Americans' Views of Health Care Costs, Access, and Quality

Abstract

For more than two decades, polls have shown that Americans are dissatisfied with their current health care system. However, the public's views on how to change the current system are more conflicted than often suggested by individual poll results. At the same time, Americans are both dissatisfied with the current health care system and relatively satisfied with their own health care arrangements.

As a result of the conflict between these views and the public's distrust of government, there often is a wide gap between the public's support for a set of principles concerning what needs to be done about the overall problems facing the nation's health care system and their support for specific policies designed to achieve those goals.

The last attempt at major reform of the U.S. health care system was made more than a decade ago. Since President Bill Clinton's failed reform proposal, the percentage of Americans without health insurance has risen; the proportion of GDP devoted to health care grows larger with every year; and out-of-pocket medical spending makes up an increasing portion of Americans' budgets. Is the public ready for another attempt at system reform? Before Clinton's 1994 effort, the aggregate indicators also revealed that the health care problem was growing and that Americans were becoming increasingly dissatisfied with the health care system. Indeed, at the time, a large review of public opinion on health care suggested that Americans were ready for major reform (Jacobs and Shapiro 1994; Jacobs, Shapiro, and Schulman 1993). Yet when health care moved onto the actual policy agenda and the perceived trade-offs of major reform were better understood, the public had second thoughts and their support dissipated.

Accordingly, as we approach the next presidential campaign and candidates already are discussing the need for major health care reform, it is time to reexamine the state of public opinion regarding health care. Over the decades, the health care issue has come to encompass a broad set of concerns, many of them controversial. In this article, we first consider the role of public opinion both in a democracy in general and in past health care policy debates in particular. Next we draw data from more than eighty opinion surveys dating back to 1980 to examine Americans' views in seven critical areas: (1) health care as a national priority for government action; (2) the state of the U.S. health care system; (3) satisfaction with their own health care; (4) health care spending and costs; (5) the uninsured and national health insurance; (6) the financial viability and future shape of Medicare, its prescription drug program, and the Medicaid program; and (7) the problem of quality health care in the United States. Last we discuss the implications of these findings for the future of the nation's health care system.

The Role of Public Opinion

A central tenet of our representative democracy is that elected officials should be responsive to the wishes and desires of the public. Although many scholars agree that public opinion plays an important role in the policy process, there is less agreement about the magnitude and circumstance of its actual influence on specific policy outcomes. Because of differences in the methods used, issues studied, and time periods examined, studies have produced varying results regarding the impact of public opinion. Some studies have shown a strong connection between public opinion and policy, with opinion more often leading policy than the reverse (see, for example, Erikson, MacKuen, and Stimson 2002a). Other research has shown public officials to be less responsive to the public, with a growing divide since the 1970s between the public and their representatives (Ansolabehere, Snyder, and Stewart 2001; Jacobs and Shapiro 2000). Finally, some researchers argue for a “contingent model” in which the degree of impact of public opinion on policy varies depending on the issue and circumstance (Manza and Cook 2002; Monroe 1998).

Past research has shown that the public's views of health care issues are more complex and conflicted than often suggested by individual poll results (Blendon and Benson 2001; Hetherington 2005; Jacobs and Shapiro 2000; Koch 1998). It therefore is difficult to argue that public opinion either drives or follows health policy. The two most recent attempts at major health care reform were made when the public was in a more liberal “mood” and wanted more from government. Both President Richard Nixon's proposals and Clinton's plan came at high points in policy liberalism in general and in health care liberalism in particular (Erikson, MacKuen, and Stimson 2002b, 84, n. 9; Stimson 2004b, 51). Yet the support for sweeping changes evaporated when the policy trade-offs became clear, and the public moved away from wanting more government involvement in health care. According to Erikson, MacKuen, and Stimson's measure of public mood, the public is once again turning to government for answers to their problems (Stimson 2004a). Our examination of twenty-five years of trends in public opinion regarding health policy will thus give us a better understanding of whether the public is finally ready for major change or will support change only at the margins, as in the past.

Health Care as a National Priority

Although Americans are concerned about many national problems, they expect that at any given time the government will address only a few of them. In regard to what most needs governmental action, this public agenda has tended to vary over the years. Although health care is currently considered an important issue, it is not as high on the nation's agenda as it was in 1993 when Bill Clinton became president. Indeed, in January 1993, 31 percent of those surveyed named health care as one of the two most important issues for government to address, thereby ranking it as second in importance. In contrast, in June 2006, during President George W. Bush's administration, 12 percent named health care, making it the fourth-highest-rated issue (Harris Interactive Poll 1993, 2006d). More recently, health care has been surpassed by a combination of the war in Iraq and the threat of terrorism. Over the past thirteen years, various domestic issues such as Social Security and education have moved up and down the agenda, sometimes surpassing health care as a priority (see Table 1).

TABLE 1.

Americans' Perceptions of the Most Important Issues for the Government to Address (Percent Naming Health Care as One of the Two Most Important)

Date	Percent
1993 (January)	31
1994 (February)	45
1995 (June)	16
1997 (June)	9
1998 (July)	15
1999 (May)	7
2000 (June)	18
2001 (July)	15
2002 (May)	8
2003 (June)	15
2004 (June)	10
2005 (June)	11
2006 (June)	12

Source:Harris Interactive Poll 2003, 2006d.

When asked on Election Day 2004 what the most important issue was to them in deciding their vote for president, voters overall ranked health care as fifth most important, and those who voted for President Bush ranked it sixth (Edison/Mitofsky/NEP 2004).

Similarly, although many experts may see issues involving the health care system as interrelated, the public often focuses at a particular time on one or two problems as most important for the government to resolve. For example, when asked in April 2006 what they thought were the two most important health or health care problems for the government to address, Americans cited health care costs as the top priority (39 percent), followed by the uninsured/access to care (25 percent) and Medicare/seniors' health care (14 percent). One percent named quality of care as one of the most important health or health care issues (Kaiser Family Foundation Poll 2006b).

Views of the State of the Health Care System

In a number of opinion surveys, a majority of Americans today express dissatisfaction with the nation's health care system, although their dissatisfaction has not reached the point that they believe the system to be in crisis and that a completely new health care system is needed.

In 2006 about four in ten Americans (38 percent) expressed a great deal or quite a lot of confidence in the nation's medical system (Gallup Poll 2006b). When asked in 2005 about five major systems in the United States, the public rated the health care system as the lowest, behind the tax, Social Security, legal, and education systems (Pew Research Center 2005a).

In 2006 only about three in ten Americans (31 percent) reported that they had a great deal of confidence in the leaders of medicine, which is significantly lower than the rate during the early 1970s and late 1990s but higher than the low point of 22 percent in 1992 and 1993 (Harris Interactive Poll 2006a) (see Table 2).

TABLE 2.

Public Confidence in Leaders of Medicine (Percentage Saying Great Deal/Quite a Lot)

1966	1971	1976	1981	1986	1992	1999	2001	2002	2003	2005	2006
73%	61%	42%	37%	33%	22%	39%	32%	29%	31%	29%	31%

Source:Harris Interactive Poll 2006a.

Since 1982, one survey organization has asked Americans whether they think their health care system works pretty well and needs only minor changes, has some good things but needs fundamental changes, or has so much wrong with it that it needs to be rebuilt completely. By this measure, the majority of Americans have never been completely satisfied with the health care system. They were the most positive in 1987, when 29 percent reported that they thought the system was working pretty well. In 1991, often seen as the starting point of the major health care reform debate of the early 1990s, only 6 percent held this favorable view. In that same year, 42 percent of Americans believed that the health care system should be completely rebuilt, the highest level ever recorded (Harris Interactive 2006e) (see Table 3).

TABLE 3.

Public Attitudes toward the U.S. Health Care System

	1982	1987	1991	1994	1998	2000	2002	2004	2006
	(%)a	(%)a	(%)a	(%)a	(%)a	(%)a	(%)b	(%)a	(%)a
On the whole, the health care system works pretty well, and only minor changes are necessary to make it work better.	19	29	6	14	15	15	20	13	13
There are some good things in our health care system, but fundamental changes are needed to make it work better.	47	47	50	54	52	52	57	50	49
The health care system has so much wrong with it that we need to completely rebuild it.	28	19	42	31	30	30	23	36	37
Not sure.	6	5	2	1	2	2	1	1	1

Note: Percentages may not add up exactly to 100 percent due to rounding.

^aSources: Harris Interactive 2006e;

^bNPR/Kaiser/Kennedy School 2002.

In 2006, one in eight Americans (13 percent) saw the system as working pretty well, while 37 percent thought it should be completely rebuilt. In short, Americans were more dissatisfied than in 1987, but less so than in 1991 (Harris Interactive 2006e).

Americans' attitudes toward the health care system are related to differences between those with secure and comprehensive health coverage and those without it. Using a dataset with a wide range of variables, we conducted a multivariate analysis of opinions about the state of the health care system (NPR/Kaiser/Kennedy School 2002). Controlling for income, education, race, and satisfaction with one's personal medical care, those who are uninsured and worried about their future ability to afford health care are significantly more likely than the rest of the public are to feel that the health care system needs major changes.

Americans are more dissatisfied with their health care system than are citizens of other industrialized countries. Between 2004 and 2006, international public opinion surveys showed that only a minority of Spanish (28 percent), U.K. (26 percent), Canadian (21 percent), and U.S. (13 percent) residents were completely satisfied with their health care system. But of the four countries, Americans expressed the highest level of dissatisfaction: more than one-third (37 percent) believed the U.S. health care system needed to be rebuilt completely. This is nearly three times the proportion of Canadian (14 percent), Spanish (13 percent), and U.K. residents (13 percent) who had this negative view of their own country's health care system. (Harris Interactive Poll 2006c; HSPH/Fundacío Biblioteca Josep Laporte 2006; Schoen et al. 2004).

Americans are far less satisfied with the availability of affordable health care in their country than the Canadians and British are with theirs, but residents of the three countries agree in their assessment of their country's quality of medical care. Nearly three-fourths (72 percent) of Americans in 2003 expressed dissatisfaction with the availability of affordable health care in their country, including about one-third (44 percent) who were very dissatisfied. Only one in four was very or somewhat satisfied, a proportion significantly lower than that in the United Kingdom (43 percent) and Canada (57 percent) (Gallup Poll 2003a).

Similarly, in 2005 only about one in five Americans (21 percent) rated health insurance coverage in the United States as excellent or good, and more than three-fourths (78 percent) rated it as only fair or poor (Gallup Poll 2005b).

However, Americans were about evenly divided about the quality of medical care in the country. In late 2005, about half of U.S. (53 percent), U.K. (55 percent), and Canadian (52 percent) residents rated the quality of health care in their country as excellent or good (Gallup Poll 2006a). Similarly, in 2006, 53 percent of Americans rated the quality of health care in the United States as excellent or good (ABC/WP 2006).

Added to their general concerns about the health care system, a significant proportion of Americans in 2006 believed that insurers and pharmaceutical companies were not doing a good job for those they served. More than four in ten (44 percent) thought that managed care companies were doing a bad job serving their consumers, and more than one-third (36 percent) thought the same about pharmaceutical companies (Harris Interactive Poll 2006b).

Even though a majority of Americans are dissatisfied with their current health care system, most do not see it as being in a state of crisis requiring immediate action. In 2006 only one in five (22 percent) described the health care system as being in a state of crisis, although this is a significantly higher proportion than in 2002 (11 percent). A majority (52 percent) in 2006 said it had major problems, a view that has remained relatively constant since 1994. Also in 2006 about one in four (23 percent) believed their health care system had minor problems or no problems at all (Gallup Poll 1994, 2000, 2002, 2003b, 2005b; HSPH/RWJF 2006b).

Views of Their Own Health Care and Health Professionals

Survey results are more positive in regard to Americans' assessments of their own health care. Even though Americans have negative feelings about their health care system, most are satisfied with the health care they themselves receive and with the health care professionals whom they most often see.

In 2006, 84 percent of Americans who had received medical care from a doctor or other health care professional during the past year rated the medical and health services they used as excellent (45 percent) or good (39 percent), and only 16 percent said they were fair or poor (HSPH/RWJF 2006a). Similarly, in 2005, 78 percent rated the quality of care they received as excellent (29 percent) or good (49 percent), whereas 20 percent said it was only fair or poor (Gallup Poll 2005b) (see Table 4).

TABLE 4.

Americans' Satisfaction with Their Own Health Care Arrangements (%)

Rating of your overall medical carea
Excellent	45
Good	39
Fair/poor	16
Quality of care you receiveb
Excellent	29
Good	49
Fair/poor	20
Satisfied with
Last visit to physicianc	92
Ability to see a doctor whenever neededd	88
Your access to high-quality medical technologyd	85
Your health insurance benefitsd	81

^aHSPH/RWJF 2006a;

^bGallup Poll 2005b;

^cHSPH/RWJF 2003a;

^dHarris Interactive Poll 2006c.

In 2003, about nine in ten Americans reported being very (62 percent) or somewhat (30 percent) satisfied with their last visit to a physician, while only 8 percent were dissatisfied (HSPH/RWJF 2003a). In 2006, more than eight in ten said they were satisfied with their ability to see a doctor whenever needed (88 percent), their access to high-quality medical technology (85 percent), and their health insurance benefits (81 percent) (Harris Interactive Poll 2006c). More than six in ten Americans (63 percent) rated their own health care coverage as excellent or good, but about one-third (32 percent) rated it as only fair or poor (Gallup Poll 2005b).

A majority of Americans trust the health care professionals with whom they have contact. In 2006, about three-fourths (74 percent) of Americans believed that hospitals were doing a good job for their patients (Harris Interactive Poll 2006b), and in 2002, about nine in ten said they trusted nurses (90 percent) and doctors (88 percent) to make the right decisions about their health care (Harris Interactive Poll 2002).

In addition, Americans have a high level of respect for the honesty of health professionals. Large majorities of Americans in 2005 rated the honesty and ethical standards of nurses (82 percent), pharmacists (67 percent), and doctors (65 percent) as very high or high, making them among the highest-ranked professions (Gallup Poll 2005c).

Why is there such a big difference between Americans' perceptions of the health care system and some health care institutions, on the one hand, and of their own care and health professionals, on the other? Most people see the quality of their day-to-day experiences with physicians, nurses, and hospitals to be reasonably satisfactory. But when they express dissatisfaction with the health care system, they are thinking about the economic insecurity they face now or may face in the future in paying their medical bills. They also are thinking about other people's problems.

Views of Health Care Spending and Costs

Over the years, some experts have expressed concerns about the high level of health spending in the United States, as reflected in the share of the gross national product spent on health care (Reinhardt, Hussey, and Anderson 2004). But these experts' concerns have not been shared by the general public. Although the public is very worried about rising health care costs, it is mainly about the increasing price of health care services and medicines, not aggregate spending. In fact, a majority of Americans want more money spent on health care.

In 2006, a survey queried Americans specifically about the overall national spending on health care and the government's spending on national health care. The majority of respondents (57 percent) thought that the United States was spending too little on health care in the aggregate, and 70 percent said that the government also was spending too little on health care. Only 26 percent thought the nation as a whole was spending too much, and 11 percent thought the government was spending too much (Pew Research Center 2006).

These results match the long-term trend in Americans' attitudes toward aggregate spending. A majority of Americans have consistently believed that the United States is spending too little rather than too much on health care (Davis and Smith 2004). Similarly, when asked in 2003 which of eight segments of the U.S. economy they saw as the highest priorities for future spending growth, health care topped the list, followed by education and defense (Harris Interactive Poll 2003).

What concerns Americans is not aggregate spending but the perceived negative impact on American families of their direct payments for health care (insurance premiums, copays, deductibles, and the cost of services and products). When asked about average Americans' spending for health care in 2006, 65 percent said that they spend too much, and only 17 percent said too little (Pew Research Center 2006).

In contrast to experts' concerns about aggregate societal or government spending, the public is concerned about the prices they have to pay for health care. In 2006 a majority of Americans believed that hospital charges (62 percent) and the price of prescription drugs (58 percent) were unreasonably high, and about half (49 percent) thought that doctors' bills were unreasonably high (Harris Interactive Poll 2006c).

The public's concerns about rising health care prices are connected to their anxiety that they might not be able to afford various health care services in the future and also the problems they have paying their medical bills today. In 2006, about one-third (32 percent) of Americans were very worried about not being able to afford the health care services they thought they needed (32 percent). As one would expect, this worry was even more widespread among low-income Americans. About half (52 percent) of Americans from households with an income of less than $20,000 per year said they were very worried about not being able to afford the health care services they needed (Kaiser Family Foundation Poll 2006a) (see Table 5).

TABLE 5.

Americans' Health Care Costs and Worries

	Had Problems Paying Medical Bills in Past Year (%)a	Money Paid Directly or Had Deducted for Health Insurance Rose in Past Five Years (%)a
Total	23	67
Household income
$75k+	8	70
$50–$74.9k	21	73
$30–$49.9k	29	69
<$30k	32	60
	Very Worried about Not Being Able to Afford Needed Health Care Services (%)b
Total	32
Household income
$50k+	20
$20k–$49.9k	34
<$20k	52

^aUSA Today/Kaiser/HSPH 2005;

^bKaiser Family Foundation Poll 2006a.

The percentage of Americans reporting that sometimes during the past year they did not have enough money to pay for medical or health care has nearly doubled during the past thirty years, from 15 percent in 1974 to 28 percent in 2005, the latter figure having remained relatively stable since the mid-1980s (Blendon and Benson 2005; USA Today/Kaiser/HSPH 2005).

In addition, a substantial share of people reported negative experiences with their medical bills. In 2005, nearly one-quarter (23 percent) of Americans said that in the past year they had problems paying medical bills. Almost two in ten Americans (19 percent) reported experiencing serious financial consequences owing to medical bills, including being contacted by a collection agency (15 percent of Americans), using all or most of their savings (12 percent), borrowing money or taking out another mortgage (8 percent), and declaring bankruptcy (3 percent) (USA Today/Kaiser/HSPH 2005).

It is interesting that more than three in five (61 percent) of those who reported problems paying medical bills were covered by health insurance. Among this group of insured adults who had trouble paying medical bills, majorities reported that the bills were for basic care such as doctors' fees (83 percent), lab work (65 percent), and prescription drugs (56 percent) (USA Today/Kaiser/HSPH 2005).

In 2005, more than one in five Americans (21 percent) said that they currently had an overdue medical bill, and almost two in ten (18 percent) said that health care costs were their biggest monthly expense after rent or mortgage payments. Finally, nearly three in ten (29 percent) estimated that they had paid $1,000 or more out of pocket for health care during the past year (USA Today/Kaiser/HSPH 2005).

In 2005, two-thirds (67 percent) of Americans said that during the past five years the amount of money they paid directly each month or had deducted from their paycheck for health insurance premiums had gone up, a figure that includes more than two-thirds of Americans with household incomes of $30,000 to $49,999 (69 percent) and $50,000 to $74,999 (73 percent) (USA Today/Kaiser/HSPH 2005).

Health Care Costs and the Chronically Ill

Health care costs present a particularly heavy burden for adults from households where someone has a chronic illness. In 2005, more than half (56 percent) of Americans reported that they or someone else in their household had been diagnosed with a chronic illness, such as heart disease, cancer, asthma, or diabetes. This group had a significantly harder time accessing health care, specifically because of cost (USA Today/Kaiser/HSPH 2005) (see table 6).

TABLE 6.

Problems with Health Care Costs among Total Adults and Those with a Chronically Ill Family Member

		No One in Your Household Has Been Diagnosed with a Chronic Illness	Total You or Someone in Your Household Has Been Diagnosed with a Chronic Illness	You or Someone in Your Household Has Been Diagnosed with …
	Total Number of Adults (%)			Heart Disease (%)	Cancer (%)	Diabetes (%)	Asthma (%)
Problems paying medical bills in past one year	23	15	29	30	33	33	40
Problem bills—contacted by collection agency in past five years	15	10	20	19	22	25	30
Problem bills—used up all or most of savings in past five years	12	7	16	17	23	19	22
Problem bills—borrowed money/took out another mortgage in past five years	8	5	10	11	14	10	14
Problem bills—unable to pay for basic necessities in past five years	8	3	12	14	21	15	17
Problem bills—bankruptcy in past five years	3	2	5	3	9	3	6
Currently have overdue medical bills	21	14	27	25	28	31	38
Not enough money to pay for health care in past one year	28	21	33	33	42	35	43
Skipped treatment, cut pills, or didn't fill prescription because of cost	29	21	35	35	43	37	44

Source:USA Today/Kaiser/HSPH 2005.

About three in ten adults (29 percent) from households where someone had a chronic illness reported having had problems paying medical bills during the past year, compared with 15 percent of adults from households where no one had a chronic disease. Adults from households where someone was chronically ill were about twice as likely as other adults to report a range of problems due to medical bills in the past five years. These problems included being contacted by a collection agency (20 percent to 10 percent), using up all or most of their savings (16 percent to 7 percent), having to borrow money or take out another mortgage (10 percent to 5 percent), and being unable to pay for basic necessities (12 percent to 3 percent).

In addition, adults from households where someone was chronically ill were more likely than other adults to report having an overdue medical bill (27 percent to 14 percent) and not having enough money to pay for medical care in the past year (33 percent to 21 percent). They also were twice as likely (20 percent to 8 percent) to report a time during the past year when they or someone in their household needed medical care and did not get it because of cost or because it was not covered by insurance (16 percent to 6 percent).

More than one-third (35 percent) of adults from households where someone was chronically ill reported that they or someone in their household skipped medical treatment, cut pills, or didn't fill a prescription because of the cost, compared with about 21 percent of adults from households where no one had a chronic illness (USA Today/Kaiser/HSPH 2005).

Causes of Rising Health Care Costs

Americans do not blame themselves for their health care cost problems, instead attributing the rising health care costs to the profits made by drug and insurance companies. In 2005, more than one-third (35 percent) of Americans believed that such profits were the most important cause of rising health care costs; 19 percent cited the high number of malpractice lawsuits; and 14 percent named the greed and waste in the health care system. In comparison, 8 percent held the costs of medical technology and drugs to be responsible, a factor that many health care experts felt was a major driver of higher health care costs. Few (5 percent) said that doctors' overly high fees were the main cause of rising health care costs (USA Today/Kaiser/HSPH 2005).

In 2005, the public was split on whether doctors were too interested in making money (49 percent agreed, and 49 percent disagreed), although the share agreeing that doctors were too interested in money has fallen since 1984, when 67 percent agreed (AMA 1984; USA Today/Kaiser/HSPH 2005).

The Malpractice Issue

As we have seen, the public considers malpractice lawsuits to be a significant causal factor in rising health care costs, although surveys show that the public sees the issue differently than many lawmakers do. Rather, the public generally sees the number of lawsuits as a bigger problem than the size of jury awards, the object of attention for many legislators.

Almost a third (32 percent) of people said in 2004 that the most important reason for rising malpractice insurance rates was too many lawyers filing unwarranted lawsuits; 15 percent attributed it to the high profits of malpractice insurers; 14 percent cited too many patients making unwarranted claims against doctors; and 11 percent said it was too many doctors making mistakes. Even though most of the policy debate has focused on capping jury awards, 9 percent chose “too many juries making excessive awards” as the main reason that malpractice costs were increasing (Kaiser/HSPH 2004b).

More than seven in ten (72 percent) people said they would favor legislation to prohibit people from filing medical malpractice lawsuits unless a qualified independent medical specialist reviewed the claim and thought it was reasonable. More than six in ten (63 percent) said they would favor legislation limiting the amount of money that could be awarded for pain and suffering to someone suing a doctor for malpractice.

Among the 63 percent who supported a cap on damages for pain and suffering, however, most favored a relatively high cap; 30 percent of this group selected a cap of $1 million or higher; 23 percent, a $500,000 cap; 16 percent, a $250,000 cap; and 15 percent, a cap of less than $250,000. (The remaining 17 percent said they either did not know or would not say what cap they favored.) (Kaiser/HSPH 2004b).

Views of the Uninsured and National Health Insurance

The United States is the only industrialized country without some form of universal health care coverage (Graig 1999), and national studies have shown that this absence has created serious problems for many Americans who do not have health insurance (IOM 2003). For example, in 2003 nearly four in ten uninsured Americans (38 percent) reported that they had delayed treatment for a serious illness during the past year, a number more than three times that of insured Americans (12 percent) (ABC/WP 2003). In addition, in 2005 uninsured Americans were twice as likely as insured adults (51 percent to 25 percent) to report that they or a member of their household had skipped medical treatment, cut pills, or left a prescription unfilled in the past year because of cost (USA Today/Kaiser/HSPH 2005).

One-third of the uninsured in 2003, compared with 11 percent of the insured, were dissatisfied with the quality of care they received. Four in ten uninsured Americans (41 percent) were dissatisfied with their ability to get the latest medical treatments, compared with 15 percent of the insured (ABC/WP 2003).

As students of U.S. health policy know, the problem of the uninsured has been the subject of continual debate during the past half century. Since World War II, three national health insurance plans have been proposed: (1) the late 1940s debate about President Harry Truman's proposed plan; (2) the 1971–1974 debate about President Richard Nixon's proposed program; and (3) the 1993–1994 debate about the Clinton administration's health care reform proposal. Despite the sparse polling information about the Nixon-era debate, what we do have shares some features with the other two debates.

Before each bill was introduced, the public already was interested in some type of national health care reform. In the years leading up to the Truman proposal, 82 percent of Americans said that something should be done to help people pay for doctor and hospital care, and 68 percent thought that Social Security should cover doctors' and hospital bills (Payne 1948). During the year before Bill Clinton's first election as president, 66 percent of Americans favored national health insurance financed by taxes, up from 46 percent in March 1980 (Blendon and Benson 2001) (see Table 7).

TABLE 7.

Americans' Attitudes toward National Health Insurance, 1980–2003

	Favor (%)	Oppose (%)	No Opinion (%)
National health insurance, financed by tax money and paying for most forms of health care
1980 (February)	50	41	9
1980 (March)	46	43	11
1981	52	37	11
1990 (March/April)	56	34	10
1990 (October)	64	27	8
1991 (June)	60	30	10
1991 (August)	54	33	12
1992 (January)	65	26	9
1992 (July)	66	25	9
1993 (January)	63	26	11
1993 (March)	59	29	12
1995	53	39	8
2000 (August)
General public	56	32	12
Registered voters	54	34	12
A national health plan, financed by taxpayers, in which all Americans would get their insurance from a single government plan
1998 (November)	42	53	5
1999 (October)	41	47	11
1999 (December)	39	51	10
2000 (July) registered voters	38	58	3
2000 (November/December)	36	57	7
2002	40	55	5
2003	46	50	4
2004	37	55	8

Source:Blendon and Benson 2001; HSPH/RWJF 2003b; Kaiser/HSPH 2004b; NPR/Kaiser/Kennedy School 2002.

Then, after each plan was introduced and the proposals were explained, opposing groups entered the debate and argued that passage of the proposals would result in a health care system worse than the existing one. Indeed, despite the general support for a national health plan, the public's actual support for the Clinton plan declined from 59 percent in September 1993 to 40 percent in July 1994 (Gallup Poll 1993; Gallup/CNN/USA Today 1994). A similar phenomenon can be found in the debate over the Truman plan. In March 1949, 38 percent opposed it, and by October 1950, after an extensive campaign by opponents, public opposition had risen to 61 percent (Gallup Poll 1949, 1950).

Three factors have historically weakened public support for a particular national health plan once it has been proposed and debated: (1) a general distrust of government; (2) a lack of public consensus on a specific national plan; and (3) an unwillingness to make sacrifices, including paying more in taxes, to implement a new national plan (Blendon and Brodie 1997).

Since the early 1970s, polls have shown that Americans greatly distrust the government's decision making (Nye, Zelikow, and King 1997). In 2005, only three in ten (30 percent) said they trusted the government in Washington to do what was right just about always or most of the time (Gallup Poll 2005a). Moreover, when Americans were asked in 2002 how much they trusted each of several groups to make the right decisions about their health care, members of Congress ranked last, distrusted by 62 percent of the public (Harris Interactive Poll 2002). Earlier studies have shown that this distrust inhibits popular support for large-scale government action, including in health care, and particularly for government programs that would raise taxes for most Americans to help disadvantaged groups (Chanley, Rudolph, and Rahn 2000; Hetherington 2005).

In addition, the public has been unable to agree on what type of national health plan they prefer. In 2000, when asked generally about national health insurance financed by taxes, 56 percent of the public (54 percent of registered voters) favored it. But when a clause was added specifying that all Americans would obtain their health insurance from a single government plan, support fell to 38 percent of registered voters, a result that illustrates the lack of public consensus on a national health plan (Blendon and Benson 2001).

Many polls do not fully convey the public's views on national health insurance. A majority of Americans are dissatisfied with the existing health care system, and a majority (58 percent in 2005) think that in principle it is the responsibility of the federal government to make sure all Americans have health care coverage (Gallup Poll 2005b). As a result, when asked about a single alternative to the status quo, most Americans approve of nearly any alternative that is presented. But these types of polling questions tend to disguise the more complex reality of the situation.

First, there is no public consensus on an alternative health care system. Instead, Americans tend to favor most of the alternatives when each is presented by itself, but given a choice among several alternatives, a majority cannot agree on one type of proposal. Second, when people answer relatively simple questions about changes in the health care system, they do not consider the trade-offs necessary to implement that alternative option. Finally, when issues like health care rationing, increased taxes, or longer waiting times are raised, public support for alternatives falls sharply.

In 2004, when given a brief, general description of various proposals, 70 percent or more of the public favored five possible ways to increase the number of Americans covered by health insurance: offering businesses tax deductions, tax credits, or other financial assistance to help them provide health insurance for their employees (88 percent); expanding state government programs for low-income people, such as Medicaid and the Children's Health Insurance program, to provide coverage for people without health insurance (80 percent); expanding Medicare to cover people between the ages of fifty-five and sixty-four without health insurance (74 percent); offering uninsured Americans income tax deductions, tax credits, or other financial assistance to help them buy private health insurance (73 percent); and requiring businesses to offer private health insurance to their employees (70 percent). Only 37 percent wanted a national single payer system, financed by taxpayers, in which all Americans would obtain their insurance from a single government plan (Kaiser/HSPH 2004b).

When asked to choose among these six approaches to increase the number of Americans covered by health insurance, the public is divided, with each of the six approaches preferred by between 12 percent and 23 percent (Kaiser/HSPH 2004b).

When offered only a single alternative to the United States' current health insurance system, a majority of Americans favored change but were unwilling to make sacrifices in order to implement another system. In 2003, by an almost two-to-one margin (62 percent to 32 percent), Americans said they preferred a universal health insurance program, in which everyone was covered under a program like Medicare, run by the government and financed by taxpayers, rather than the current health care system, in which some people obtain their health insurance from private employers but others have no insurance. But support for a universal program declined sharply if such a program would mean waiting lists for nonemergency treatment (39 percent) or a limited choice of doctors (35 percent), scenarios depicted by opponents of both the Truman and the Clinton plans (ABC/WP 2003).

Concerns about covering more of the uninsured are related also to Americans' reluctance to raise taxes. In 2004, half (50 percent) of Americans considered the amount of federal income taxes they had to pay to be too high, with 43 percent saying it was about right and almost no one (3 percent) thinking their tax burden was too low (Gallup Poll 2004).

While most Americans (74 percent) believed in 2003 that legislation was needed to help more people get health insurance, less than half were willing to pay more in taxes to achieve this goal. Given three choices, 47 percent said that the government should make a major effort to provide health insurance for most uninsured Americans, which might require a tax increase to pay for it. Another 37 percent thought the government should make a limited effort to provide health insurance for some of the uninsured, which would mean more government spending, and 13 percent preferred to keep things as they are (HSPH/RWJF 2003b).

The size of the tax increase matters. In 2005 nearly two-thirds (64 percent) wanted the U.S. government to guarantee health insurance for all citizens, even if it meant raising taxes (Pew Research Center 2005b). The public's reluctance to raise taxes substantially, however, is illustrated by findings from a 2004 poll. A majority (62 percent) of Americans disagreed with the statement “If the only way to make sure that everyone can get health care services they need is to have a substantial increase in taxes, we should do it” (Harris Interactive Poll 2004).

The Massachusetts Universal Health Plan

One example of how these conflicts in public opinion can help shape legislation can be seen in the recent developments in Massachusetts. A law was passed in 2006 requiring all residents to have health insurance. Although low-income residents will receive state subsidies to help pay their insurance premiums, everyone must pay something for health services. The plan will penalize people who are currently uninsured and do not obtain an insurance policy and will charge fees to employers who do not provide coverage. But the law will impose no new across-the-board taxes to reach its objective.

This law is a compromise among three ways of solving the problem of the uninsured: an individual mandate, an employer mandate, and an expansion of public programs. It also reflects the fact that no single approach had majority support among the public and that each approach on its own was subject to criticism that substantially reduced public support. Likewise, it responds to the lack of public support for a broad-based tax increase to solve this problem.

The basis for this compromise can be found in a 2003 survey asking Massachusetts adults to choose which of three statements came closest to what they thought the government should do for the uninsured. Nearly half (47 percent) said they would like the government to make a major effort to provide health insurance for nearly all of the uninsured, even though that might require a tax increase to pay for it. But a nearly equal proportion chose an alternative that did not involve a tax increase, either making a more limited effort (34 percent) or leaving things as they were (11 percent) (Blendon et al. 2003).

As we have seen nationally, in 2003 the majority of Massachusetts residents supported a wide range of possible new state initiatives to cover the uninsured, but with conditions. Although some proposals had more statewide support than others, there was no clear consensus for a single policy proposal to address the problem. Moreover, many residents were not strongly committed to these various proposals. Indeed, when challenged by negative arguments used in earlier debates, their support plummeted, usually leading to individual policy proposals that were not favored by a majority (see Table 8). But by including elements of the various proposals, Governor Mitt Romney and the Massachusetts legislature were able to settle on a compromise that encompassed these diverse public views.

TABLE 8.

How Negative Arguments Affect Support for Proposals to Cover the Uninsured among Adults in Massachusetts

	Initially Favors	Favors after Challenge
Expanding existing state programs	82%	55%
What if you heard that expanding these programs would require raising taxes to pay for the costs?
Employer mandate	76%	35%
What if you heard that it would be so expensive that employers would be forced to lay off workers?
Tax credits and deductions for the uninsured	70%	36%
What if you heard that the amount of tax relief would not be enough to cover the cost of a private plan?
Legally requiring all residents to have health insurance	56%	22%
What if you heard that even with the government's help, people won't be able to afford insurance and the law would cause financial hardship?
Single-payer government plan	50%	30%
What if you heard that you would have to wait longer for some hospital and specialty care?

Source:Blendon et al. 2003.

The Financial Viability and Future Shape of the Medicare Program

The sharp fault lines of the American public's views can also be seen in the debate about the future of Medicare. Although most Americans have a positive opinion of Medicare, they think the program will face serious financial problems in the future. In 2004, about three-fourths of seniors (75 percent) and of the American public as a whole (73 percent) had a favorable view of the Medicare program (Kaiser/HSPH 2004a).

In 2003, about one in five (18 percent) thought the Medicare program was in crisis; 51 percent thought it had major problems but was not in crisis; and 22 percent thought the program had minor or no problems. Seniors were significantly less likely than nonseniors to see the Medicare program as facing a crisis. Only 8 percent of those aged sixty-five and older, compared with 20 percent of those aged eighteen to sixty-four, believed the Medicare program was in crisis (Kaiser/HSPH 2003).

As is the case of the health care system more broadly, a large majority of Americans believe that Medicare faces serious financial problems but currently do not agree on what to do about them. This debate has revolved around two main issues: how the existing program should be changed to make it more viable financially and the role of private choices in the future shape of Medicare.

Over the years, various experts and commissions have recommended a range of possible solutions to Medicare's financial problems, many of which face substantial public opposition. In 2003, majorities opposed requiring seniors to pay a larger share of costs (89 percent), raising the age of eligibility (67 percent), and raising payroll taxes (56 percent). Rolling back the recently enacted tax cuts generated the greatest support, 70 percent. A majority (57 percent) also supported asking higher-income seniors to pay higher premiums, an action that Congress has already taken. Americans were divided on reducing payments to doctors and hospitals for treating people on Medicare, with 49 percent in favor and 46 percent opposed (Kaiser/HSPH 2003).

The second debate pertains to the role of private choices and whether the government should encourage retirees to choose private plans. Although Medicare remains popular, the public is split over this issue. Asked about the future of the program, half (50 percent) of Americans in 2003 felt that seniors should continue to receive health insurance through Medicare, and 41 percent thought they should obtain health insurance through private plans (Kaiser/HSPH 2003).

Seniors clearly prefer to build on the Medicare program with which they are familiar, and adults under age sixty-five have a more favorable view of private plans. In 2003, about seven in ten (72 percent) of those aged sixty-five and over felt that seniors should continue to get their health insurance through Medicare rather than private plans (16 percent). Adults under age sixty-five, however, were fairly evenly divided on whether most seniors should continue to be covered by Medicare or private plans (45 percent versus 46 percent) (Kaiser/HSPH 2003).

In regard to their own insurance coverage, seniors were far more likely to prefer the current Medicare program to private plans (63 percent versus 19 percent). Adults under age sixty-five, however, preferred private plans (56 percent) to Medicare (31 percent) for their future health coverage (Kaiser/HSPH 2003). These contrasting perspectives will likely influence future Medicare debates as the population ages.

The Medicare Prescription Drug Law

The Medicare prescription drug law became a major flash point for the debate about public and private roles in Medicare. The legislation as enacted had beneficiaries choose from a large number of private plans rather than adding a government-administered benefit to the existing Medicare program.

In 2006, shortly after the law was implemented, half (50 percent) of seniors liked the general idea that a drug benefit had been added to Medicare, and 41 percent disapproved (ABC/WP 2006). But when asked more specifically about the new drug benefit program itself, roughly equal numbers of seniors viewed it favorably (32 percent) as unfavorably (30 percent). Nearly four in ten (39 percent) were neutral or not sure whether they had a favorable or unfavorable view (Kaiser Family Foundation Poll 2006c).

During the summer of 2006, while the drug benefit was still relatively new to seniors, those who had enrolled were satisfied with their plan, with more than eight in ten seniors (81 percent) enrolled in a Medicare prescription drug plan being satisfied with it. But of those enrollees who had used their drug plan, about one in five (18 percent) had had a major problem related to filling prescriptions (Kaiser Family Foundation Poll 2006c).

When asked in April and May 2006 to judge the success or failure of the Medicare Part D prescription drug program, 10 percent considered it a success, 11 percent thought it was a failure, and 12 percent had a mixed opinion. But a majority of seniors said that either it was too early to tell (49 percent) or they did not know (18 percent). Among enrollees in the prescription drug program, 70 percent were satisfied with the program, with two-thirds of enrollees (67 percent) saying it was very/fairly easy to enroll and 28 percent, very/fairly difficult (Harris Interactive Poll 2006c).

Until they have had more experience with the Medicare prescription drug plan, seniors will probably not be able to judge the program or the concept (which could be expanded) of competing private-sector choices versus a single government program.

In addition to this debate, the public supports two policy proposals for lowering the cost of prescription drugs that may be important in the future but are not in the current Medicare prescription drug law: allowing the importation of drugs from Canada and having the federal government negotiate with drug companies for lower prescription drug prices for people on Medicare.

In 2006, about three-quarters (74 percent) of Americans said they favored changing the law to allow them to buy prescription drugs from Canada (Harris Interactive Poll 2006c). In 2005, more than two-thirds thought that the change would make medicines more affordable without sacrificing safety or quality (70 percent) and disagreed that allowing drugs imported from Canada would lead U.S. drug companies to do less research and development. Nearly two-thirds (65 percent) also disagreed that it would expose Americans to unsafe medicines from other countries (Kaiser/HSPH 2005).

At the same time, three-quarters (77 percent) of Americans said they favored changing the law to allow the federal government to use its buying power to negotiate with drug companies to obtain a lower price for prescription drugs for people on Medicare. Majorities say that such a change would make medicines more affordable for people on Medicare (78 percent) and that it makes sense because the government already negotiates prices for the Departments of Defense and Veterans Affairs (68 percent). A majority (57 percent) disagreed that it would lead U.S. drug companies to do less research and development (Kaiser/HSPH 2005).

Majorities also believe that each of these measures would provide at least some help in reducing prescription drug costs overall. In 2005, more than three-quarters said that allowing Americans to buy prescription drugs imported from Canada would help a lot (42 percent) or some (37 percent) in reducing prescription drug costs in the United States, while 18 percent thought it would not help much or at all. Similarly, about eight in ten said that allowing the federal government to negotiate with drug companies to lower drug prices for people on Medicare would help a lot (31 percent) or some (48 percent) in reducing prescription drug costs, but 18 percent thought it would not help much or at all (Kaiser/HSPH 2005).

The Medicaid Program

In regard to the numbers of people enrolled, Medicaid, the federal-state insurance program for low-income and disabled people, is now the nation's largest public insurance program, exceeding even Medicare.

Today, Medicaid is seen as a very important program by the general public. In 2005, nearly three-fourths (74 percent) of adults said Medicaid was a very important government program, ranking it close behind Social Security (88 percent) and Medicare (83 percent), equal to federal aid to public schools (74 percent), and above defense and military spending (57 percent) (Kaiser Family Foundation Poll 2005).

Nonetheless, politically Medicaid is often discussed both positively and negatively. It is seen as the country's safety net program for low-income people, but also as a program that is becoming too expensive and is threatening the stability of future federal and state budgets.

As a result, six in ten Americans believe that Medicaid is in a financial crisis (22 percent) or has serious problems (39 percent). Policymakers have offered a number of proposals designed to address these concerns, but in 2005 when the public was asked about several of them, none received majority support. About four in ten favored reducing the number of people qualifying for the program (44 percent), lowering payments by Medicaid for prescription drugs (42 percent), lowering payments to doctors and hospitals (41 percent), increasing enrollees' copayments and deductibles (41 percent), and not permitting middle-class elderly to transfer their assets to children in order to qualify for Medicaid (37 percent).

One Medicaid cost-saving proposal that has received much attention in Washington would allow states to offer fewer basic benefits than currently required by federal law. In 2005, nearly six in ten people (58 percent) believed that all states should be required to offer the same set of core health care benefits in order to receive federal funding, whereas nearly four in ten (39 percent) said states should be able to decide which benefits to offer (Kaiser Family Foundation Poll 2005).

As we saw with Medicare, the public is concerned about the financial future of the Medicaid program but is unwilling to support many of the specific policy proposals that might help resolve its problems.

Views of Quality of Care

As discussed previously, most Americans are satisfied with the quality of medical care they and their families receive, and they do not see the issue as a top problem. However, they are worried about the possibility that in the future they or a family member could be the victim of a medical error, a specific type of quality-of-care problem. Indeed, nearly half (48 percent) of the public said in 2004 that they were concerned about the safety of the medical care that they and their families received (Kaiser/AHRQ/HSPH 2004).

The public reports substantial experience with medical errors. After being read a common definition of a medical error, about one in three people (34 percent) said that they or a family member had been subject to a medical error at some point in their life. This included 21 percent of all Americans who reported that a medical error had caused “serious health consequences” such as death (8 percent), long-term disability (11 percent), or severe pain (16 percent). About one in seven of those who said that the error caused serious health consequences (14 percent, or 3 percent of all Americans) reported that they or their family filed a malpractice lawsuit as a result (Kaiser/AHRQ/HSPH 2004).

Americans are most likely to cite a heavy workload, inadequate staffing, and poor communication among health care providers as causes of medical errors. About three in four (74 percent) said in 2004 that health care professionals' workload, stress, or fatigue was a very important cause of medical errors. Nearly as many said that doctors' lack of time with patients (70 percent), too few nurses in hospitals (69 percent), and health professionals' not working together or not communicating as a team (68 percent) also were very important causes of medical errors. And nearly half (46 percent) named the lack of computerized medical records as a very important reason for medical errors (Kaiser/AHRQ/HSPH 2004).

Americans support some other proposed policy solutions to the quality-of-care problem, particularly to reduce the number of medical errors. When read a list, the majority of Americans in 2004 thought the following would be very effective in reducing the number of medical errors: (1) giving physicians more time to spend with patients (79 percent), (2) requiring hospitals to develop ways of preventing medical errors (72 percent), (3) improving health professionals' training (72 percent), (4) requiring hospitals to report all serious medical errors to a state agency (71 percent), (5) increasing the number of nurses in hospitals (67 percent), (6) reducing the work hours of physicians in training to prevent fatigue (66 percent), (7) using only physicians trained in intensive care medicine in intensive care units (66 percent), and (8) suspending the licenses of health professionals who make medical errors (54 percent) (Kaiser/AHRQ/HSPH 2004).

The public is divided on the widely discussed policy issue about whether care for certain procedures should be limited to high-volume medical centers. In 2002, 49 percent thought that an error would be more likely at a low-volume center. But the other half thought either that an error would be more likely at a high-volume center (23 percent) or that volume would make no difference (26 percent). The majority of the public, however, did not think limiting certain high-risk procedures to high-volume-performing medical centers would be a very effective way of reducing the likelihood of medical errors (Blendon et al. 2002).

Opinion polls point to a gap between the views of the public and many experts on proposed approaches to preventing medical errors and improving quality of care. One of the central tenets in the experts' reports is that errors should be viewed as due primarily to failures of organizational systems rather than failures of individuals. But this is not a premise that the public embraces. Rather, Americans believe that the health professionals responsible for errors with serious consequences should be sued, fined, and subject to suspension of their licenses. In other words, they hold individual health professionals personally responsible for errors. Although they support making more quality information available to consumers and requiring hospitals to develop ways of preventing future errors, the public currently does not support legislative changes enabling individuals who make errors to escape sanctions (Blendon et al. 2002).

Nevertheless, Americans recognize the existence of quality problems and are interested in receiving more objective information in order to make better-informed health care decisions. They generally believe that a provider's history of medical errors and professional experience is the most useful information to assess quality of care. For example, in 2004, seven in ten (70 percent) of those people surveyed said that information about medical errors or mistakes would tell them “a lot” about the quality of care in a hospital. Consumers were almost as likely to report that the number of times a hospital had performed a particular test or surgery (65 percent) and the number of patients dying after surgery (57 percent) told them “a lot.” Fewer, but still about half, said that how patients rate the quality of a hospital's care (52 percent) or the number of patients who do not receive standard recommended treatments (47 percent) told them “a lot” about quality (Kaiser/AHRQ/HSPH 2004).

The public believes that information from health care providers about quality of care should be required by law. More than nine in ten Americans (92 percent) said that reporting serious medical errors should be required, and most (63 percent) wanted this information released publicly. Almost nine in ten (88 percent) said that physicians should be required to tell a patient if a preventable medical error had seriously harmed the patient (Kaiser/AHRQ/HSPH 2004).

Despite widespread national efforts to give the public some of this quality-of-care information, surveys show that most of them cannot remember receiving any of it, and few report using it for their own health care decisions. In 2004 about one out of three (35 percent) people said they had seen information comparing the quality of health plans, hospitals, or doctors in the past year—a higher percentage than in 2000 (27 percent) (Kaiser/AHRQ 2000; Kaiser/AHRQ/HSPH 2004).

Only one in five (19 percent) Americans in 2004—up from 12 percent in 2000—said they had used comparative quality information about health plans, hospitals, or other providers to make decisions about their own care. More specifically, 14 percent of consumers in 2004 said they had used quality information to choose health plans, 8 percent to choose hospitals, and 6 percent to choose doctors (Kaiser/AHRQ 2000; Kaiser/AHRQ/HSPH 2004).

When looking for information on quality of care, people were most likely to ask their doctor, nurse, or other health professional (65 percent said they were very likely to do this) or to ask their friends and family (65 percent). Fewer would go online (37 percent), contact someone at their health plan (36 percent), call a state agency (18 percent), or refer to a section of a newspaper or magazine (16 percent) (Kaiser/AHRQ/HSPH 2004).

People were also more likely to choose a hospital according to familiarity (61 percent) rather than a high rating (33 percent). They were divided as to what was more important when choosing a surgeon—whether he or she had treated a friend or family member without any problems (48 percent) or had received high ratings (46 percent). They also were divided as to which was more important when choosing a health plan—whether it was recommended by a friend (45 percent) or rated highly by experts (49 percent) (Kaiser/AHRQ/HSPH 2004).

One reason that many people may not rely on quality ratings when making decisions is that a majority do not discern much difference in the quality of health care offered by hospitals, doctors, or health plans in their local area. In 2004 about four in ten could find noteworthy differences in quality among area hospitals (38 percent) and health plans offering coverage in their area (37 percent). About one-third saw big differences in quality among family/primary care doctors (33 percent) and among medical specialists (34 percent) in their area (Harris Interactive Poll 2004).

Conclusions

Our review of more than twenty-five years of public opinion regarding health care policy has shown that Americans are, at the same time, both dissatisfied with the current health care system and relatively satisfied with their own health care arrangements, a situation that has not changed substantially since the time of the proposed Clinton health care plan (Jacobs, Shapiro, and Schulman 1993). As a result of the conflict between these perspectives, there often is a wide gap between the public's support for a set of principles concerning what needs to be done about the overall problems facing the nation's health care system and their support for specific policies designed to achieve those goals (Hetherington 2005). When confronted with the trade-offs, which could include changing their health care arrangements or benefits or raising taxes, the public tends to reject policies addressing the national problems that most concern them. This can be seen in Americans' widespread support, in principle, of a national health insurance plan and their nearly consensual recognition that Medicare and Medicaid face serious long-term financial problems that need to be fixed. Despite these conflicting views, the public usually has been unwilling to support those policies that would offer universal coverage or make Medicare and Medicaid financially more secure.

Without any major changes in national health care policy, Americans are likely to remain anxious about the impact of future health care costs on their ability to buy health care. Accordingly, public support for major reform could grow in this environment, particularly if national leaders were again to focus on the issue. The challenge, should the issue reemerge, is that although a majority of Americans express dissatisfaction with the nation's health care system and say they favor universal health insurance coverage, they do not feel the system is broken beyond repair. In addition, they have not reached a consensus on an alternative health care system or on the specific type of national plan to cover the uninsured.

Another challenge is the growing income inequality in the United States and its impact on the nation's public policy decision-making process. Recent research has shown that government decisions are more responsive to the policy preferences of upper- and middle-income groups (Bartels 2005; Gilens 2005; Jacobs and Skocpol 2005). Our analysis found a continuing difference in satisfaction with the current system between those who have higher incomes, have health insurance coverage, and feel secure about their future health coverage, and those who do not. In recent years, this situation may have delayed serious action on major reform, because the more politically influential people remain most satisfied with the status quo.

If, however, financial insecurity about health care expands to more of the middle class and the problem of the uninsured worsens, these anxieties may allow the issue of major reform to reemerge. In addition, this issue is likely to gain more prominence among the public and voters if war and terrorism recede as national priorities.

Without a fiscal crisis in Medicare or Medicaid, the public is unlikely to support major reform in these programs, and so two issues will remain unresolved. The first is whether or not the public will support the tax levels necessary to sustain the Medicare and Medicaid programs in their current form. The second is whether or not the public will support private-sector, market-oriented approaches within these public programs.

These are the questions likely to shape the health policy debates of the coming years.