Happy with Health Care?

The American Association of Health Plans (AAHP)—the main HMO trade association—has a novel strategy for persuading Congress not to take patients' rights seriously. Rather than arguing with polling data that shows broad public support for tough HMO regulation, they point to other polling data showing that Americans are basically satisfied with managed care plans. Therefore, not to worry, say the lobbyists at AAHP; the whole thing will blow over and legislators can get away with avoiding the issue.

Well, so far, not so good. Last month, the House passed a stringent HMO bill, with the support of 60 Republicans and almost every Democrat, that makes it easier for patients to visit doctors they prefer, get emergency-room bills paid, and receive experimental treatments, as well as making it substantially easier to sue HMOs (the provision of the bill most strenuously opposed by AAHP). Evidently, House lawmakers were not convinced they could get away with ducking the issue, despite the AAHP's argument.

Of course, the Senate bill is much weaker, and we're a long way from final legislative action. The issue is likely to resurface in the 2000 campaign, and the same argument will be rolled out again by the HMO industry. It's worth asking: Do they have a case? Is the public basically pretty happy with the health care plans they have and therefore pretty unconcerned with improving their health care?

Let's start with the grain of truth in the HMOs' case. It's true that large majorities, including those with HMOs, say they are "satisfied" with the quality of health care they receive from their insurance plan—a public opinion finding of long standing. But it's also true that HMO members are less satisfied than members of other types of plans. For example, a July 1999 CBS poll found that 86 percent of insured people were satisfied with the quality of care received under traditional fee-for-service plans, compared to 69 percent among those with HMOs.

Secondly, for virtually any institution or policy one might choose to name, poll findings about personal satisfaction are invariably the most optimistic. There is considerable dispute about why this is so, but analysts generally agree that focusing on such ratings understates the public's level of concern in any given area. For example, no one would argue, presumably, that the public is delighted with the educational system today and not particularly concerned with improving the public schools simply because parents tend to give high ratings to the school their own children attend.

And thirdly, it's not surprising that a majority of Americans express broad satisfaction with their health plan because in most years they do not experience serious illness. After all, who sees our health care system at its nastiest? Sick people who get turned down when they and their doctors seek authorization for care or who can't afford sudden medical bills.

Finally, once you look beyond personal-satisfaction ratings for health insurance plans, there is plenty of evidence of public concern about HMOs in particular and the health care system in general. Take the general effect of HMOs on the delivery of health care. A June 1998 NBC/Wall Street Journal poll found 54 percent saying HMOs have hurt patients developing long-term relationships with a particular doctor, compared to 14 percent who say they've helped. Analogous figures for doctors, not insurers, controlling treatment were 54-14 percent; for being able to see a specialist, 50-22 percent; for spending adequate time with a doctor, 47-13 percent; for doctors informing patients about available options, 47-16 percent; and for providing access to all available medical treatment, 45-24 percent.

An August 1998 Kaiser Family Foundation/Harvard University survey found a similar pattern. Over three-fifths (62 percent) said that HMOs have made it harder to see medical specialists in the past several years, compared to 23 percent who said it has become easier; by 53 to 29 percent, the public said HMOs made it harder, not easier, to get care in general; by 56 to 23 percent, people said HMOs have decreased, not increased, the quality of health care for patients; and by 50 to 25 percent, they said HMOs have decreased, not increased, the quality of care for people who are sick.

This is a pretty negative assessment and helps explain why the public is so supportive of HMO regulation, despite their professed personal satisfaction with their own health care plans. As HMOs have come to dominate the health care marketplace, care and access to care have gone down in people's view, and they want that trend stopped.

But how about the other part of AAHP's argument—what public opinion analysts call salience? Perhaps there is considerable dissatisfaction with HMOs' effect on health care, and people would like to see the situation improved, but it doesn't really matter to them very much. The HMOs' hoped-for model here is campaign finance reform, where the public consistently endorses the need for change and just as consistently fails to get very excited about such change. To buttress their case, the HMOs point to recent surveys that show a "patients' bill of rights" ranking relatively low in a list of the public's legislative priorities.

The HMOs' problem here is the very high salience of health care as a general issue these days. Indeed, only education and Social Security typically run ahead of health care as important issues in the public's view. In effect, HMO regulation is serving as a lightning rod for public concerns about a very salient issue. That is, even though a patients' bill of rights just scratches the surface of the public's health care concerns, lawmakers realize they have to do something to address the issue, and a patients' bill of rights is a comparatively easy step to take.

And just what are these other concerns? Start with the fact that the public sees the need for major change in the health care system. A July 1999 CBS poll found 61 percent of the public agreeing that while there are good aspects to the system, fundamental changes are needed, and an additional 25 percent called for completely rebuilding the system. Just 12 percent endorsed the idea that only minor changes are necessary.

The major changes the public has in mind—outside the HMO issues just discussed—would appear to be driven by concerns about cost and coverage. A July 1998 CNN/Time poll found 43 percent saying American's ability to get health care coverage had gotten worse in the past five years, compared to 18 percent who said the ability to get coverage had improved. Even more lopsided, the same poll showed 64 percent saying health care costs had gotten worse and just 11 percent saying they had gotten better. Consistent with these sentiments, an open-ended question in the July 1999 CBS poll found "insuring everyone" and "health care costs" were the public's two top problems with the health care system. Similarly, in the July 1998 NBC/Wall Street Journal poll, the public's top three problems with the health care system were: "too many children lack adequate health care coverage," "long-term care for the elderly is unaffordable to most people," and "too many Americans lack adequate health care coverage."

Reflecting these concerns, the overarching issue of universal coverage is making a comeback, with both Democratic contenders for the presidential nomination reviving the subject. The NBC/Wall Street Journal poll just mentioned found 77 percent of the public supporting a guarantee of coverage for all Americans regardless of health or employment status, about as high a level as the same poll found in late 1993, before the defeat of the Clinton health plan. Similarly, in the July 1998 CNN/Time poll, 69 percent said they thought the federal government should guarantee health care for all Americans, close to the level of support in late 1993 and the highest recorded since that time.

Evidently, despite Americans' willingness to say they are "satisfied" with their health care plans, they harbor a lot of worries about the future—about treatment that could be denied them, about costs that could ruin them, and about loss of coverage—that make health care a tremendously potent political issue. HMOs are therefore whistling in the dark when they try to convince politicians that people don't care. On the contrary, not only is the public likely to look unfavorably on those who stand in the way of a patients' bill of rights, they are likely to demand more change even if such a bill actually passes. In that case, HMO lobbyists will be scrambling for new arguments—though if past experience is any guide, they will rely on the misrepresentation and misuse of polling data to make their case.