It's arguably the most personal and universal of all voter concerns: health care. Few families are immune from worries about finding or paying for good medical attention, which in turn is linked to issues such as job security, insurance coverage, and racial discrimination.
An overwhelming majority of Americans told Gallup this year that cost, accessibility, and quality of health care are "extremely important" or "very important" factors in deciding how they will vote in November's presidential election. When polled, people repeatedly say that health care should be a top priority for government, ranking in some surveys ahead of Social Security, taxes, and education.
During the 1990s, the nation gained some control of spiraling health care costs, largely as a result of employers requiring workers to join health management organizations (HMOs) and other managed care plans. At the behest of the Nixon administration, Congress had encouraged the expansion of HMOs in 1973 by giving them special legal rights, including immunity from malpractice lawsuits. Now Congress is considering the Patients' Bill of Rights, which would remove that legal immunity and mandate easier patient access to specialists - changes that could increase the cost of care. Americans are wrestling with these and other health care tradeoffs.
This is partly because health care bills are rising again. Economists say the upward trend reflects the increasing medical needs of the nation's aging population and the spread of costly new medical treatments and prescription drugs. Private spending on health care moved past $1.1 trillion in 1998. That number is expected to more than double by 2008, representing an estimated 16.2 percent of the nation's gross domestic product, according to the federal Health Care Financing Administration. Meanwhile, insurance premiums have taken wing again, soaring by 8.2 percent in 1998 alone.
Uncertainty about cost and service is driving voter concerns about the rapidly evolving health care system. More than 100 million people are now covered by HMOs and other managed care plans, which are in flux in terms of coverage and pricing. During this adjustment period, Americans have very mixed feelings: People say they are satisfied with their HMOs but also express many worries and suspicions. They endorse reform proposals but back off when costs are mentioned. Some examples of the public's ambivalence:
Cost. Most Americans say they "worry a great deal" about problems such as the elderly not being able to afford prescription drugs or long-term care. Yet more than two in five say that HMOs help keep out-of-pocket expenses reasonable.
Access. The 1990s saw the number of Americans without health insurance swell from about 35 million to 44 million. Eight in 10 people surveyed agree that this figure is a major problem. But most people say they would not support a 1 percent increase in income taxes to provide universal coverage.
Regulations. Three out of four Americans say the government should mandate easier patient access to medical specialists and permit lawsuits against HMOs. But this support falls by 25 percent if the new protections are linked to higher insurance premiums.
Quality. Nearly four in 10 of those surveyed are concerned that their health care plan might deny them certain kinds of medical treatment, and most people say they worry a lot about insurance companies making medical decisions instead of doctors. Yet eight in 10 people also say they are satisfied with their managed care plan and would recommend it to other people.
One explanation for these paradoxical findings: Cost cutting at HMOs - or, as the industry would have it, sensational media coverage of isolated problems - has badly shaken people's trust. And trust is a priceless asset in medicine, where a placebo can work wonders. In matters of confidence, HMOs and other managed care plans come in dead last, behind doctors, hospitals, and several government programs. Only three in 10 Americans told Princeton Survey Research last year that they trust HMOs to do what is right for them all or most of the time.