Over the past few years numerous studies and reports

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1 The Uninsured, The Working Uninsured, And The Public Many Americans appear to be unaware of just how many workers still lack insurance coverage. by Robert J. Blendon, John T. Young, and Catherine M. DesRoches ABSTRACT: Recent opinion surveys show a high level of public support for the current employer-based health insurance system. Many Americans are not aware that this system is endangered or that the number of uninsured persons is growing. The public appears to favor a two-track system for the working uninsured strengthening the existing employer-based system and developing a parallel system for those without employer coverage. Over the past few years numerous studies and reports have highlighted the growing numbers of Americans without health insurance and, in particular, the rise in the number of persons who are employed but lack health insurance coverage. These trends suggest that for many Americans the link between employment and health insurance is becoming increasingly fragile, and if trends continue, it will worsen in the years ahead. A number of recent policy proposals call for expanding the government s role in helping uninsured persons to obtain coverage. Some proposals would sever the link between employment and health insurance altogether and replace the employer-based system with a new system for obtaining coverage. 1 Many of these proposals would involve major changes in the way millions of Americans obtain health insurance and the amount and types of taxes and premiums they pay. As a result, deliberations over these proposals are likely to be seen as important by a large proportion of the American public. Given the attention that these proposals will receive and the fact that public opinion can have a major influence on public policy, it is important to better understand the public s attitudes about many of the issues related to resolving the nation s uninsurance problem. 2 This paper uses data from recent national opinion surveys to show DATAWATCH 203 Robert Blendon is a professor of health policy and political analysis at Harvard s School of Public Health and John F. Kennedy School of Government. John Young is a research project director, and Catherine DesRoches is a research associate, at the Harvard School of Public Health ThePeople-to-People Health Foundation, Inc.

2 D a t a W a t c h 204 PUBLIC OPINION what Americans think about six key areas relating to this issue. First, where on the public s agenda is the issue of the nation s uninsured? Second, what does the public know about the problem today? Third, what do Americans think government should do about people without health insurance? Fourth, what do Americans wish to do about the current employer-based health insurance system? Fifth, are Americans willing to pay increased taxes or premiums to help the uninsured purchase coverage? Finally, what are the implications of these findings for those concerned with solving the problem of the working uninsured? Data Sources And Methods The data presented here are derived primarily from three sources. The first is five surveys designed by researchers at the Harvard School of Public Health for the Robert Wood Johnson Foundation (RWJF). The interviews were conducted via telephone by International Communications Research (ICR) during five separate time periods between 9 April 1999 and 5 July 1999 with randomly selected samples of 1,000 1,200 adults nationwide. The second consists of specific results drawn from ten other surveys conducted nationwide between 1993 and We compiled these data from the Public Opinion Location Library (POLL) database at the Roper Center for Public Opinion Research from the Louis Harris subscription service, the Henry J. Kaiser Family Foundation, and the Employee Benefit Research Institute (EBRI). The third source is the National Journal s Cloakroom polling Web site. These polls involved telephone interviews with 1,000 2,000 randomly selected adults. When interpreting these findings, one should recognize that all surveys are subject to sampling error. Results may differ from what would be obtained if the whole U.S. adult population had been interviewed. The size of this error varies with the number of persons surveyed and the magnitude of difference in the responses to each question. Most national public opinion surveys have sample sizes of about 1,200 persons, in which the results will, with a 95 percent degree of confidence, have a statistical precision of ±3 percent of what would be obtained if the entire population had been interviewed. The sampling error for 2,000 respondents is ±3 percent. Findings The uninsured and the public s agenda. When respondents were asked whether something should be done about the nation s uninsurance problem, the majority (79 percent) responded that it is important for government to pass legislation to address this issue. 3 However, the priority that the public places on resolving problems H E A L T H A F F A I R S ~ V o l u m e 1 8, N u m b e r 6

3 with the health care system more broadly is not as high as it was earlier in the decade. In 1994 the public ranked health care as the second most important issue for government to address. In 1999 health care did not rank as high; it fell behind education, crime/ violence, Social Security, the economy, jobs, and concerns over taxes. Similarly, when asked to name the two most important issues for government to address, the proportion of respondents who chose health care as one of the top two has fallen from a high of 55 percent in 1994 to 9 percent in June Since 1994 the proportion of respondents naming health care as the most important issue has not reached 20 percent. 4 However, during the recent debate in Congress on a patients bill of rights, two other polls found an upswing in support for the health care issue. 5 It is not yet clear if this sudden change in priorities will be sustained or if it is only a response to the spotlight cast by the debate onto this issue. Among the most important health care issues, the problem of the uninsured also has become a somewhat lower priority, as quality of care has become an issue of greater concern. The public was asked to select the single most important health care issue: cost of care, people not covered by health insurance, or quality of care. The proportion of people naming the uninsured as the single most important health care issue for government to address was 35 percent in 1993 and 31 percent in 1999 (Exhibit 1). There also has been a substantial decrease in the number choosing cost and a marked increase in the number choosing quality of care, with almost twice as many choosing quality in 1999 as in This may reflect both the overall slowdown in the rate of health care cost increases since 1993 and the DATAWATCH 205 EXHIBIT 1 Americans Health Care Priorities, 1993 And 1999 Most important issue Cost People not covered by health insurance Quality of care All equally important (vol.) Among those choosing quality of care Doctors and hospitals do a bad job of treating patients Health plans and HMOs make it too hard for people to get care Neither (vol.) Both (vol.) 42% % SOURCES: NBC News/Wall Street Journal poll (March 1993); and Harvard School of Public Health/Robert Wood Johnson Foundation/International Communications Research poll (May 1999). NOTES: Vol. means that a response was volunteered. HMO is health maintenance organization. a Not applicable

4 D a t a W a t c h 206 PUBLIC OPINION rapid increase in managed care enrollment over the same period. 7 In a follow-up question, those who chose quality as the most important issue were asked whether they meant that doctors and hospitals were doing a bad job of treating patients or that health plans and health maintenance organizations (HMOs) were making it hard for people to get the care they need. When presented with these choices, 74 percent identified barriers to care in managed health plans and HMOs as the major quality problem, and 13 percent chose the level of care provided by doctors and hospitals. 8 Public knowledge of the problem. Surveys show that many Americans are not aware that the number of uninsured Americans continues to grow and of the barriers that uninsured persons face when trying to get needed care. Two recent surveys found that although the percentage of nonelderly Americans with no health insurance has increased from 14.8 percent in 1987 to 18.3 percent in 1997, the majority of respondents did not know that the number of uninsured is increasing or how many Americans are uninsured. 9 Only half of respondents knew that the number of uninsured persons has risen over the past five years (Exhibit 2). Similarly, the second survey showed that only 28 percent knew that more than forty million people lack insurance. While 26 percent thought that the number was less than twenty million, 14 percent believed it to be thirty to forty million, and 15 percent said that they did not know (not shown). 10 Likewise, although most of the uninsured are from families in which someone works, half of the public believed that most are from families in which no one is employed. 11 Although many Americans do not know how many people are uninsured or their employment status, the majority believe that the uninsured are able to get the health care they need. When asked in 1993 about uninsured persons access to care, 43 percent of respondents said that the uninsured are able to get the care they need from doctors and hospitals (Exhibit 3). When the question was repeated in 1999, 57 percent now believed this to be the case. This finding suggests that the public may be unaware of the barriers to health EXHIBIT 2 Americans Beliefs About The Number Of Uninsured Persons, Number has increased Number has stayed the same Number has decreased 50% Number of uninsured is over 40 million a 28 SOURCE: Harvard School of Public Health/Robert Wood Johnson Foundation/International Communications Research poll (May 1999). a Employee Benefit Research Institute/Greenwald and Associates poll (April 1998). H E A L T H A F F A I R S ~ V o l u m e 1 8, N u m b e r 6

5 EXHIBIT 3 Americans Beliefs About The Status Of The Uninsured, 1993 And 1999 Uninsured are able to get the care they need from doctors and hospitals Uninsured are not able to get the care they need Quality of care received by the uninsured is Not as good as that of the average insured person The same as that of the average insured person SOURCES: Harvard School of Public Health/Robert Wood Johnson Foundation/Marttila and Kiley poll (October 1993); and Harvard School of Public Health/Robert Wood Johnson Foundation/International Communications Research poll (April 1999). a Not applicable. 43% % care faced by the uninsured, which, as recent research indicates, may be getting worse as managed care penetration increases. 12 What should be done. In spite of the high level of public confusion about this issue, considerable public support exists for increasing governmental efforts to aid the uninsured. When respondents were asked to choose a statement that came closest to what they thought government should do for the uninsured, 49 percent said that they would like the government to make a major effort to provide insurance for nearly all of the uninsured, 32 percent that the government should make only a limited effort, and 14 percent that the government should leave things as they are (Exhibit 4). Among those who said that government should make a limited effort to provide insurance for some of the uninsured, concerns about higher taxes and government interference were cited as the primary reasons for the lack of interest in a major governmental program. Of that group, 56 percent said that it would cost taxpayers DATAWATCH 207 EXHIBIT 4 Americans Beliefs About What Government Should Do About The Uninsured, 1999 Total 14% 32% 49% Reasons for opposing a major effort a Oppose higher taxes Too much government interference in health care Would make the problem worse Doesn t require a large government program Isn t a big problem 65% b 21 SOURCE: Harvard School of Public Health/Robert Wood Johnson Foundation/International Communications Research poll (May 1999). a Among those who say that government should keep things as they are or make a limited effort. b Not applicable. 56% b

6 D a t a W a t c h 208 PUBLIC OPINION too much, half thought that there was already too much government interference in health care, and one-third thought that expanding government programs would make the problem worse. The employer-based insurance system. A growing body of research has explored the decline in employer-based coverage among the nonelderly population, citing rising health care costs, an increase in the number of low-income families, and the shift away from manufacturing to the service sector as reasons for this decline. 13 In spite of this research documenting the increasingly fragile link between employment and insurance, there is no public consensus for moving away from our current employer-based insurance system to some other system of financing, particularly by those who now have employer-based coverage. When respondents with employer-based coverage were asked to select from a list the benefit they would most like to get from an employer, 64 percent chose health insurance over other benefits, including pension, paid leave, or life insurance (Exhibit 5). Similarly, most of the employed (75 percent) said that they would rather have their employer purchase health insurance for them than have additional wages and purchase it themselves (not shown). 14 Given the general level of public approval for the current employer-based insurance system, it is not surprising that a majority of respondents did not support any one policy proposal that would sever this link. Approximately one-third favored either a requirement for employers to provide health insurance to all employees or a system of individual tax credits, and 21 percent supported a national tax-based health insurance plan. 15 In recent years two private-sector policies have been discussed in response to the problem of the uninsured: strengthening the employer-based system through requiring more employers to purchase EXHIBIT 5 The Most Important Employer-Provided Benefit To Persons With Employer-Based Health Coverage, 1994 And 1996 Health benefits Pension/retirement plan Paid vacation/sick leave Disability insurance Life insurance Child care/parental leave benefit None of these SOURCES: Gallup Organization poll (July 1994); and Employee Benefit Research Institute/Greenwald and Associates poll (November 1996). a Not applicable. 59% % H E A L T H A F F A I R S ~ V o l u m e 1 8, N u m b e r 6

7 health insurance for their employees, and moving to a system of tax credits and deductions for individuals to purchase insurance on their own. Surveys show that about equal proportions of Americans favor either option. This near-equal division among the public on this issue has not changed since 1993 (Exhibit 6). 16 Willingness to pay taxes. As shown earlier, there is substantial public concern about raising taxes or insurance premiums as a way of expanding coverage for the uninsured. In 1999, by a small majority (55 percent), Americans expressed a willingness to pay some level of increased tax or insurance premium to finance coverage for the uninsured. African Americans and younger respondents (ages eighteen to thirty-four) were more likely to say that they would be willing to pay higher health insurance premiums or taxes. For registered voters the figure was slightly lower (53 percent). 17 However, a prior survey of self-identified voters in the 1998 congressional election showed even less willingness among voters than among the public at large to pay taxes to cover the uninsured (46 percent). 18 Increased taxes is also an important element of any discussion of the comprehensiveness of benefits for the uninsured. When this issue was raised in 1999, 61 percent of the public preferred offering the uninsured a more limited package of insurance benefits versus one that is more comprehensive and requires higher taxes. There has been no change on this since DATAWATCH 209 Conclusions And Policy Implications The American public shows clear support for a new initiative that would expand coverage for a portion of the nation s uninsured population. However, a substantial segment of the public is sensitive about new taxes and wary of large government programs. If a new initiative seems too costly or bureaucratic, these concerns could EXHIBIT 6 Americans Preferences For Individual Versus Employer-Based Health Insurance, 1993 And 1999 Which would be better? Employers would be required to provide coverage for all of their workers and the government would cover the cost of the unemployed 43% 46% Individuals would be given tax credits and deductions to buy their own health insurance Neither Not sure SOURCES: NBC News/Wall Street Journal poll (March 1993); and Harvard School of Public Health/Robert Wood Johnson Foundation/International Communications Research poll (June/July 1999)

8 D a t a W a t c h 210 PUBLIC OPINION sway public support away from any new program for the uninsured. There is no public consensus on the best way to respond to the nation s uninsurance problem. Americans are divided not only about what type of health insurance system they would favor in the future, but also about whether the nation should be moving away from the current employer-based system at all. There appears to be substantial public support for strengthening rather than dismantling this system, particularly among those who have employer-based coverage. The majority of working Americans and their families (64.2 percent) today receive coverage through an employer, and any policy that serves to change this relationship can be expected to receive tremendous public scrutiny. 20 The findings suggest support for some type of a two-track system of expanding coverage for the working uninsured. One approach that seems to fit the public mood would rely on public policies analogous to those that have evolved in the pension field (such as individual retirement account or 401k plans). There are government tax incentives and regulations for employers that choose to offer a pension program for their employees. For persons who do not have access to employer-sponsored pensions, a separate system of tax incentives and regulations is set up to encourage them to invest in individual retirement accounts. This dual system recognizes the political reality of today s pension situation for working people. Those who have an employer contributory pension plan want to keep it and have it expanded. Those who do not would like the opportunity to participate in a parallel system, albeit not as generous. This is the exact situation facing expanding health insurance coverage for working Americans today. Finally, our findings provide clear evidence of the need for public policy professionals to be more involved with educating the public about the nation s growing uninsurance problem and, in particular, the effect it has on access to health insurance and health care for working people and their families. Until this occurs, the public may remain unwilling to support any of the alternative policy proposals now on the policy agenda. This work was supported through grants to Harvard University by the Robert Wood Johnson Foundation and the Henry J. Kaiser Family Foundation. NOTES 1. M.W. Serafini, One in Six and Counting, National Journal (17 July 1999): See, for example, A.D. Monroe, Public Opinion and Public Policy, , Public Opinion Quarterly 62, no. 1 (1998): 6 28; and B.I. Page and R.Y. Shapiro, Effects of Public Opinion on Policy, American Political Science Review (March 1983): H E A L T H A F F A I R S ~ V o l u m e 1 8, N u m b e r 6

9 3. Harvard School of Public Health/Robert Wood Johnson Foundation/International Communications Research poll (Storrs, Conn.: Roper Center for Public Opinion Research, 22 April 15 May 1999). 4. Louis Harris and Associates poll (Storrs, Conn.: Roper Center, 17 April 1999). 5. National Journal s Cloakroom, Fox News poll (19 July 1999); and National Journal s Cloakroom, CBS News poll (16 July 1999). 6. NBC News/Wall Street Journal poll (March 1993); Harvard/RWJF/ICR poll (16 20 April 1999); and Harvard/RWJF/Marttila and Kiley poll (Storrs, Conn.: Roper Center, October 1993). 7. S. Smith et al., The Next Ten Years of Health Care Spending: What Does the Future Hold? Health Affairs (September/October 1998): The rate of increase in consumer out-of-pocket payments has slowed from 7.6 percent in to 2.9 percent in G.A. Jensen et al., The New Dominance of Managed Care: Insurance Trends in the 1990s, Health Affairs (January/February 1997): The percentage of insured workers in some form of managed care increased from 51.1 percent in 1993 to 73 percent in Harvard/RWJF/ICR poll (22 April 15 May 1999). 9. P. Fronstin, Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 1998 Current Population Survey, EBRI Issue Brief no. 204 (Washington: Employee Benefit Research Institute, December 1998), Harvard/RWJF/ICR poll (19 23 May 1999); and EBRI/Greenwald and Associates poll (April 1998). 11. Henry J. Kaiser Family Foundation/Harvard/Princeton Survey Research Associates poll (Storrs, Conn.: Roper Center, July 1996); and Working and at Risk: Kaiser/Commonwealth 1997 National Survey of Health Insurance (December 1997). 12. P.J. Cunningham et al., Managed Care and Physicians Provision of Charity Care, Journal of the American Medical Association 281, no. 112 (1999): See, for example, R. Kronick, Health Insurance, : The Frayed Connection between Employer and Insurance, Inquiry 28, no. 4 (1991): ; D. Chollet, Employer-Based Health Insurance in a Changing Work Force, Health Affairs (Spring I 1994): ; R. Kronick and T. Gilmer, Explaining the Decline in Health Insurance Coverage, , Health Affairs (March/April 1999): 30 47; and R. Kuttner, The American Health Care System: Employer-Sponsored Health Insurance, New England Journal of Medicine 34, no. 3 (1999): P. Ostuw, Health Insurance Continues to Be Most Important Benefit According to Recent EBRI Gallup Poll, EBRI Notes 17, no. 11 (Washington: EBRI, November 1996); and EBRI/Greenwald poll (April 1999). 15. R.J. Blendon et al., Voters and Health Care in the 1998 Election, Journal of the American Medical Associatio n (14 July 1999): ; and Kaiser/Harvard/PSRA poll (4 November 1998). 16. NBC News/Wall Street Journal poll (March 1993); and Harvard/RWJF/ICR poll (30 June 5 July 1999). 17. Harvard/RWJF/ICR poll (9 13 April 1999). 18. Blendon et al., Voters and Health Care; and Kaiser/Harvard/PSRA poll (4 November 1998). 19. Harvard/RWJF/ICR poll (9 13 April 1999); and Harvard/RWJF/Marttila and Kiley poll (October 1993). 20. Fronstin, Sources of Health Insurance. DATAWATCH 211