In recent years, attempts to increase health care coverage for specific populations

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1 Americans Views About The Adequacy Of Health Care For Children And The Elderly Americans believe strongly that government should meet the basic health care needs of both groups. by Marc L. Berk, Claudia L. Schur, Debbie I. Chang, Erin K. Knight, and Lawrence C. Kleinman ABSTRACT: Recent attempts to increase health coverage for specific populations incrementally have been more successful than efforts to dramatically reconfigure the health care system. We present findings from a survey to assess support for programs for children compared with those for the elderly, as well as the public s desire to prioritize whether the needs of one should be addressed over the needs of the other. Americans believe that the health care needs of both children and the elderly are not being met, and there is clear and widespread support for a government role in ensuring adequate health care. In recent years, attempts to increase health care coverage for specific populations incrementally have been more successful than efforts to dramatically reconfigure the U.S. health care system. The Balanced Budget Act (BBA) of 1997 created the State Children s Health Insurance Program (SCHIP), which expanded public coverage for children, and the prescription drug benefit of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 expanded public benefits for the elderly. Such approaches have been consistent with U.S. public opinion. 1 Moving forward, the specter of large budget deficits raises the importance of defining health care priorities. The views of the American public may influence whether future incremental reforms address the needs of children, the elderly, or both. When one examines current attitudes and priorities regarding government spending, it is helpful to document existing spending practices and policies. It is Marc Berk (berk-marc@norc.org) is vice president and senior fellow at NORC at the University of Chicago, in Bethesda, Maryland, where Claudia Schur is a principal research scientist. Debbie Chang is senior vice president and executive director, Nemours Health and Prevention Services, at the Nemours Foundation in Newark, Delaware. Erin Knight is a special assistant at the Nemours Foundation, and Lawrence Kleinman is the chief public health/community-based research officer and directs the Center for Research Evaluation and Planning, Nemours Health and Prevention Services, Nemours Foundation. W September 2004 DOI /hlthaff.W Project HOPE The People-to-People Health Foundation, Inc.

2 Children & Elderly also useful to consider these issues in light of potentially competing priorities, such as children and the elderly, given the vulnerable nature of both populations. Current government spending on health care for the elderly far exceeds that of children: Per capita government spending on health care for the elderly in 2001 was $4,360, compared with $258 for children (Exhibit 1). Overall, there was an 8:1 ratio of total public spending for the health care of the elderly compared with that of children, and the difference is likely to grow when the Medicare prescription drug benefit is implemented. Direct comparisons between funding for the elderly and for children are complicated and must be interpreted in light of the different health problems and corresponding health care needs and costs each group experiences. Further, differences in spending reflect differences in health status as well as different programmatic approaches, particularly the fact that Medicare provides almost universal coverage of the elderly while Medicaid and SCHIP cover only lowincome children. Susmita Pati and colleagues examine differential social welfare spending for children and the elderly during They find that total spending for the elderly continues to exceed that for children when the range of social welfare benefits, including those for education, are included in the calculations and that the gap between the two groups has grown over time. The importance of clarifying public attitudes is highlighted when one considers that more than twelve million children and almost four million elders are living below the federal poverty level. Indeed, the inadequacy of current programs for both groups is suggested by the 7.8 million American children who remain uninsured and by anecdotal tales of elderly Americans who are unable to fill their prescriptions or for whom the new drug benefit may prove to be insufficient. The issue of intergenerational equity essentially, how society allocates resources between generations was given considerable attention in the 1980s. However, there has been little recent empirical work examining national percep- EXHIBIT 1 Public Health Care Spending For Children, Working-Age Adults, And The Elderly, 2001 Age group Total Population (millions) Total spending ($ millions) 726,354 73, , ,355 Public spending ($ millions) 264,916 18,812, ,243 Percent public spending Per capita public spending ($) ,360 Percent below poverty SOURCE: NORC tabulations of data from the Medical Expenditure Panel Survey (MEPS), NOTES: Population estimates are weighted record frequencies. Public expenses include payments by Medicare, Medicaid, the Department of Veterans Affairs (VA), TRICARE (formerly CHAMPUS), other federal, other state/local, workers compensation, other public, and other sources. Estimates of the percentage of each age group below the federal poverty level are also from MEPS. HEALTH AFFAIRS ~ Web Exclusive W4-447

3 tions of spending on the elderly and on children. A survey conducted by the Gallup Organization in 2000 asked registered voters to state their spending priorities: 42 percent supported providing health insurance to the 11 million children without coverage compared with 33 percent who believed that providing prescription drug coverage to the 12 million elderly without coverage was a higher priority. 3 A 1997 poll asked Kansas residents: If you could pick only one group for which you could increase state government spending which group would it be elderly, children, poor, people with disabilities or others? 4 Thirty percent picked the elderly, and 33 percent picked children. However, when asked to select one group for which to cut state government spending, twice as many respondents selected the elderly as children (11 percent versus 5 percent). Another poll conducted in 1991 found that 81 percent of respondents strongly or somewhat favored guaranteeing a basic set of benefits to all children, like we guarantee Medicare and Social Security to all senior citizens. 5 To better understand how Americans view the adequacy of health care for children compared with that of the elderly and to understand their current priorities regarding this care, the Nemours Foundation commissioned NORC at the University of Chicago to conduct a survey to assess support for programs for children compared with the elderly, as well as the public s desire to prioritize whether the needs of one should be addressed over the needs of the other. As the 2004 presidential election approaches and much controversy remains about health care spending, we believed that a survey regarding the government s role in ensuring funding for health care for these two populations would be particularly salient. In this paper we report the results from the survey. Survey Data And Methods The survey field work was implemented by International Communications Research (ICR) as part of a larger survey that asks a core set of demographic questions and then adds additional questions from separate funders. The survey was conducted by telephone during 4 18 June Using a random-digit-dialing approach, 2,013 respondents from a nationwide sample were interviewed. They were asked a series of questions concerning their views on public funding of health care programs for children and for the elderly. 6 The ICR survey makes up to four attempts to call each number. Calls are made at different times and on both weekdays and weekends. The survey randomly selects a single respondent within each selected household. The methodology employed is similar to that used for political polling. The short field period does not allow the calculation of a response rate that would be comparable with those of a government-sponsored survey having field periods of several months. ICR weights the data to ensure a survey that is nationally representative with respect to key demographic variables. Estimates discussed below are weighted, using a process that takes into account the disproportionate probabilities of household W September 2004

4 Children & Elderly selection because of the number of separate telephone lines and the probability associated with the random selection of an individual household member. Following application of these weights, the sample is post-stratified and balanced by key demographics such as age, sex, region, and education. We used SAS to perform all analyses. Where noted, differences in the distribution of responses are statistically significant using a chi-square test at the.05 level. Study Findings Perceptions of whether needs are being met. Respondents were read the following statement: The health care needs of America s children are currently been met. They were then asked whether they strongly agreed, agreed, disagreed, or strongly disagreed. Children were defined as being less than age eighteen. Respondents were also read the statement: The health care needs of elderly Americans are currently been met ; elderly people were defined as age sixty-five and older. Overall, 59 percent of the population did not believe that the needs of children were being met (Exhibit 2). A slightly higher proportion did not believe that the needs of the elderly were being met. Variation across demographic groups was similar for both statements. Women expressed more concern than men about the needs of both children and seniors, and adults ages were more likely than those ages or age 65 and older to disagree that needs were being met. The effect of income was apparent only in relation to children. The wealthiest cohort those earning $75,000 or more were more likely than those earning less than $25,000 to express disagreement. Of interest, households without children were more likely than households with children to believe that children s health care needs were not being met. This was true in terms of the health care needs of the elderly as well. Large differences were found according to political party preference, with more Democrats than Republicans believing that health care needs were not being met for either children or the elderly. Perceptions about spending. Our findings suggest that the public does not view the level of government funding for health care for the elderly as greatly exceeding that for children. Despite the eightfold greater spending for the elderly, every population group examined failed to report this as its dominant perception (Exhibit 3). Overall, only 18 percent responded that a lot more is spent on the elderly than on children, and 15 percent believed that somewhat more is spent on the elderly than children. Men, college graduates, and people with higher incomes were more likely to believe that the majority of resources were allocated for the elderly, yet fewer than one-third stated that a lot more was spent. Democrats and Republicans were equally likely to have these perceptions about spending. Views on the role of government. The overwhelming majority of Americans believe that government should ensure adequate funding for health care for lowincome children as well as for the low-income elderly (Exhibit 4). Although some variations exist, no demographic groups indicated less than 83 percent support for HEALTH AFFAIRS ~ Web Exclusive W4-449

5 EXHIBIT 2 Percentage Of U.S. Adults Who Do Not Believe That The Health Care Needs Of Children And The Elderly Are Being Met, 2004 Percent who disagree or strongly disagree Sample size Needs of children are being met All 2, Sex Male Female Age Income Less than $25,000 $25,000 $49,999 $50,000 $74,999 $75,000 or more Race White Black Household With children Without children Party Democrat Independent Republican 1,011 1, , , a a a a a 62 Needs of elderly are being met SOURCE: NORC Survey on Children s Health Care Issues, June a p <.05 for chi-square test of differences within sex, age, income, race, household status, and political party categories for each column. 70 a government to ensure funding for health care for low-income children or less than percent support for low-income elderly. We then asked questions to determine whether the support for government funding was primarily driven by concern about inability to pay for care. When we asked if government should ensure adequate funding for health care for all children and all elderly (without the income qualifier), support was almost as high (Exhibit 4). Strong support for the funding of health care for both children and the elderly, regardless of income, was evident among all demographic groups. Support for a government role in ensuring that health care is adequately funded exhibited a noticeable age trend: More than 90 percent of those ages agreed with the statement, and this proportion gradually declined with each succeeding 63 a a a a a a W September 2004

6 Children & Elderly age cohort but was never lower than 76 percent. Although this trend was most noticeable regarding support for funding care for all children regardless of income, those age sixty-five and older were uniformly less likely to be in favor of a government role in care, even when addressing the elderly themselves. We noted small, statistically significant differences between Democrats and Republicans in terms of support for a government role in ensuring support for low-income elderly and children. The percentage of Republicans comfortable with ensuring support for all children and the elderly was discernibly lower than those comfortable with covering low-income populations; in contrast, Democrats seemed equally comfortable with both (Exhibit 4). Preferences about spending. Although the intergenerational issue may be of interest to policymakers, we found that the public does not support prioritization of either the elderly or children at the expense of the other. The survey found 59 percent of respondents holding the opinion that the government should be spending about the same on children s health care as on health care for the elderly (Exhibit 3). The figures in Exhibit 3 were remarkably stable across sex, age, income, education, race, household composition, and party affiliation. Among those who did prefer prioritizing one group over another, there were some differences by cohort. Twenty-seven percent of those ages thought that more should be spent on children, compared with only 11 percent in this cohort who thought that more should be spent on the elderly (data not shown). Among the near-elderly (ages 55 64), this finding was reversed: 17 percent indicated that more should be spent on children, and 22 percent, that more should go to the elderly. Discussion According to our findings, Americans believe that the health care needs of both children and the elderly are not being met, and there is clear and widespread sup- HEALTH AFFAIRS ~ Web Exclusive W4-451

7 EXHIBIT 4 U.S. Adults Views On The Role Of Government In Ensuring Funding For Health Care For Children And The Elderly, 2004 Percent who agree or strongly agree that the government should ensure funding for health care of lowincome children/elderly Percent who agree or strongly agree that the government should ensure funding for health care for all children/elderly Children Elderly Children Elderly All Sex Male Female Age Income Less than $25,000 $25,000 $49,999 $50,000 $74,999 $75,000 or more Race White Black Household With children Without children Party Democrat Independent Republican a 94 a a 90 a 96 a 94 a a a a 90 a 85 SOURCE: NORC Survey on Children s Health Care Issues, June a p <.05 for chi-square test of differences within sex, age, income, race, household status, and political party differences for each column. port for a government role in ensuring adequate health care. This broad-based support transcended demographic and political party lines and extended to include support for such a governmental role regarding all children and all elderly, regardless of income. At the same time, our findings offer evidence that the public does not understand the current allocation of resources. Although governmental spending on the elderly vastly exceeds that for children, most Americans, including those with a college education, do not report this to be the case. When asked about the relative priority that government should place on the health care needs of children versus 80 a a a a a a a a 93 a 77 W September 2004

8 Children & Elderly Medicaid and SCHIP stand in contradistinction to public opinion that supports funding for all children, regardless of income. those of the elderly, Americans clearly do not want government to choose, with a majority indicating that government should be spending about the same on children as it does on the elderly. In light of the apparent lack of understanding about current spending, the public sentiment that supports equal funding for health care for children and the elderly should probably be interpreted not as a call for an enormous shift of resources from one group to the other but as evidence that the public considers these needs to be of equal and high priority. It is useful to consider current health care programs in light of the apparent popular support for government s ensuring adequate funding of health care for all children and all elderly. Medicare, the federal health insurance program for the elderly, is essentially universal and thus consistent with the opinions reported here. On the other hand, Medicaid and SCHIP, the federally sponsored insurance programs for children, are means tested and vary in the adequacy of coverage from state to state. They thus stand in contradistinction to public opinion that supports adequate funding for all children, regardless of income. Given the broad-based support we have found for a governmental role in ensuring adequate health care for both groups, regardless of income notably encompassing majorities of both political parties it is useful to consider why universal health coverage remains politically remote. Partial explanation may be found in where the issue of children s health lies on the public s radar screen. A recent review of public opinion on children s health care issues noted that people do not immediately recognize health care as a major issue for children. 7 In fact, when asked what group has the biggest problem getting adequate health care coverage, the public identified unemployed adults (31 percent), seniors (28 percent), working parents and their children (20 percent), and then children specifically (8 percent). This relatively lower level of concern does not indicate that children are not a high priority in the public s mind; rather, it indicates that issues other than health are seen to be more critical to children s needs. Thus, educating the public about children s health care issues including access to health care and levels of child poverty may be an important precursor to increasing real support for fully addressing children s health care. Moreover, the public s apparent failure to understand the actual allocation of resources for health programs for children and the elderly may explain why there is not a popular movement to change the status quo. Helping the public understand current health care needs and allocation for each population group may increase the likelihood of successful reform. Finally, more work needs to be done to fully understand what the public means when it calls for a government role in ensuring adequate health care. Previous ex- HEALTH AFFAIRS ~ Web Exclusive W4-453

9 perience, such as the Medicare Catastrophic Coverage Act, which was passed in 19 and repealed in 19, suggests that Americans may be supportive of new benefits for themselves and others until they clearly see the attached price tag. Thus, before effective political change can occur, efforts must be made to learn in more depth about the public s views and to increase awareness of both the costs and benefits of change. We found that americans want the government to ensure funding for adequate health care for both children and the elderly, even as they are confused about the current (and presumably future) financing of this care. In supporting care for all children as well as all elderly, these findings may offer unexpected direction for policymakers. This study is one of a series of household surveys designed for Health Affairs that NORC has conducted on health policy related topics. Funding for this survey was provided by Nemours Health and Prevention Services, at the Nemours Foundation. The views presented are those of the authors and do not reflect the opinions of Nemours or NORC. The authors thank Sreelata Kintala of NORC for her programming support and research assistance. NOTES 1. R.J. Blendon and J.M. Benson, Americans Views on Health Policy: A Fifty-Year Historical Perspective, Health Affairs 20, no. 2 (2001): 33 46; and R.J. Blendon et al., Health Care in the Upcoming 2000 Election, Health Affairs 19, no. 4 (2000): S. Pati et al., Generational Differences in U.S. Public Spending, , Health Affairs 23, no. 5 (2004): Sponsored by Cable News Network (CNN), USA Today, conducted by the Gallup Organization, 6 8 October Data provided by the Roper Center for Public Opinion Research, University of Connecticut. 4. Kansas Poll, 1997, Robert Poresky and Leonard Bloomquist, principal investigators, Institute for Social and Behavioral Research, Kansas State University, Penn, Schoen, and Berland Associates Inc., A copy of the questionnaire can be obtained from the authors; send to berk-marc@norc.org. 7. Public Knowledge, Communicating Children s Health Care Quality: A Review of Public Opinion (Unpublished manuscript, January 2003). W September 2004