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Americans express broad, and in some cases growing, discontent with the U.S. health care system, based on its costs, structure and direction alike - fueling cautious support for a government-run, taxpayer-funded universal health system modeled on Medicare.
In an extensive ABCNEWS/ Washington Post poll, Americans by a 2-1 margin, 62-32 percent, prefer a universal health insurance program over the current employer-based system. That support, however, is conditional: It falls to fewer than four in 10 if it means a limited choice of doctors, or waiting lists for non-emergency treatments.
Support for change is based largely on unease with the current system's costs. Seventy-eight percent are dissatisfied with the cost of the nation's health care system, including 54 percent "very" dissatisfied.
Indeed, most Americans, or 54 percent, are now dissatisfied with the overall quality of health care in the United States -- the first majority in three polls since 1993, and up 10 points since 2000.
Yet apprehension about the system is counterbalanced by broad satisfaction among insured Americans with their own current quality of care, coverage and costs -- a situation that tends to encourage a cautious approach to change. While the system is seen to have gaps, flaws and an uncertain future, it's also seen to work for most people.
Among insured Americans, 82 percent rate their health coverage positively. Among insured people who've experienced a serious or chronic illness or injury in their family in the last year, an enormous 91 percent are satisfied with their care, and 86 percent are satisfied with their coverage.
Still, cost concerns are prompting some evasive action: Nearly one in four Americans, 23 percent, say they or someone in their family put off medical treatment in the last year because of the cost. (Among uninsured people, this soars to 49 percent.) And 12 percent say they or someone in their household bought prescription drugs from a foreign country -- a violation of federal law.
In addition to universal coverage, there are other areas in which the public favors change. Nearly seven in 10 say it should be legal to buy prescription drugs from foreign countries, despite the FDA's safety qualms. Three-quarters favor the $400 billion plan to cover prescription drugs in Medicare; most would pay higher taxes to fund it. Most also favor the creation of HMO-based Medicare options that cover prescription drugs but limit the choice of doctors.
There's long been a schism in concern about health care costs: Most Americans are dissatisfied with the costs of the system overall, and apprehensive about their future expenses -- but satisfied with their own current costs.
That continues, but the gap may be narrowing. In this poll, 64 percent of insured people remain satisfied with their own health care costs -- a sizable majority, but down from a high of 75 percent in a 1995 ABCNEWS poll. (And among uninsured people, far fewer -- 30 percent -- are satisfied with their costs.)
Moreover:
Fifty-nine percent of insured Americans are worried about being able to continue to afford health insurance in the future (a quarter are "very" worried). This doesn't include those who currently lack health coverage -- 17 percent of adults in this survey.
Two-thirds of insured Americans say their health insurance premiums have been going up lately; a third say they've been rising sharply. Fewer but still a sizable number, 44 percent, say their deductibles and co-pays have been rising.
Most people don't blame their employer: Among those who have employer-supported plans, just about a quarter say their employer is paying less of the cost of their coverage. As many say their employer is paying more.
As noted above, 54 percent of Americans are now dissatisfied with the overall quality of health care in this country, up from 44 percent in 2000. Notably, that includes 52 percent of insured Americans, as well as 67 percent of those who lack insurance.
Directions and Income Gaps
The structure, fairness and direction of the current system raise concerns as well. Fifty-three percent of privately insured Americans are worried about losing their insurance because of the loss of a job (three in 10, "very" worried).
And the ranks of the uninsured -- up last year, according to the Census Bureau -- prompt some alarm: Eighty percent (up from 71 percent in 1999) say it's more important to provide health care coverage for all Americans, even if it means raising taxes, than to hold down taxes but leave some people uncovered.
In terms of the future, 64 percent of Americans think the country is headed toward a system of rationed health care, in which an increasing number of treatments won't be covered because they're too costly, not essential or have too little chance of success. And nearly eight in 10 oppose those kinds of restrictions.
As to be expected in a primarily employer-based program, there is a huge income gap in insurance haves vs. have-nots. Among Americans with household incomes of $50,000 a year or more, just eight percent are uninsured. Among those with incomes under $50,000, the number of uninsured swells to one in five. Among just those with incomes under $20,000, it grows to nearly one in three.
Similarly, lower-income Americans are much less apt to have private insurance. Among those with incomes under $20,000, just 30 percent have private insurance; the rest have government-based coverage (Medicare or Medicaid), or none. Among people in $50,000-plus households, by contrast, 83 percent are privately insured.
All the concerns cited above underlie the public's interest in universal care. This poll asks people what they'd prefer -- a "universal health insurance program, in which everyone is covered under a program like Medicare that's run by the government and financed by taxpayers," or "the current system, in which most people get their health insurance from private employers, but some people have no insurance."
Previous polls have asked this differently; one last year asked if people would support or oppose "a national health plan, financed by taxpayers, in which all Americans would get their insurance from a single government plan," and found 40 percent support. The wording in this ABCNEWS/ Washington Post poll weighs the proposal against the current system, and adds the Medicare model to the description. Context also can play a role; this poll asks about universal health after a long and probing series of questions on the current system.
As noted, support for this universal system is conditional. If it limited Americans' choice of doctors, support drops sharply, from 62 percent to 35 percent. Likewise, if it meant waiting lists for some non-emergency treatments, support falls to 39 percent.
There also are political and ideological aspects to views on universal health. Democrats favor it by more than 3-1, and liberals by 6-1, while Republicans and conservatives divide evenly. The current system is preferred by a majority (52 percent) in one group: People with household incomes over $100,000 a year.
Comparisons With Canada's Health System
Views of the government-run universal health system in Canada also show the public's interest in such a system. Suspending customary chauvinism, just 29 percent of Americans think the overall U.S. health care system is better than Canada's; more, 37 percent, think it's worse than Canada's.
There are distinctions on particular aspects of the two systems. Americans by 34-16 percent are more apt to say the U.S. system offers better quality of care. But by 18-41 percent they say the U.S. system is worse when it comes to cost; and by a narrower 27-34 percent they see the U.S. system as worse in terms of availability of coverage.
As noted, personal experience with the current system is positive, which serves to temper all these concerns. Among all Americans -- even those who lack coverage -- large majorities express satisfaction with their quality of health care (85 percent), ability to see a doctor (83 percent), ability to see good specialists (78 percent) and ability to get the most sophisticated treatments (77 percent).
Among uninsured Americans these ratings are lower -- but, perhaps surprisingly, still mostly positive: Sixty-nine percent rate the quality of their health care positively; 73 percent, their ability to see a doctor; 55 percent, their ability to see top-quality specialists; 58 percent, their ability to get the latest treatments.
There are areas in which public views do not support some criticisms of the current system; one is the suggestion that it's too complex to understand. Instead, 83 percent of insured Americans say they are familiar with the terms and conditions of their plan (although fewer, 36 percent, are "very" familiar with these).
Similarly, among those who have a choice of plans (57 percent), eight in 10 again say they are familiar with the options available to them.
In another area, most insured people don't report persistent problems collecting on their claims. Eighty percent say their plan "tends to pay your medical expenses without much problem," essentially unchanged since 1997.
Twenty-nine percent say their insurer has refused to pay all or part of a treatment that they thought should have been covered. Of those who fought it, just over a quarter did win better coverage.
Methodology
This ABCNEWS/ Washington Post poll was conducted by telephone Oct. 9-13, 2003, among a random national sample of 1,000 adults. The results have a three-point error margin. Fieldwork was conducted by TNS Intersearch of Horsham, Pa.
See the full questions and results .
Previous ABCNEWS polls can be found in our Poll Vault .
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