent who say they or another family member living in their household, have done each of the following in the past 12 months because of the cost:
Not filled a prescription for a medicine
Cut pills in half or skipped doses of medicine
Skipped dental care or checkups
Put off or postponed getting health care needed
Had problems getting mental health care
Relied on home remedies or over-the-counter drugs instead of going to see a doctor
Skipped a recommended medical test or treatment
Source: Kaiser Family Foundation Health Tracking Poll (conducted March 8-13, 2011)
‘Yes’ to any of the above
SLIDE ‹#›
At the same time that most Americans are satisfied with their coverage, however, recent decades have seen real concerns about the cost of health care, and it is cost which Americans seem to most want policymakers to address. Most Americans report worrying about the rising cost of care and coverage, and as you can see in this slide, fully half report that in the past year, they had to put off some sort of care because they couldn’t afford it. For example, a third have skipped dental care or checkups, and 32 percent say there have been instances where they relied on home remedies or over the counter drugs because they didn’t feel they could afford a trip to the doctor.
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Uninsured More Likely to Skip Needed Care
| Percent who report… | All | Insured (under age 65) | Uninsured (under age 65) |
| Problems paying medical bills | 23% | 21% | 48% |
| Skipped dental care or checkup | 33 | 30 | 58 |
| Putting off needed care because of cost | 28 | 25 | 64 |
| Not filled a prescription for a medicine | 21 | 19 | 50 |
Source: Kaiser Family Foundation Health Tracking Poll (conducted March 8-13, 2011)
SLIDE ‹#›
And having health insurance doesn’t give you ironclad protection against the rising cost of care. Among the insured, as you can see in the middle column, one in five have had problems paying medical bills in the past year, and a similar proportion have left a prescription unfilled because of cost concerns.
Problems of cost are, however, much more widespread among the millions of Americans who don’t have health insurance. For example, among the uninsured, half have had problems paying medical bills over the past year, half have left a needed prescription unfilled because they couldn’t afford it, and nearly six in ten have skipped dental care because of cost.
Putting all these pieces together, we’re left considering a public that on the one hand is critical of the health care system as a whole and is struggling with the rising cost of health care and coverage, but on the other hand is, in most cases, satisfied with the coverage they themselves have. This leads to an opinion climate where people are looking for fixes and improvements, but are wary of any changes that might threaten what they have.
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I’d like to ask you to think about uninsured Americans – that is, people with no health insurance at all. Would you say that more of them are…
Employed people and people from families in which someone is employed (correct answer)
Unemployed people and people from families in which no one is employed or Don’t know (incorrect answer)
Most Wrongly Believe Uninsured Population Dominated by Unemployed
SLIDE ‹#›
Since we’ve mentioned the critical topic of the uninsured, it’s worth pointing out that there is a fair bit of public misperception about this group. As has been true for the past ten years, the majority of Americans wrongly believe that most of the uninsured live in households where no one is working, as you can see in this slide. In fact, most uninsured live in households where at least one person is employed. This misunderstanding may impact the way Americans feel about extending federal aid to those without health insurance. Lack of public awareness of some of the key realities of our health care system is one hallmark of public opinion, and I’ll return to that a bit later in the talk.
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Nurses and Patient Groups Most Trusted on Policy Recommendations
How much confidence do you have in each to recommend the right thing for the country when it comes to health care?
None
Only a little
A fair amount
A great deal
Pharmaceutical or drug companies
Groups representing senior citizens
Hospitals
Small business groups
Note: Question asked of half sample. Never heard of group and Don’t know/Refused answers not shown.
Source: NPR/Kaiser Family Foundation/Harvard School of Public Health Survey on the Role of Health Care Interest Groups (conducted August 28 – September 13, 2009)
Consumer groups
Labor unions
Health insurance companies
Groups representing the country’s major corporations
Nurses groups
Groups representing patients
Doctors groups
SLIDE ‹#›
So far we’ve considered the public’s views of the health care system in a generic sense. Now let’s turn to their views of various players in this arena. As this slide shows, Americans are most likely to trust the recommendations of nurses organizations and patient rights groups when it comes to getting advice on health care policy. Other groups trusted by a majority: doctors, seniors citizens, hospitals, small business groups and consumer groups. On the other side of the spectrum, Americans place least trust in the health policy recommendations of pharmaceutical companies, big business, health insurance companies and labor unions.
There is one group, if you can describe it that way, not mentioned in this slide that’s extremely important to our discussion of public opinion on health policy, and that’s the federal government. To understand Americans’ views of health policy, you have to understand that while Americans are incredibly proud of our national democracy, and three in four say the United States has the best system of government in the world, they don’t hold the federal government itself in very high standing.
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38%
39%
39%
30%
32%
30%
26%
26%
25%
18%
14%
drug companies groups rep corps health insur cos. labor unions consumer grps small business grp hospitals groups rep srs dtrs groups groups rep patients nurses -0.38000000000000111 -0.39000000000000112 -0.39000000000000112 -0.30000000000000032 -0.32000000000000112 -0.30000000000000032 -0.26 -0.26 -0.25 -0.18000000000000024 -0.14000000000000001 none
30%
24%
25%
23%
9%
8%
10%
7%
7%
5%
3%
drug companies groups rep corps health insur cos. labor unions consumer grps small business grp hospitals groups rep srs dtrs groups groups rep patients nurses -0.30000000000000032 -0.24000000000000021 -0.25 -0.23 -9.0000000000000024E-2 -8.0000000000000043E-2 -0.1 -7.0000000000000021E-2 -7.0000000000000021E-2 -0.05 -3.0000000000000002E-2 fair drug companies groups rep corps health insur cos. labor unions consumer grps small business grp hospitals groups rep srs dtrs groups groups rep patients nurses 0.21000000000000021 0.23 0.26 0.26 0.39000000000000112 0.36000000000000032 0.41000000000000031 0.38000000000000111 0.41000000000000031 0.43000000000000038 0.46 great deal drug companies groups rep corps health insur cos. labor unions consumer grps small business grp hospitals groups rep srs dtrs groups groups rep patients nurses 0.1 9.0000000000000024E-2 9.0000000000000024E-2 0.17 0.15000000000000024 0.24000000000000021 0.2 0.26 0.24000000000000021 0.27 0.33000000000000135
If you were to grade the overall performance of the federal government, what grade would you give – A, B, C, D or F?
Note: Don’t know/Refused answers not shown.
Source: Washington Post/Kaiser Family Foundation/Harvard School of Public Health Role of Government Survey (conducted September 22-October 3, 2010)
Grading the Federal Government
A
B
C
GRADE OF…
D
F
In general, do you think the federal government is (mostly focused on the right things), or (mostly focused on the wrong things)?
55% Mostly focused on wrong things
39% Mostly focused on right things
6% No opinion
SLIDE ‹#›
In this slide, you can see that a narrow majority of Americans would give the overall performance of the federal government a C or even a D on a traditional report card. Only 3 percent were willing to give the poor feds an A, dwarfed by the 19 percent who gave it an F. Not just is its performance lacking, fully 55 percent say the federal government is just plain focused on the wrong things. These views become very relevant in health policy to the extent that people view the federal government as involved in various aspects of the marketplace.
For those who follow politics, it won’t surprise you to know that views of the federal government differ depending on people’s political party identification. Following their national party’s ideology, rank and file Republicans tend to be more skeptical of the central government while Democrats tend to want the federal government to play a larger role and independents come out somewhere in the middle.
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Sales Mostly focused on right things Mostly focused on wrong things No Opinion 0.39000000000000035 0.55000000000000004 6.0000000000000032E-2
Wide Partisan Divide Throughout First Year of ACA’s Existence
Percent who say they have a favorable opinion of the health reform law:
Democrats
Independents
Republicans
2010
Source: Kaiser Family Foundation Health Tracking Polls
ACA signed into law on March 23, 2010
2011
SLIDE ‹#›
These differences actually play out in health policy more than you might imagine. Take the 2010 health reform law, the Affordable Care Act or ACA, for example. The most consistent and dramatic divisions of opinion we’ve found in Kaiser polling both before and after passage of the ACA have been partisan divisions.
You can see the partisan gap in this slide, which shows the year since health reform became law in March 2010. In the spring of 2011, roughly seven in ten Democrats reported having a favorable view of the law, compared to only one in ten Republicans. Independents were divided, tilting negative. These patterns stretched across the entire first year of the law’s existence.
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Examples of Differing Views Across Demographic Groups
Source: First chart from Kaiser Family Foundation/Harvard School of Public Health The Public’s Health Care Agenda for the 112th Congress (conducted January 4-14, 2011). Others from Kaiser Family Foundation Health Tracking Poll (conducted March 8-13, 2011)
Percent who have a “very favorable” view of expanding the Medicaid program (as part of ACA):
White
African American
Hispanic
Under age 65
Seniors
Men
Women
Percent who have a “very unfavorable” view of the health reform law:
Percent who worry about having to pay more for care or coverage:
SLIDE ‹#›
There are other important divisions of opinion when it comes to health policy, as you can see in this slide. Race is one. African Americans – who as a group are less likely than whites to have health coverage and to receive needed care -- are more likely than whites to favor efforts to cover the uninsured, to increase federal regulation of health care, and to support increased spending on Medicaid.
Age is another. Seniors, all of whom are eligible to receive coverage through the federal Medicare program, often have somewhat different views on health policy issues. They have been less likely, for example to support the 2010 health reform law.
Finally, there is gender, where differences do exist but are more modest than in these other areas. Women are more likely to have contact with the health care system, to worry about the cost of coverage, and to prioritize health policy as a topic for policymakers to address.
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MEDICARE, the government health program for people 65 and older and certain people with long-term disabilities
MEDICAID, the government program that provides health insurance and long-term care to certain low-income adults and children
The Personal Importance of Medicare and Medicaid
Not too important
Very important
DK/ Refused
Source: Kaiser Family Foundation/Harvard School of Public HealthThe Public’s Health Care Agenda for the 112th Congress (conducted January 4-14, 2011)
How important for you and your family are each of the following government programs?
Somewhat important
Not at all important
Not too important
Very important
DK/Refused
Somewhat important
Not at all important
SLIDE ‹#›
Since we’ve mentioned both Medicare and Medicaid, which together provide health insurance for nearly one in three Americans, let’s briefly turn to look at the public’s views of these two signature federal health care programs. Views on these two programs make clear that just because Americans don’t express overwhelming approval for the federal government doesn’t mean they reject all its handiwork. In fact, three in four Americans rate both of these as “very important” programs.
As you can see in this slide, in both cases, majorities say the program is important in their own PERSONAL lives. Overall, 55 percent say Medicare is “very important” to their family, with another 22 percent calling it “somewhat important”. When it comes to Medicaid, 39 percent call it very important and another 20 percent somewhat important.
Now the rapid rise in spending on these two federal health care programs is a top health policy concern in Washington, especially among those focused on the growing national deficit, and 38 percent of Americans also say they are very concerned by these spending increases (significantly lower than the proportion who express concern over rising costs faced by individuals, but still a noteworthy amount).
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very import somewhat dk not too not at all 0.39000000000000284 0.2 2.0000000000000011E-2 0.16 0.23
extremely
very import somewhat dk not too not at all 0.55000000000000004 0.22 1.0000000000000005E-2 0.11 0.11
If Congress decides to reduce the deficit by reducing spending on federal programs and services, I’d like to know in which programs you would be willing to see spending reduced. For each program, tell me if you would support major spending reductions, minor spending reductions or no reductions at all.
Over Half Oppose Cuts to Medicare, Social Security, and Education; About Half To Medicaid
Note: Don’t know/Refused answers not shown.
Source: Kaiser Family Foundation/Harvard School of Public Health The Public’s Health Care Agenda for the 112th Congress (conducted January 4-14, 2011)
National defense
Public education
Foreign aid
Medicaid
Funding for the conflict in Afghanistan
Social security
Medicare
Aid to farmers
Expanding insurance coverage under the health reform law
Unemployment insurance
Salaries and benefits for federal government workers
Food stamps
NO reductions
Support MAJOR reductions
Support MINOR reductions
SLIDE ‹#›
Still, few Americans would support MAJOR CUTS in either Medicare or Medicaid. As this slide shows, 8 percent say they would be willing to see major reductions in Medicare spending to reduce the budget deficit, and another 35 percent would support minor cuts. This leaves 56 percent not willing to accept any cuts in Medicare. Nearly half – 47 percent – say they are not willing to accept any cuts to Medicaid. This aspect of public opinion poses serious challenges to those wanting to rein in the federal budget deficit.
This leads to a more general point: it’s a human tendency to resist giving up something you have and prize, be it money, health care or health coverage. This is a principle to keep in mind when you look at surveys that ask Americans whether they support desirable goals.
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foreign aid salaries fed workers funding for afghanistan expand insurance coverage food stamps aid to farmers unemployment national defense medicaid medicare publc education ss 0.11 0.15000000000000024 0.23 0.26 0.35000000000000031 0.36000000000000032 0.37000000000000038 0.38000000000000272 0.47000000000000008 0.56000000000000005 0.63000000000000556 0.64000000000000556 minor foreign aid salaries fed workers funding for afghanistan expand insurance coverage food stamps aid to farmers unemployment national defense medicaid medicare publc education ss 0.36000000000000032 0.43000000000000038 0.31000000000000238 0.4 0.41000000000000031 0.44 0.41000000000000031 0.4 0.39000000000000284 0.35000000000000031 0.24000000000000021 0.27 major foreign aid salaries fed workers funding for afghanistan expand insurance coverage food stamps aid to farmers unemployment national defense medicaid medicare publc education ss 0.52 0.41000000000000031 0.43000000000000038 0.29000000000000031 0.23 0.18000000000000024 0.2 0.21000000000000021 0.13 8.0000000000000043E-2 0.13 8.0000000000000043E-2
Would you be willing to pay more — either in higher health insurance premiums or higher taxes — in order to increase the number of Americans who have health insurance, or not?
Sacrifice Is Unpopular
Note: Asked of half sample July-November 2009. Don’t know/Refused answers not shown.
Sources: NBC News/Wall Street Journal Poll (Jun. 1991), Kaiser Family Foundation/Harvard School of Public Health Polls (Nov. 1996; Nov. 1998; Oct. 1999; Nov. 2000; Feb. 2003; and Nov. 2004), Washington Post/ Kaiser Family Foundation/Harvard School of Public Health Survey (May 2007), KFF/HSPH The Public’s Health Care Agenda for the New President and Congress (Dec. 2008); Kaiser Family Foundation Health Tracking Poll (Jun, Jul, Aug, Sep, and Nov 2009)
Yes
No
2009
SLIDE ‹#›
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For example, for many years surveys found that most Americans expressed a good deal of concern about the number of their fellow citizens that lack insurance. But as this slide shows, across this same time period, it was difficult to find a majority who said they personally would be willing to pay more in order to increase the number of Americans who have health insurance.
You might by this point have begun to wonder: how much does the American public actually KNOW about the complicated health policy topics we’re discussing. It’s a fair question, but one that has to be treated respectfully. As we’ve discussed, Americans do have more personal experience with health policy than with some other policy topics, but of course they also have many other issues and concerns on their mind, not the least of which is dealing with their day to day lives. And levels of knowledge, of course, differ depending on the specific topic.
To generalize about cost, for example, most people tend to know that health care costs are going up, but have a tendency to be more likely to blame this on bad actors – people committing fraud, or drug companies claiming too much profit – than on more systemic causes such as use of expensive new technologies or extended life spans.
1991 1996 1998 1999 2000 2003 2004 2007 2008 Jun Jul Aug Sep Nov 0.48000000000000032 0.47000000000000008 0.49000000000000032 0.52 0.49000000000000032 0.42000000000000032 0.51 0.58000000000000007 0.49000000000000032 0.54 0.44 0.55000000000000004 0.46 0.54 Column1 1991 1996 1998 1999 2000 2003 2004 2007 2008 Jun Jul Aug Sep Nov yes
1991 1996 1998 1999 2000 2003 2004 2007 2008 Jun Jul Aug Sep Nov 0.47000000000000008 0.47000000000000008 0.46 0.39000000000000234 0.46 0.52 0.45 0.39000000000000234 0.47000000000000008 0.41000000000000031 0.51 0.42000000000000032 0.49000000000000032 0.42000000000000032
Misperceptions About Important Policy Details Can Linger
| FALSE STATEMENTS ABOUT HEALTH REFORM LAW Affordable Care Act (ACA) | Percent who recognize statement as false | INCORRECT | |
| Percent who believe true | Don’t know | ||
| Government panel will make decisions about end-of-life care for Medicare recipients | 45% | 40% | 15% |
| Undocumented immigrants will receive financial help to buy insurance | 42% | 41% | 16% |
| Create a new government run insurance plan to be offered along with private plans | 27% | 59% | 14% |
Source: Kaiser Family Foundation Health Tracking Poll (conducted December 1-6, 2010). Wording shown here is abbreviated.
SLIDE ‹#›
There are also instances of widespread misunderstandings in terms of key policy details. For example, as you can see in this slide, four in ten continued to wrongly believe that the ACA includes so-called “death panels” even a year after the law was passed, and six in ten believed the law includes a government-run insurance plan alongside private plans, which it doesn’t. These persistent misperceptions likely impact the public’s overall views of health reform.
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Public Opinion Can Be Malleable in Face of Countervailing Information
Please tell me if you think lawmakers should keep or repeal the element of the health reform law that will require nearly all Americans to have health insurance or else pay a fine.
Keep
Repeal
ASKED OF THOSE WHO THINK LAWMAKERS SHOULD REPEAL INDIVIDUAL MANDATE:
Note: Follow up question asked of those who initially said lawmakers should repeal the individual mandate element of the health reform law. Responses on bottom graph are based on total, where “keep” includes those who initially said keep and those who said keep after hearing the follow up question. Don’t know/Refused answers not shown.
Source: Kaiser Family Foundation Health Tracking Poll (conducted March 8-13, 2011)
Keep
Still repeal
What if you heard that without such a requirement, people may wait until they are seriously ill to buy health insurance, which will drive up health insurance costs for everyone? Would you still say lawmakers should repeal this part of the law?
SLIDE ‹#›
Lack of knowledge is related to another hallmark of public opinion on health policy: the malleability of opinion on complicated topics. For example, in a recent survey, we found that only 27 percent of Americans wanted to keep the individual mandate as part of the ACA, that’s the provision that will require every American to have health insurance or else pay a financial penalty. But if we provide people with a countervailing fact about this policy, such as telling them that ‘without such a requirement, people may wait until they are seriously ill to buy health insurance, which will drive up health insurance costs for everyone”, we find that opinion shifts a fair bit, as you can see in this slide. In other words, providing people with more or different knowledge on a topic with which they may be generally unfamiliar has the potential to change their views, or to show that opinion on the topic is “soft”.
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employer 0.27 repeal employer 0.67000000000000548
keep
employer 0.4 still repeal employer 0.48
Public Opinion Takeaways
Public is critical of the health care system, but satisfied with own.
Major exception is high cost of care and coverage.
Most trusted: groups representing nurses and patients for policy recommendations. Least trusted: drug companies and big business.
Most Americans are critical of the federal government’s performance.
Differences by race/ethnicity, age, and gender.
Majority of Americans value Medicare and do not want cuts to the program.
Public do not want to make personal sacrifices.
Many have misconceptions and limited knowledge on specific health policy issues.
Limited knowledge mean public opinion can sometimes be malleable on complex issues results.
SLIDE ‹#›
We’ve really just scratched the surface, here, but time’s up. Let’s go over a few of the takeaways: (read content of slide)
The American public is critical of the health care system as a whole, but satisfied with most aspects of their own personal health care.
The big exception – and often the top of their priority list – is the high cost of care and coverage. Many Americans report struggling to pay for treatments, with the uninsured particularly at risk.
Groups representing nurses and patients are the most trusted when it comes to policy recommendations. Least trusted: drug companies and big business.
Meanwhile, most Americans are critical of the federal government’s performance, with major differences by political party.
In other areas, healthy policy opinions differ across racial and ethnic groups, between seniors and non-seniors, and by gender.
The large majority of Americans value Medicare, and few would be willing to see cuts in the program, even in the name of deficit reduction.
And in general, many members of the public are loathe to make personal sacrifices, even for health policy goals they support.
In the health arena, as in other areas, Americans harbor misconceptions and limited knowledge on some issues.
Low knowledge levels mean public opinion on complex issues can sometimes be quite malleable.
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Resources
Kaiser Family Foundation Public Opinion, www.kff.org/kaiserpolls
A fully searchable archive of more than 70 years worth of survey questions on health issues. The database includes more than 60,000 questions drawn from al public polls conducted on these topics, including but not limited to Kaiser health surveys.
Blendon, R., Brodie, M., Benson, J., and Altman, D., American Public Opinion and Health Care. CQ Press, 2011.
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SLIDE ‹#›
I hope that if there’s a topic in health policy you haven’t seen covered here you’ll go to our website at www.kff.org/kaiserpolls. Not only will you find all our polling, and we do quite a bit, but you’ll find a free search feature that lets you sift through ALL publicly released polls on health care topics. And if you want to get even wonkier about it, head to your library and check out American Public Opinion and Health Care by Robert Blendon, Mollyann Brodie, John Benson and Drew Altman, published by CQ Press in 2011. It’s written by our top polling gurus here along with some colleagues at Harvard and covers pretty much every topic in the book, so to speak.
Thanks a lot for sticking with me.
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