What Does the Public Understand About Health Care?

When newspaper publisher Benjamin Franklin championed essential component of democracy, he could hardly have "freedom of the press," enshrining free speech as an envisioned the media environment today—ubiquitous, powerful and flourishing in an electronic age that encompasses radio, television and the Internet. As the media have evolved, so has the need for journalists to renew their understanding of and commitment to their stewardship. Sound Partners for Community Health provides an opportunity for both broadcasters and communities to explore their understanding of the role media plays in democracy and community life.

From journalism's earliest days, its scholars and practitioners have endorsed the notion that journalists must understand the full communications process: Who says what to whom through what channel with what effect? To serve the public interest, journalists must also look at how a story is reported, asking: "What gets covered, and to what end? What is the public understanding of a certain social problem? What information does the public need to be able to weigh alternative solutions? How does the journalist best present information to engage the public in an issue?"

To answer these questions and analyze the framing of an issue, a journalist must explore a body of knowledge that includes public opinion, public education and media impact. The exploration presented here focuses on public opinion polling and invites grantees to consider the journalist's relationship to the formation of public opinion and, ultimately, public policy.

News has never been so much in the news. Indeed, the way in which journalists cover the news has rarely been subjected to so much intense scrutiny from both within and outside the profession. Major metropolitan dailies like The Washington Post have assigned entire beats to the coverage of the news. The findings of a specialized breed of political scientist known as media effects scholars, well respected in their field but otherwise obscure and virtually unknown, are now the subject of major front-page features.

Polling, in particular, has become a fact of life in national news coverage, and this is especially true in an election year. National polling gives both journalists and candidates a way to take the public's pulse on a given subject. But it also raises questions that journalists should weigh before incorporating polling into their programming, including:

• Is it a good poll? (i.e., is it statistically accurate?)
• Who conducted the poll and why? How did they formulate the specific questions they chose to ask?
• Does the poll reflect the public sentiment in my locality? How do I know?
• Is there any local polling on the same issue that I can use to compare and
  contrast with national polls?

Our goal in providing cursory overviews of public opinion in each of the five content areas is to look critically at the role of opinion polling in the ongoing public discussion of a complex set of issues. When Benton searched for public opinion data on the five broad content areas, the results returned public opinions with a much narrower focus than expected.

The search also illustrated the fact that public opinion polling results often raise more questions than they answer.

Reading the Sound Partners content overviews and public opinion overviews in tandem, it becomes clear that public opinion polling is not covering the issues identified by experts in each content area. The issues tackled are complex social problems that raise difficult and often contradictory issues that are not easy to resolve. In order to find meaningful and long-lasting solutions, we must work toward developing a better understanding of public perceptions of the issues. Recognizing the role that mass media play in shaping the way Americans think about social issues is an important part of determining how issues get covered and are understood by readers, listeners and viewers. Reporters should read the content and public opinion overviews with a critical eye, asking the questions that both the experts and the polling numbers leave unasked.

The methodology used by the Benton Foundation in collecting public opinion research in each of the five Sound Partners content areas parallels the process reporters might use in getting a baseline of public opinion to begin crafting content for their reporting. The overviews draw on a search and analysis of recent public opinion collected from the archives at the Roper Center for Public Opinion Research at the University of Connecticut. Data reviewed is from 1997 through 1999, except when noted otherwise.

Public Opinion on Young Children's Health Issues

According to public opinion, people rarely think of access to health care as a problem for children. Health-related issues like substance abuse and teenage pregnancy are seen instead as problems with society's values. People tend to associate lack of health care coverage with the elderly and working poor adults.

• When people think of problems facing children, few consider health care. When people are asked specifically to identify the top two or three most important health problems facing children, their concerns tend to cluster around diseases like AIDS (23 percent), infectious diseases (17 percent), cancer (10 percent), asthma (36 percent) and behavioral problems like substance abuse (15 percent), smoking (11 percent), dietary concerns (10 percent), alcohol (7 percent) and teenage pregnancy (3 percent). Only five percent cite lack of medical care as an issue.1
• Children's lack of health coverage is largely invisible to the public. When asked who (among a list of specific choices) has the biggest problem getting adequate health care coverage, only eight percent point to children. More likely answers are unemployed adults (31 percent) and seniors (28 percent), followed by working parents and their children (20 percent) or children specifically (8 percent).2 This perception has been largely unchanged since at least 1990, when only 11 percent could point to poor children as the largest group Medicaid serves.3
  Although few people think of access to health care as an issue for children, 91 percent believe in principle that children have a right to health insurance.4 If asked, 83 percent of Americans say that it is a major problem that "too many children lack adequate coverage."5

• People are willing to place a variety of requirements on HMOs, including requirements that benefit children. For instance, they would require HMOs to:

- "allow parents to choose a pediatrician as their child's primary-care
physician"(89 percent favor; 54 percent strongly);

- "provide access to pediatric specialists . . . and hospitals that specialize in treating children" (87 percent favor; 53 percent strongly);

- "allow parents of children with special health care needs . . . to choose a pediatric specialist to be their child's primary-care physician" (90 percent favor; 57 percent strongly); and

- "measure and report to the public specifically on the quality of children's health care they provide " (87 percent favor; 52 percent strongly).6

Public Opinion on Youth Substance Abuse

According to public opinion, parents recognize children's substance and alcohol abuse as a leading concern in our society. When asked what is the most important issue facing their teenagers (the one thing that concerns you most), 21 percent said drugs. Only social pressures (29 percent) received a higher ranking.7

• Parents indicate that they have enough information and are comfortable about speaking with children and teens about substance use. Fifty-two percent of parents believe that they "have all I need" to raise issues about drugs with their children. More than 90 percent of parents report that it is easy (64 percent very easy; 29 percent somewhat easy) to speak with their teenagers about topics like alcohol and drugs. Further, more than 95 percent of adults indicated that they have discussed issues surrounding alcohol and drugs with their teenagers (89 percent a lot; 19 percent somewhat).8

• Adults get information or advice on talking to children about tough issues like sex, drugs and violence from a variety of sources, as follows.

A Lot
Some
A Little
None
Don't Know / refused

School/PTA
11%
29%
25%
34%
1%

Clergy/church
26%
24%
16%
34%
Less than .5%

Books
40%
33%
14%
13%
Less than .5%

Media
22%
34%
23%
21%
Less than .5%

Other Parents
14%
35%
24%
27%
Less than .5%

• Parents believe that community sources influence the way children and teens think about issues like drugs. More than 70 percent of parents believe that churches have influence (35 percent a lot of influence; 39 percent some). Fifty-nine percent of parents indicated that teachers and schools have influence. But parents also believe that media (87 percent)-television, the Internet and magazines-and peers (87 percent) exert influence on how their children and teens think about these issues. Despite the role external factors play in influencing teens, parents believe that the family, including father, mother and siblings, have an influence as well (76 percent a lot of influence; 23 percent some).9

Public Opinion on Health Care Safety Net

During the 1990s, health care and creating a safety net were discussed at the national, state and local levels, with politicians and health care providers weighing in on what works best. If past elections are a barometer, issues of health care and coverage will dominate the 2000 presidential election.

The costs of health insurance are on Americans' minds. When asked why health care costs have gotten worse in the last 5 years in America, more than 78 percent indicated that paying more for health insurance and for services not covered by insurance was driving up costs.10

• There is general concern that all Americans be guaranteed health care coverage. A September 1999 survey of registered voters asked participants what they think about health care and health insurance and what was most important for the federal government to address. Forty-one percent responded "a guarantee that everyone has health insurance"; 22 percent responded "a patient bill of rights to give doctors and patients enrolled in HMOs more say in medical decisions"; 14 percent responded "less government interference in health care"; and 12 percent responded "increasing competition among insurance providers to keep costs down." Only nine percent indicated a prescription drug benefit for seniors.11
• Concerns about the uninsured are prevalent. Fifty-one percent of respondents believe that over the next 10 years, the number of uninsured Americans will rise. Forty-seven percent of respondents know that the uninsured are employed people and people from families in which someone is employed. But 58 percent of respondents believe that despite lack of insurance, the uninsured are able to get the medical care they need from doctors and hospitals.12 When this question was asked again in 1999 the responses changed, with 46 percent indicating that people without health insurance are able to get treatment.13

• The responsibility for financing health care belongs to the federal government. Sixty-three percent polled indicated that the federal government is responsible; 19 percent indicated state government, 5 percent each named local government and private organizations, and 9 percent responded that individuals are
  responsible.14 More than 55 percent believe that the federal government should help uninsured families and children get health insurance; 23 percent believe this is more important than cutting federal income taxes and 20 percent think it's more important than paying down the national debt.15

• Many believe Medicare reform can help solve the problem. More than 75 percent of respondents favor or strongly favor expanding Medicare to include younger retirees and uninsured Americans between the ages of 55 and 64 who are willing to pay higher premiums.16

Public Opinion on Aging and Chronic Illness

As America ages, concerns about aging, chronic illness and the increased need for long-term care proliferate. Polling questions tend to place the issues of aging and long-term care in an economic paradigm. Most public opinion research has focused on whether Americans are concerned about the rising costs of caring for our elderly, rather than on gauging the public's knowledge of outpatient medical and nursing care, home health care, adult day care, housing with support services and other supports for the aging and chronically ill.

• Public opinion is split on whether funding for long-term health care is an issue. When asked if they believe they have enough money to pay for long-term care like nursing home or home health care and retirement, approximately 50 percent of respondents report that they are either very confident or somewhat confident, while about 46 percent say they are not too confident or not at all confident. When asked if they had considered insurance coverage for long-term care or nursing home needs, 36 percent responded yes while 63 percent responded no.17
• When those polled are asked to identify the most important problem facing the country today, issues around aging and chronic illness rank below the top 20. When prompted, respondents acknowledge Medicare and HMO reform; how- ever, only three percent identify these as important problems.18
• Concerns about aging are felt by adults whose parents are aging. More than 75 percent of respondents said they were extremely concerned or somewhat
  concerned about the quality of care their parents will receive in their elderly years. When asked about the prospect of living to a very old age, concerns about financial security and failing health topped the charts. There was no mention of the other types of concerns that emerge with aging.19

• Some polls have begun to explore quality-of-life issues and aging. In 1999, a poll explored where respondents believed they would spend the last years of their lives and where they wanted to spend the last years of life if given a choice. Overwhelmingly, respondents chose living independently in their homes (62 percent independently; 72 percent at home).20

Public opinion polls indicate that Americans are unaware of the types of services available to the elderly and chronically ill. There is little recognition of the role Medicare plays in providing long-term care, nursing-home care, and other similar services, and little understanding of how various proposed Medicare reforms would affect the issue. But when asked whether Medicare reform should offer free home health care, a majority said yes.

Public Opinion on End-of-Life Issues

In 1998, a survey of public opinion research conducted by the Benton Foundation found that the public had developed an awareness of the issue of end of life, but was just beginning to "debate the pros and cons and the implication-both for day-to-day and public decision-making-of end-of-life decisions." Public opinion on the topic has not changed significantly since then. Public opinion surveys continue to focus on exploring the role doctors play in end-of-life decisions and on how the public feels about the process of ending life, especially physician-assisted suicide (PAS). The following are some of the major findings in the most recent public opinion research:

Public opinion on physician-assisted suicide continues to be closely divided. Approximately 35 percent of adults surveyed indicated that they strongly agree or agree that a 72-year-old male dying from an incurable disease should ask for a physician-assisted suicide; 12 percent neither agreed nor disagreed, and 47% disagreed or strongly disagreed. When a slight nuance was added (ask doctors to increase the use of pain medication, even if it might lead to premature death), 70 percent of adults surveyed strongly agreed or agreed with the statement, while only 15 percent disagreed or strongly disagreed.21 It seems, however, that the public expects practices to change. In a 1998 Gallup Poll, adults surveyed were asked if physician-assisted suicide will be commonplace in the year 2025. Sixty- eight percent responded yes, while only 21 percent responded no.

Americans continue to address end-of-life issues as private concerns. Eighty- nine percent of those surveyed said that "family" has the responsibility of caring for the dying; only 25 percent mentioned state government, and only 20 percent said the local community.22

• There is significant support for hospice services for terminally ill patients. More than 80 percent of adults surveyed either strongly agree or agree that a person 72 years old expecting to get continually worse with more and more pain "and who will die within 18 months" should choose hospice services. When this same question was asked with the terminal patient dying within two months, the results did not vary significantly.23
• A terminally ill person should prepare written instructions explaining what his/ her future care should be. More than 90 percent of those surveyed strongly agree or agree with this statement, while only 4 percent disagree. No one surveyed strongly disagreed with the statement.24

1 The Robert Wood Johnson Foundation Poll, conducted by Harvard University and the
University of Maryland; 1,501 adults nationally; November 1997.

2 Great Expectations, funded by the Coalition for America's Children, conducted by Lake Research and the Tarrance Group; 800 presidential voters nationally; December 1996.

3 Kids' Clout, sponsored by NACHRI, conducted by Pen and Schoen; 1,000 adults nationally; June 1990.

4 The Robert Wood Johnson Foundation Poll, conducted by Harvard University and the
University of Maryland; 1,501 adults nationally; November 1997.

5 NBC News/Wall Street Journal poll, conducted by Hart and Teeter Research Companies; 2,006 adults nationally; June 1998.

6 NACHRI Study by Lake Research; 1,000 adults nationally; February 1998.

7 National Center on Addiction and Substance Abuse at Columbia University; 1,000 adult parents of teens ages 12 to 17; May 8, 1999.

8 CBS News; 731 adults; May 1999.

9 Kaiser Family Foundation/Children Now; parents of children ages 6 to 16; 880 adults
nationally; September 15, 1998.

10 Greenberg Quinlan Research; 1,005 registered likely voters nationally; September 1999.

11 Greenberg Quinlan Research; cited above.

12 Princeton Survey Research Associates; 751 adults; November 1998.

13 Belden Russonello & Steward; 1,500 adults; May 1999.

14 Center for Survey Research, UVA; 2,047 adults; January 1996.

15 Public Opinion Strategies and Lake, Snell, Perry, & Associates; 800 adults; September 1999.

16 Princeton Survey Research Associates; 1,007 adults; March 1998.

17 Mathew Greenwald & Associates; 1,500 adults; March 1998/March 1999.

18 Princeton Survey Research Associates; 3,973 adults; July 1999.

19 Yankelovich Partners, Inc.; 1,017 adults; May 1999.

20 Princeton Survey Research Associates; cited above.

21 General Social Survey 1998; 2,832 adults; February 1998.

22 National Hospice/Gallup; adults; multiple responses accepted; September 1996.

23 General Social Survey 1998, cited above.

24 General Social Survey 1998, cited above.