A Kellogg Foundation Health Initiative
Community Voices:  HealthCare for the Underserved

Community Voices  |  National Survey  |  News Release

I. Introduction

II. Executive summary of key findings

III. Detailed findings

I. Introduction

The healthcare debate disappeared from the front page of the nation’s newspapers after the Clinton healthcare initiative failed early in the President’s first term in office. The needs, however, remain. The Community Voices Initiative, supported by the W.K. Kellogg Foundation, seeks to introduce new ideas and develop solutions to the needs of communities in which healthcare is lacking.

IssueSphere asked Belden Russonello & Stewart to undertake public opinion research to look at how Americans view their own and the public’s access to healthcare as it now exists and what might be changed. The following report covers findings from a national survey of American about:

• the cost, access, and quality of healthcare today;

• the role of the insurance industry; and

• interest in proposals to make changes in the way healthcare is delivered

The survey was conducted in the latter half of May, 1999 among 1,500 adults age 18 and older, residing in the US. The random-digit-dial sample was provided by Survey Sampling, Inc., and interviewing was performed by telephone.

II. Executive summary of key findings

The great majority of Americans believe that healthcare should be a right -- something that we guarantee to all. Support for this position holds among all political and demographic groups -- left to right and rich to poor.

The medical services that the public believes should be guaranteed is comprehensive, ranging from basic doctor visits, survery and emergency treatment, prenatal care and childbirth, to eye and dental care, treatment for mental illness and substance abuse, and prescription drugs. Treatment for drug and alcohol abuse is supported by a smaller number than other services, yet this too garners a sizable majority (67%). Only alternative medicines, such as acupuncture or herbal medicines, is not approved as a services that should be guaranteed to all.

The American healthcare system is itself ailing according to public opinion, according to the great majority. Only 15% say it is in good health. Half call it "somewhat ill," 26% say it is in "critical condition," and nine percent call the system "terminally ill."

While many members of the public regard their own access to health care as satisfactory, they are seriously concerned with the condition of the health care system as it exists for other Americans. Two thirds say their own access to health care deserves an A or a B, but that only two in ten say access for low-income people should get these marks. Nearly half would give a D or an F to the system for making way for low-income people.

The public views the healthcare system as performing well in the more complex and sophisticated aspects, providing a high quality of professional and technical infrastructure. This includes training medical professionals, providing specialists as well as general practitioners, and making technological and research advances. Americans also say their system performs well in the most fundamental area of making sure babies and children can get the care they need in early in life.

However, taking care of the old and homebound, communicating well with patients, and securing oral health are areas of less satisfaction.

And the system is seen as failing to keep a handle on costs and industry profit-making.

III. Detailed findings

Most Americans believe we should all have a full range of healthcare services guaranteed.

• Eight in ten Americans are in agreement that access to healthcare should be guaranteed or a right. Fifty-eight percent strongly agree and 21% more agree somewhat that it should be "guaranteed." When we substituted the term "healthcare should be a right," virtually the same percentages agreed (59% strongly and 20% somewhat).

Majorities in all subgroups of the population that we examined agree that it should be guaranteed or be a right. That is, even among conservatives, Republicans, and older Americans, large majorities agree. However, agreement that healthcare should be a fundamental right is strongest among liberals (71% agree strongly) and Democrats (70%), the uninsured (71%), people who have never received public assistance (66%), and Blacks (65%) and Hispanics (66%) [Questions 7a and b].

• A majority agree that we should guarantee healthcare for legal immigrants -- when we single out this group, although the figures reveal less enthusiasm than when the question speaks more generally. Thirty-three percent agree strongly and another 33% agree somewhat when asked about guaranteeing healthcare for legal immigrants and 39% agree strongly and 31% somewhat when we use the term "a right." [Questions 8a and b]

• The public believes basic healthcare has many parts. Americans say the comprehensive coverage that should be guaranteed includes a wide array of services, from basic doctor visits and emergency service, to eye and dental care. The table below shows that well over eight in ten support guaranteeing a comprehensive set of services.

One area of less support is treatment for drug and alcohol problems -- but even in this case 67% say it should be included.

The one major exception is alternative medicines such as acupuncture and herbal medicines. Only 43% approve of covering these services. [Question 9-21]

While many members of the public regard their own access to health care as satisfactory, they are seriously concerned with the condition of the health care system as it exists for other Americans.

• Two thirds of Americans say they would grade their own access to healthcare with an A (33%) or a B (35%). Twenty percent give it only a C and 10% a D or an F. People with the least financial resources, minorities, single parents, and of course those without health insurance, are less satisfied with their access than others. [Question 22]

• When thinking about the nation as a whole, forty-eight percent call it "somewhat ill," 26% say it is in "critical condition," and nine percent call the system "terminally ill." Only 15% say the healthcare system in the US is "in good health." [Question 5]

• Nearly half of the public gives failing and near failing grades to the "access low-income people in this county generally have to health care (27% D and 20% F). Only 21% give it an A (eight percent) or a B (13%), and 25% a grade of C. [Question 23]

• The public is split in their impressions of whether people in their communities who do not have health insurance are able to get the care they need (41%) or unable to get treatment (46%).

The public views the system as doing good job at the high end -- providing a high quality of professional and technical infrastructure -- and in the most fundamental area of starting children out right. However, taking care of the old and homebound, communicating well with patients, and securing oral health are areas of less satisfaction. And the system is seen as failing to keep a handle on costs and industry profit-making.

• As the table shows, American medicine and healthcare are seen as fairly successful in training medical professionals, making sure there are enough physicians, both specialists and generalists, and technological advances and research. [Questions

Taking care of children is another area of success; 56% grade the system an A or a B on "making sure babies and children get the care they need early in life." [Question 31]

• On the other hand, the public tells us the system is just all right when it comes to getting physicians to communicate thoroughly with patients, and providing adequately for the elderly. [Question 34 and Question 33]

• The healthcare system is barely getting by, according to public opinion, in providing adequate dental and oral health care and making homecare available and affordable for the elderly and sick. [Question 35 and Question 36]
  
  

• Finally at the bottom of the attributes of our system lies the issue of cost and profits. More Americans say the system deserves a D or and F on making sure patients needs come before the economic interest of the health industry; and fully half give these bad grades to the system for failure to control costs. [Question 26 and Question 32]

Affordability of care is the most troubling area for Americans when thinking about their own healthcare situation.

• Overall, the most pressing concern with healthcare in the US is cost (44%), as compared to quality (29%) or access (24%). [Question 4]

• Nearly three in ten (29%) say they have been with out health insurance at some time within the last five years, because they could not afford it. This is particularly true of 18 to 29 year olds (43%), and people with incomes under $25,000 (44%).

Clearly the public believes too much of the decision making about health is in the hands of insurance companies: Only one percent of Americans believe that insurance companies should have the biggest say in the kind of healthcare they receive, but 42% say insurers do have that control. Sixty-five percent believe they themselves should have the most say, and another 31% would give that responsibility to their doctors.

Who has the biggest say over the kind of healthcare you receive?

Twenty six percent say their insurance company has refused to pay for services they felt were needed. This is particularly true of people who have been on public assistance at some time (38%). [Question 58]

The public gives the insurance industry weak grades on choice and reimbursement issues. In the case of allowing doctors to make decisions about treatment, allowing people enough choice of doctors, allowing patients to see specialists, and reimbursing enough, only about a third of the public would grade the health insurance industry and A or a B. About a third concedes the industry a C on each of these and the final third gives a D or an F. [Question 37, Question 38, Question 39, Question 40]

 

	A+B	A	B	C	D	F
Allowing patients to see specialists when patients believe it is important	37%	16%	21	34	18	10
Allowing doctors -- rather than insurance companies -- to make the decisions about treatment.	33%	17%	16	28	21	15
Paying for or reimbursing people for enough of their medical expenses	31%	11%	20	34	20	10
Giving people enough choice about who their doctor is.	30%	12%	18	32	20	16

Furthermore, the public holds the insurance industry responsibly for driving up costs. Eighty-five percent agree (63% strongly) that "much of the expense of healthcare in this country is created by insurance bureaucracy." [Question 43]

HMOs and PPOs come in for serious criticism: By a ratio of two to one, Americans say managed care has decreased the quality of healthcare for the patient (60%). Only 28% say they have improved it. Members of HMO and PPO programs are as critical as other people. [Question 45] A plurality (49%) say managed care plans have harder to get preventive services such as immunizations and routine exams. [Question 44]

The Community Voices Initiative is exploring ways to improve healthcare for the underserved in this country. In focus groups and then in the survey we presented various ideas for changing the way the system operates. The results reveal that the public believes all of the array of ideas -- from customizing to local communities to training more minorities and women as professionals -- to would improve healthcare in the US. However, there are clearly some proposals that are more popular than others and a few that do raise the objections of a minority.

Localizing: A key concept of the Initiative is devolution, bringing choices, resources, and decisions to the local level and away from centralized decisions and services.

• The aspect in this category that is most popular is customizing services to local communities. We tested this two ways and each were viewed as being great improvements. Seventy-five percent said customizing health services to the local communities, such as "services for the elderly or for people with HIV or some other special need," would be an improvement (33% said it would improve healthcare very much). When we changed used the phrase "such as for families who don’t speak English or for the needs of different ethnic or cultural groups in a community," 70% called customizing an improvement (37% very much). [Question 51a and 51b] (Half the sample was asked each version of the question.)

• The public also likes the idea of moving services to more convenient places. Sixty-eight person say shifting "routine healthcare out of large hospitals and into local community centers" would be an improvement (31% very much). Similarly 69% say the system would be bettered by offering more services "in places such as schools, factories, and shipping centers" (32% very much). [Question 50 and question 53]

• The vulnerable spot in the proposal to reorganize on a more local design, is in creating "local health systems that make the decisions about what services to offer on the community level. Only 19% say this would improve the situation very much and another 37% say it would be somewhat of an improvement -- giving this concept a total of 56% in the positive column. While there is more positive feeling about this than negative, the level of enthusiasm is less than with other suggestions. [Question 47]

• A small majority say that having one uniform system would be an improvement -- but here again, support is not extensive and opposition is sizable. Thirty four percent say it would be very much an improvement and another 19% say it would be somewhat of one, for a total of just over half (53%) in the favorable column. Meanwhile, 27% say it would worsen the system -- the highest number is opposition to any of the concepts we tested. [Question 46]

In short, while a majority could be ginned up in support of uniform healthcare, ideas about customizing services and moving resources to de-centralized smaller systems have considerably more resonance with the public.

Record keeping: Anther popular idea is keeping individual medical records in a computer database, so that it can be shared among health and welfare organizations. Thirty-five percent say this would very much improve the system and another 28% say it would be somewhat of an improvement. Two in ten, however, say this would worsen the situation.

[Question 55]

More preventive care: One of the most popular ideas we put forth is moving "financial resources out of specialized medicine and into more preventive and primary care." Seven in ten (69%) say this would be an improvement. A third (31%) say it would be very much an improvement. Opposition, at seven percent, is negligible. [Question 52]

Variety of providers and services: Drawing more women into medicine and to a slightly smaller extent, attracting more minorities are seen as good development (61% and 56% respectively call there improvement). However, a third or more say encouraging more women and more to become doctors and other health professionals would not make much difference. [Question 49 and Question 48]

Offering alternative medicine along side traditional Western medicine is viewed as an improvement by 57% (24 very much) and as make little impact by 26%. Only nine percent say the system would be made worse. [Question 54]

G. A new federal department

The great majority (67%) of the public would approve of the establishment of a new department in the federal government to provide health insurance for unemployed and low income, working people. Most -- 44% -- are strongly in favor of such a move.

 
A Kellogg Foundation Health Initiative
Community Voices: HealthCare for the Underserved

Community Voices  |  Summary of Findings  |  News Release

[Also online: PDF (Portable Data Format) version of survey, requires Acrobat Reader]

Do you consider ______ as services that should be included in basic healthcare that everyone is guaranteed? [SPLIT A]/that everyone has a right to? [SPLIT B]*

 

	Yes	No	DK/ Ref
9. Doctor visits and surgery, when sick or injured	92%	6	1
10. Routine check ups	89%	10	1
11. Prenatal care for pregnant women	93%	5	1
12. Childbirth	90%	8	2
13. Trips to the emergency room	89%	8	2
14. Dental check ups and oral health care	87%	11	2
15. Eye check ups and care	88%	11	1
16. Treatment for mental illness	88%	10	2
17. Treatment for drug and alcohol problems	67%	29	4
18. Prescription drugs	87%	11	1
19. Alternative medicines, such as acupuncture or herbal medicines	43%	50	7
20. Flu shots	80%	18	2
21. Immunizations for children	96%	4	*
*Percents are a combination of answers to both versions A and B.

22. If you were to use grades, as if you were in school, would you give A, B, C, D, or F to the ACCESS you and your family have to healthcare?

A 33% B 35 C 20 D 6 F 4 DON’T KNOW 1 REFUSE *

I would like for you to grade our healthcare system on the following. First, would you say our healthcare system should get an A B C D or F on ________________

 

	A	B	C	D	F	DK/ Ref
25. Training highly qualified doctors and other health professionals.	28%	38	24	5	2	3
26. Making sure the needs of patients come before the economic interests of the health industry.	14%	14	30	22	17	2
27. Making enough primary care doctors or general practitioners available to take care of the population.	22%	27	33	11	4	2
28. Making advanced medical technology available.	23%	31	29	11	4	3

 

	A	B	C	D	F	DK/ Ref
29. Making medical specialists available.	18%	30	32	12	4	3
30. Conducting the kind of medical research that improves Americans’ health and well-being.	24%	35	27	7	3	4
31. Making sure all babies and children get the care they need early in life.	26%	30	27	9	4	4
32. Keeping healthcare costs down.	13%	11	26	24	25	2
33. Making sure the elderly get enough care.	20%	21	30	18	9	3
34. Getting doctors to give patients enough information.	19%	25	33	15	6	1
35. Making sure people get enough dental and oral health care.	14%	18	34	20	10	3
36. Making healthcare workers available and affordable for elderly and sick people at home.	18%	17	30	21	9	4

Thinking about the insurance industry, would you grade it as A B C D or F on:

 

	A	B	C	D	F	DK/ Ref
37. Giving people enough choice about who their doctor is.	12%	18	32	20	16	2
38. Allowing doctors -- rather than insurance companies -- to make the decisions about treatment.	17%	16	28	21	15	3
39. Paying for or reimbursing people for enough of their medical expenses.	11%	20	34	20	10	4
40. Allowing patients to see specialists when patients believe it is important.	16%	21	34	18	10	2

Here are some ideas that various people have suggested for changing healthcare in this country. Please tell me as I read each one if you think it would improve the system, make it worse, or not have much impact. [Is that very much or somewhat?] The first one is... [ROTATE}

 

	Very much improve	Smwht improve	Smwht make worse	Very much worse	Not much impact	DK/ Ref
46. Create one uniform national healthcare system for everyone, so that all of us have the same coverage	34%	19	10	17	13	6
47. Create local health systems that make the decisions about what services to offer on the community level	19%	37	9	8	21	5
48. Encourage more minorities to become doctors and other healthcare professionals	29%	27	2	1	38	3
49. Encourage more women to become doctors and other healthcare professionals	34%	27	1	1	34	2
50. Shift routine healthcare out of large hospitals and into local community centers	29%	39	6	3	18	5
Base N= 750 Split A 51a. Customize health services to the needs of local communities, such as services for the elderly or for people with HIV, or some other special needs	33%	42	4	2	14	5
Base N= 750 Split B 51b. Customize health services to the needs of local communities, such as for families who don’t speak English or for the needs of different ethnic or cultural groups in a community	37%	33	4	4	17	6
52. Move financial resources out of specialized medicine and into more preventive and primary care	31%	38	5	2	16	7

 

	Very much improve	Smwht improve	Smwht make worse	Very much worse	Not much impact	DK/ Ref
53. Offer more health services in places such as schools, factories, and shopping centers	32%	37	3	3	22	3
54. Offer more alternative medicine along side traditional Western medicine	24%	33	5	4	26	8
55. Keep records of individuals’ medical history in a computer database that can be shared with other health and welfare organizations	35%	28	7	12	14	4