What Americans Are Looking For in Health-Care Reform

WITH the Clinton administration poised to offer a plan for revamping the way health care is paid for in the United States, a huge effort to influence public opinion on this subject is about to begin. We'll be hearing many competing claims on what the people "really want." Fortunately, Americans' views have already been plumbed extensively. These data give us a clear, unequivocal picture of what they want - and don't want - to see happen.

The public wants major change in the health-care system. This does not mean, though, that most are unhappy with their present arrangements. Quite the contrary. Very large majorities believe they are now getting excellent medical treatment. They like their doctors and the relationships they have with them. On one critical dimension of health care, however, there is intense dissatisfaction that ripples through judgments on the entire system. The dramatic increases in the price of health services have hit p eople's pocketbooks and shaken their confidence that they will be able to afford needed care.

Looking at what the US spends for health care, it is easy to see why cost-related dissatisfaction and fears have grown so explosively. In 1960, we spent about $90 billion for health services, putting outlays in dollars of 1982 purchasing power. In these same constant 1982 dollars, spending rose in 1990 to more than $360 billion. Since 1960 the share of the country's gross domestic product going to health care has nearly tripled to more than 13 percent.

Even when, as is true for a majority of Americans, the bulk of the costs are paid directly through private insurance plans or Medicare, the total bills are shocking. The average cost per day of treating a patient in 1990 was about $940 at community hospitals in California, $825 at hospitals in Connecticut. From the shock at such figures comes fear: If I lose my health insurance coverage, how could I cope with such runaway prices? And many people see their employers, staggering under rising health-benefit

costs, push for more employee co-payment of insurance premiums or for limits to coverage.

Recognition also is growing that, whatever the type of insurance coverage, the individual ultimately pays the bill - in higher taxes; in reduced services in other areas as governments divert resources; and in smaller pay increases as employers have to spend a larger part of total compensation on health benefits.

Finally, the dramatic price escalation has greatly increased concerns about access. The vast majority of Americans believe that basic health care should be available to everyone. The shock of rising prices has heightened public sympathy for those with inadequate insurance coverage and has expanded support for seeing that they are covered.

In various ways, then, runaway costs have fueled a demand to "Do something!" But what? One thing that must happen is real cost control. The Clinton administration's proposals, and most other plans being discussed, call for additional tax levies to help pay for the revamped system. Surveys show that the public will in fact support a substantial tax hike under certain conditions. But, as Humphrey Taylor, a leading authority on public opinion and health policy, points out in the May/June issue of The Public

Perspective, "The key to this support for new taxes is the essential belief that the new plan will work to control costs and provide security and (ultimately) universal access."

On the matter of what part the government should play in the new health-care system, public opinion is mixed. We want costs curbed and security and access extended, and we will accept a bigger government role if that is needed to achieve these ends. Yet we also value the large element of individual choice that many people have in the present system - choice, for example, among physicians and other care providers. In addition, the public's generally negative view of government performance clearly affects its thinking about the prospects of more government in the health-care area.

When Gallup asked the public (February 1992) whether they would "more confidently entrust the management of the American health-care system to ... the private insurance industry or the federal government," by 52 percent to 33 percent they said the insurance industry - which itself is not loved. (Eleven percent volunteered the response of "neither.") In January 1992, Gallup asked respondents which of two broad approaches they preferred - "government-sponsored national health insurance or reform of our cur rent private health-care sytem." The latter carried by better than 2 to 1. The public's call, then, is for health-care reform that involves government management as minimally as possible, consistent with the overriding goal of containing costs and extending security and access.