KFF designs, conducts and analyzes original public opinion and survey research on Americans’ attitudes, knowledge, and experiences with the health care system to help amplify the public’s voice in major national debates.
National Survey Of Obstetricians/Gynecologists On Contraception And Unplanned Pregnancy: Attitudes And Practices With Regard To Abortion
The survey findings show only one third of obstetricians/gynecologists practicing today perform abortions. Younger doctors, doctors in multi-specialty group practices, and doctors practicing in the South and Midwest are among those least likely to perform abortions. The survey also finds that many of the physicians who do not perform abortions say they would, however, offer Mifepristone, if approved by the Food and Drug Administration. A press release summarizing the findings and questionnaire topline data is available.
This report reviews the major options available to states to achieve the savings in Medicaid required by the joint budget resolution passed by Congress in June 1995. The report analyzes ways to reduce spending growth for acute and long-term care services and considers stricter eligibility criteria. The authors conclude that reductions in spending growth are too great to be met without cutting eligibility as well as costs per beneficiary.
The Use of Mainstream Media to Encourage Social Responsibility:
The International Experience
Executive Summary
The Henry J. Kaiser Family Foundation commissioned the Advocates for Youth Media Project to carry out a study titled The Use of Mainstream Media to Encourage Social Responsibility: The International Experience. The study examines the outcomes of programs using mass media entertainment to stimulate changes in health behaviors.
Entertainment-education is defined as the process of putting educational content in entertaining formats and messages in order to increase knowledge about an issue, create favorable attitudes, and change overt behavior concerning the educational issue or topic (Singhal, 1993, and Brown & Singhal, 1993). International public health programs, especially those dealing with reproductive health, have more experience using and evaluating this approach than their domestic counterparts. These international experiences using entertainment for public health education offer relevant lessons for the United States and can be used in the development of similar domestic programs.
This study’s findings are based on:
Interviews with the agencies most active in international entertainment-education
An examination of the evaluation results of 52 entertainment-education projects; and
A literature review.
Ten important “lessons learned” relating to the advantages and limitations of using this approach for public health education and promotion purposes in the United States emerged from the study:
1. Entertainment-education can be used for promoting knowledge, attitude and behavior change, but it may not always be the most appropriate approach for meeting behavior change objectives. While many agree that entertainment-education is useful in creating awareness or interest in a topic, some dispute the claim that entertainment education can provoke behavior change. Behavioral objectives can be unrealistic unless the entertainment is associated with another project component involving interpersonal contact.
2. Knowledge of the audience should drive the project. It is essential to begin the project planning process by determining whom the project aims to help with what situation or problem. A thorough exploration of the target audience, including their needs, concerns, interests and preferences, should be the foundation to determine the appropriate strategy for reaching that audience. Only after conducting this research should an entertainment-education strategy be considered.
3. Entertainment-education projects should be developed according to a methodology that includes formative research, pretesting, monitoring of outputs and evaluation of impact All of the agencies interviewed utilize a similar methodology for developing entertainment-education projects and felt strongly that this process helped to ensure the quality of the outcomes.
4. Working with celebrities can be an asset to a project, but only under certain circumstances. Celebrity endorsement is only important if the formative research shows that the audience would find a celebrity both attractive and a credible source of information on the issue. The most popular celebrities aren’t always the best spokespeople for a cause.
5. Entertainment-education offers the advantage that, at least internationally, airtime often can be obtained for free. A well-crafted entertainment-education product should be so appealing that television and radio stations will want to broadcast it at no cost to draw viewers and listeners. However, to guarantee the best time slot for reaching the target audience, it is sometimes necessary to pay, even internationally.
6. Evaluation of entertainment-education projects may not be able to prove that behavior change has occurred as a result of the intervention. Tracking studies may help to identify whether behavior change has taken place, but it is difficult to measure and attribute change to a single initiative accurately.
7. Longer-term sustained efforts should be sought if entertainment-education is to be used most effectively. Long-term interventions that can be sustained over time enhance the probability of real impact, since audiences must be sufficiently exposed to the proposed behavior change and its benefits to develop understanding and positive attitudes toward the change. It takes time to build characters which represent the pro-social values and ideas, as well as to build the audience’s identification with those characters.
8. Entertainment-education may not be the best way to target small pockets of need. Unless behavior change is sought among a majority of viewers, listeners or readers of the selected entertainment media, entertainment-education may not be the best approach to meeting a project’s objectives.
9. Linkages with existing media and social agency infrastructures would be essential to the success of a U.S.-based project. Simply producing an attractive entertainment-education product is not an end in itself; it must be developed as a way to link audiences with something more, such as information or services.
10. Competition on the airways in the United States presents a challenge to domestic entertainment-education, but not necessarily an insurmountable one. It is easier for an entertainment-education project to reach its objectives in developing countries where there is less competition for audiences.
Further explanation of these lessons and a detailed inventory of 52 entertainment-education projects are contained in the full report (#1092), available by calling the Henry J. Kaiser Family Foundation’s publications request line at 1-800-656-4533.
An examination of how other countries have used the popular media to promote social responsibility, particularly in the area of sexual and reproductive behavior. In addition to providing an overview about the evolution of “entertainment-education,” the report provides case studies of initiatives world-wide ranging from Mexican “telenovelas” to an Indian comic strip to a Jamaican radio soap opera. When possible, evaluations of the projects are included. The authors cite lessons for the United Statesfrom these other nations’ experiences that may be relevant in the development of similar programs in this country.
Block Grants In Health and The States: Concerns and Criteria
This report examines some issues raised surrounding block grants and suggests some criteria that might be used to examine proposals during the current debate.
A report summarizing the campaigns of proponents and opponents to the California Health Security Act (Proposition 186) of 1994. The report includes findings from research commissioned by the Kaiser Family Foundation on the potential financial and administrative impact of the Act on California, as well as an analysis of the paid media campaigns on the issue (see also #1026, Statewide Surveys of Californians on Public Attitudes Toward the Single Payer Ballot Initiatives (Proposition 186), #1027, Analysis ofthe California Health Security System (Proposition 186), and #1028, California Health Security Act: A Look at the Administrative Issues, National Academy of Social Insurance for more information on Proposition 186).
This report provides an analysis of key issues in the design and implementation of medical savings accounts for the Medicare population. It focuses on benefit design, eligibility, enrollment, risk selection and adjustment, and the effects of managed care.
This year, Medicaid will finance health and long-term care services to more than 35 million low-income Americans. In its role as a purchaser of health services for low-income families, Medicaid increasingly relies on managed care to deliver care. Almost 8 million Medicaid beneficiaries, predominately poor children and their parents, now receive health care services through a broad array of managed care arrangements, including Health Maintenance Organizations (HMOs) and less structured primary care case management systems.
Virtually every state is increasing their reliance on managed care as a health care delivery model for its Medicaid population. As of June 30, 1994, 23 percent of Medicaid beneficiaries were enrolled in managed care arrangements, up from 14 percent in 1993. Due to the growing interest in managed care from both the State and Federal governments, the number of Medicaid beneficiaries enrolled in managed care is expected to continue to rise in the foreseeable future.
This brief summarizes current trends in Medicaid managed care enrollment, describes the major models of Medicaid managed care, and raises issues for consideration with regard to managed care for low-income populations.
Medicaid Managed Care Enrollment
In response to pressures to contain the growth of State and Federal Medicaid spending and to concerns about access to health care for low-income individuals, the use of managed care arrangements in Medicaid has grown dramatically in recent years. In 1983, 750,000 beneficiaries — 3 percent of the Medicaid population — were enrolled in managed care. In 1994, about 7.8 million beneficiaries — 23 percent of all Medicaid enrollees — were enrolled in managed care arrangements. The most significant growth occurred between 1993 and 1994, when Medicaid managed care enrollment grew 63 percent, from 4.8 million beneficiaries to 7.8 million (HCFA, 1994) (Figure 1).
The increase in the number of managed care enrollees is paralleled by a growth in the number of states moving toward managed care for their Medicaid population. In 1981, 85 percent of all Medicaid managed care enrollment took place in four states — California, Maryland, Michigan, and New York. By 1994, these states accounted for less than a quarter (24 percent) of the Medicaid managed care population. As of June 1994, all states except for Alaska, Connecticut, Maine, Nebraska, Oklahoma, Vermont, and Wyoming reported having at least one managed care program (HCFA, 1994). Appendix Table 1 displays the number of Medicaid enrollees in managed care plans by state as of June 1994.
The growth in Medicaid managed care mirrors private sector trends. It reflects the widely held belief that managed care can improve health care access as well as promote cost containment and budget control. Changes in federal policy designed to promote the use of Medicaid managed care also have made managed care appealing to many states.
Populations Enrolled In Medicaid Managed Care
The principal populations enrolled in Medicaid managed care have been children and adults in poor single-parent families who receive Aid to Families with Dependent Children (AFDC) and low-income pregnant women and children, rather than the elderly or disabled. While low-income adults and children accounted for 73 percent of the 32.1 million Medicaid beneficiaries, their health care costs accounted for 27 percent of total program spending in 1993. Compared to the elderly and disabled, the AFDC and poverty-related populations generally require fewer and less expensive services and are, therefore, less costly.
The shift to Medicaid managed care from fee for service for the elderly and disabled population has been less dramatic. Although 18 states offered managed care plans for disabled or elderly beneficiaries eligible for Supplemental Security Income (SSI) in 1993, only a small fraction of this population is enrolled in managed care. Some Medicaid managed care programs are also directed at services for beneficiaries with specific conditions such as AIDS, high-risk pregnancy, substance abuse, mental illness, and diabetes. Two states with statewide Medicaid demonstrations, Tennessee and Oregon, include in their mandatory managed care programs acute care services for the SSI disabled and elderly populations who are not in long term care institutions.
State Options For Medicaid Managed Care Enrollment
To establish Medicaid managed care programs, a state usually must obtain one of two types of waivers from HCFA — Section 1915(b) freedom-of-choice waivers and Section 1115 research and demonstration waivers. Section 1915(b) of the Social Security Act allows states to obtain waivers to certain federal Medicaid requirements without having to meet the formal requirements of a Section 1115 program. States need this waiver to require beneficiaries to select a primary care provider and to lock them into that provider for more than one month at a time. A 1915(b) waiver is also needed for a state to operate a program in only part of the state or a program that is limited to certain categories of beneficiaries. As of October 1994, 38 states and the District of Columbia had 71 Section 1915(b) waiver programs (HCFA, 1995).
States that are interested in testing new methods of administering Medicaid and other Social Security Act programs apply for waivers of Section 1115 of the Social Security Act. Section 1115 waivers permit the Secretary of the U.S. Department of Health and Human Services (HHS) to authorize states to develop statewide managed care systems that do not meet federal statutory requirements. Up until 1993, Arizona was the only state to have a statewide Medicaid managed care demonstration. Since a liberalization and revision of the Section 1115 review and approval process in 1993, the Secretary approved statewide managed care demonstrations in eight additional states (Florida, Hawaii, Kentucky, Ohio, Oregon, Rhode Island, South Carolina, and Tennessee). Besides shifting the traditional Medicaid population into mandatory managed care, all of the recently approved section 1115 waivers extend coverage to certain low-income individuals and families not currently eligible for Medicaid. Together, the five operational statewide waivers (Arizona, Hawaii, Oregon, Rhode Island, and Tennessee) cover an estimated 1.9 million beneficiaries. (For further information, see the Commission’s Discussion Brief, Medicaid Section 1115 Waivers, forthcoming)
Medicaid Managed Care Models
Generally speaking, managed care arrangements — whether under Medicaid, Medicare, or in the private sector — share certain features, including: formal enrollment by individual patients; formal contractual agreements between providers and payers; and some level of “gatekeeping” or utilization control performed either by a primary care physician or a separate administering arm of the payer, or both.
Medicaid managed care arrangements can be divided into three major types:
Fee-for-service primary care case management (PCCM): In a PCCM, a specific provider, usually the patient’s primary care physician, is responsible for acting as a “gatekeeper” — that is, approving and monitoring the provision of virtually all covered services to beneficiaries assigned to him or her. PCCM providers or “gatekeepers” contract directly with State Medicaid agencies and are paid on a fee-for-service basis. Payment generally includes a per-patient monthly case management fee to compensate for the provider’s expanded administrative responsibilities. The PCCM providers do not assume financial risk for the provision of these services.
Limited-risk Prepaid Health Plans (PHPs): Under limited risk arrangements, State Medicaid agencies contract with entities known as prepaid health plans (PHPs) to provide to enrolled beneficiaries a specified range of services. As in the case of full-risk plans, the PHP receives fixed monthly capitation payments for each eligible enrollee. The PHP often subcontracts with individual practitioners and clinics for the provision of the covered services, in the process shifting some of the financial risk to them. Additionally, some PHPs that meet the definition of an HMO are treated as PHPs through special statutory exemption.
Full-risk plans (HMOs or HIOs): Under a fully capitated plan, State Medicaid agencies contract with a corporate entity for a fixed monthly fee per eligible enrollee for the delivery of a specified set of services. The contractor assumes the financial risk of providing all of the medically necessary services under the contract (the contractor will often reinsure against the risk of high-cost cases). The contractor often subcontracts with hospitals and other providers for the actual delivery of care, in the process shifting some of the financial risk to them. The major type of full-risk plans are Health Maintenance Organizations (HMOs), which may be Federally qualified or State certified, and in which the contracting entity and the providers are integrated into one plan. The other type of full-risk contractor is the Health Insuring Organization (HIO), which essentially operates as a fiscal intermediary and is not integrated with the provider network that actually delivers the services.
Of the 340 Medicaid managed care plans in operation in the spring of 1994, almost two-thirds were full-risk plans (HMOs or HIOs), 22 percent were limited risk PHPs, and 14 percent were PCCM arrangements. The trend among Medicaid managed care arrangements is moving away from limited-risk toward full-risk plans. As Figure 2 shows, the proportion of full-risk plans increased between 1993 and 1994 from 55 percent of total plans to 64 percent of all Medicaid managed care plans, while the proportion of PHPs declined from one third to one fifth of all plans.
Enrollment trends mirror this trend toward full-risk contracting. Of the 7.8 million Medicaid beneficiaries enrolled in managed care as of June, 1994, more than half were enrolled in full-risk contractors(HMOs or HIOs), almost one third were enrolled in PCCMs, and less than one sixth were enrolled in PHPs. Until recently, much of the growth in Medicaid managed care enrollment came from expanded enrollment in PCCMs. However, with most of the new statewide demonstrations requiring enrollment in full-risk plans, the proportion of managed care enrollees in HMOs appears to be growing. From 1993 to 1994, Medicaid beneficiary enrollment in HMOs and HIOs jumped from 44 percent to 54 percent of all Medicaid managed care enrollees (Figure 3).
Lessons From The Medicaid Managed Care Literiture
To provide some guideposts for the use of Medicaid and managed care in the future, the Kaiser Commission on the Future of Medicaid reviewed more than 130 journal articles and studies on Medicaid’s experiences with managed care to identify major findings and issues regarding access, cost, quality, and patient satisfaction. The literature reflects the diversity of approaches tried and the evolving nature of managed care. It shows that managed care is not a single model of delivering care, but rather a broad array of health care financing and delivery arrangements. The tremendous variety in the structure and scope of managed care and limitations in the study design of many of the projects make generalizations difficult. Results are often mixed across evaluations, but some common themes do emerge(Rowland and colleagues, 1995):
Impact on access to care: There is evidence suggesting that managed care shifts the type of care and the site of care. Most studies show a decline in the use of specialist services and the use of emergency rooms as a service site. There is little evidence, however, to suggest that managed care either increases or decreases the number of physician visits, the use of preventive health services, or inpatient hospital care.
Impact on health care costs: Evidence about cost savings are almost equally divided between studies that show program savings and those that show program costs similar to or above traditional fee for service. The literature suggests that when savings are achieved, they can range from five percent to 15 percent relative to fee for service.
Impact on the quality of care and patient satisfaction: The quality of care in fee-for-service and managed care arrangements is about equal. Overall patient satisfaction with Medicaid and managed care is high. Satisfaction with medical care appears to be most affected by the beneficiaries’ ability to remain with their previous source of care.
Impact on special populations: Medicaid covers a wide range of low-income individuals, including families with children, the elderly, people with disabilities, and those in need of long term care. Most of the studies of Medicaid enrollees in managed care are based on low-income families and do not include elderly or disabled beneficiaries. Therefore, the experience with managed care for special populations is extremely limited.
Implications And Issues In Medicaid Managed Care
Many of managed care’s principal features have the potential to improve access to care for the low-income population. By managing the beneficiary’s care and ensuring that services are integrated and coordinated, managed care can overcome the fragmentation often experienced in the fee-for-service system. By promoting early intervention and preventive care, it also can lead to better access to primary care and reduced reliance on emergency rooms as a site of care. Lastly, by increasing the availability of primary care, managed care can help reduce hospitalizations for conditions that could have been treated in an ambulatory setting.
For the low-income population, realizing the potential benefits of managed care is, however, a challenging task. As the move toward managed care in Medicaid continues, a number of key issues must be addressed.
State Implementation: Care must be taken in designing and implementing managed care systems for low-income populations. Ensuring that plans have provider networks in place, educating both providers and beneficiaries on how managed care works, and understanding the unique needs and characteristics of the Medicaid population requires a considerable amount of time and effort.
Monitoring and Oversight: Just as overutilization is a problem in fee-for-service systems, underutilization may be a problem in managed care because care incentives are reversed. In prepaid systems where providers are reimbursed a capitated payment per individual for a range of services, there is an incentive to limit service use, particularly inpatient and specialty care. Protections and adequate enforcement, therefore, are needed to assure quality and access to health care for low-income enrollees. It also is important that payment levels to participating providers are adequate to maintain quality.
Populations Enrolled: Medicaid covers a diverse population, that includes nine million elderly and disabled individuals. States, however, have focused their managed care expansions on children and adults in low-income families rather than the elderly and disabled populations. Due to the complex and costly health care needs of elderly and disabled populations, setting capitation rates and finding plans willing to serve this population will require considerable more effort than has occurred with managed care expansions for children and adults in low-income families. It may be prudent to use managed care demonstration programs to gain experience in developing payment rates and in recruiting an appropriate mix of specialty and primary care providers before enrolling large numbers of elderly and disabled beneficiaries into managed care programs. Unless adequate attention is given to these issues, many individuals with serious medical needs could be at risk of not getting adequate health care.
Cost Savings: The potential for cost savings for managed care in Medicaid should be carefully evaluated. Research suggests that, in the private sector, spending on insured services would have been reduced by 17 percent nationwide if all insured people had been enrolled in group/staff model HMOs or other equally effective HMOs in 1990 (CBO, 1995). In the Medicaid program, the most rigorously designed studies suggest that managed care savings are not assured. Evidence about cost savings was almost equally divided between studies that show program savings and those that show program costs similar to or above traditional fee for service. When savings occurred, they were in the range of five percent to 15 percent (Hurley, Freund, and Paul, 1993). Several reasons will likely account for less predictable managed care savings in the Medicaid program.
First, savings to overall Medicaid expenditures are likely to be modest because states are now primarily enrolling the least costly of the Medicaid population groups — children and adults in low-income families who primarily use acute care services. Acute care expenditures for low-income families accounted for 23 percent of total Medicaid spending in 1993 (Figure 4). Therefore, even if savings in Medicaid managed care programs are in the range of five percent to 15 percent relative to fee for service, as the literature suggests, and if all the adult and children beneficiaries were enrolled in managed care arrangements, overall Medicaid savings would amount to only one percent to two percent of total current expenditures (Holahan, 1995).
Second, operating under tight budget constraints, Medicaid has, in many cases, reimbursed providers at rates that are substantially below private sector rates. Given the low provider payment rates, savings from managed care are more difficult to achieve in Medicaid than in private health plans using discounted rates.
Finally, outreach efforts and care coordination may be more costly for a low-income population. Learning to navigate a managed care system is difficult for most health care consumers and potentially even more so for low-income individuals. Education and support services that are fairly limited in most commercial plans will be needed to provide effective health care to the low-income population.
Managed care is not an instant solution to improve access to health care for the Medicaid population and to save dollars. Making managed care work in Medicaid requires considerable attention to understanding the needs, cultural preferences, and characteristics of poor communities. Adequate time and resources in program design coupled with continuous monitoring and oversight of program implementation are needed to ensure that the potential benefits of managed care are realized.
The Kaiser Commission on the Future of Medicaid was established by the Henry J. Kaiser Family Foundation in 1991 to serve as a forum for analyzing, debating, and evaluating future directions for Medicaid reform. The Commission is not associated with the Kaiser Permanente Medical Care Program or the Kaiser Industries.
Both the Kaiser Commission on the Future of Medicaid and the Kaiser Family Foundation are involved in other analytic efforts in the area of Medicaid and managed care. The Kaiser Family Foundation, jointly with the Commonwealth Fund, is sponsoring case studies and consumer surveys in five states (California, Minnesota, New York, Oregon, and Tennessee) that are restructuring the delivery of health care to their Medicaid-eligible and uninsured populations by converting from fee for service to managed care. The Kaiser Family Foundation is also sponsoring a series of focus groups in the same states of low-income Medicaid beneficiaries concerning their experiences with, and attitudes toward, managed care.
References
Congressional Budget Office. 1995. The Effects of Managed Care and Managed Competition, CBO Memorandum, February.
Congressional Research Service. 1993. Medicaid Source Book: Background Data and Analysis (A 1993 Update), House Commerce Committee Print 103-A, January, pp. 1009-1038.
General Accounting Office. 1993. Medicaid States Turn to Managed Care to Improve Access and Control Costs, GAO/HRD-93-46, March.
Health Care Financing Administration, Medicaid Bureau. 1993. Medicaid Managed Care Enrollment Report Summary Statistics as of June 30, 1993, Washington, DC: U.S. Department of Health and Human Services.
Health Care Financing Administration, Office of Managed Care. 1994. Medicaid Managed Care Enrollment Report Summary Statistics as of June 30, 1994, Washington, DC: U.S. Department of Health and Human Services.
Holahan, John. 1995. The Implications of Past Medicaid Spending Growth for Future Debates, The Urban Institute, January.
Hurley, Robert, Freund, Deborah, and Paul, John. 1993. Managed Care in Medicaid, Ann Arbor, Michigan: Health Administration Press.
Rowland, Diane, Rosenbaum, Sara, Simon, Lois, and Chait, Elizabeth. 1995. Medicaid and Managed Care: Lessons from the Literature, Kaiser Commission on the Future of Medicaid, March.
This policy brief highlights Medicaid’s use of managed care, describes key findings from the literature with regard to access, costs and quality of care and discusses issues related to Medicaid and managed care. Information on Medicaid enrollment in managed care at the state level is also included.
New Survey finds most Americans oppose slowing the growth of Medicare to balance the budget or cut taxes, but would support changes to avoid bankruptcy
Embargoed for release until: 9:30 AM EST Thursday, June 29, 1995
Contacts: Matt James Tina Hoff (415) 854-9400
–Public Favors Incremental Rather than Sweeping Reforms–
–Significant Generational Differences on Medicare Reform–
Washington, D.C. — A new survey has found that close to three out of four Americans (73%) support reducing the rate of growth in Medicare spending if the goal of the reductions is to avoid the bankruptcy of the Medicare program. However, less than half the public supports major reductions in Medicare spending growth if the goal is to balance the Federal budget (44%) or provide a tax cut (28%).
The Kaiser/Harvard/Harris Survey on Medicare also found that most Americans (70%) know that the Medicare program is in danger of going bankrupt, and many (48%) express a high level of concern over that possibility. Nearly half (49%) say they are aware that Medicare “has been going bankrupt” for a long time.
Redesigning Medicare
The survey also found that while most Americans support Medicare changes to ensure the fiscal solvency of the program, most are leery of a major redesign of the program. A plurality of the public, 45%, support Congress making changes in the Medicare program as long as the changes still “preserve Medicare basically as it is.” Two out of five adults (40%) support a complete redesign of the program, and a minority (14%) say Medicare should be left as it is. When given a choice between the current system, in which you get a Medicare policy directly from the government, and the option of receiving a voucher to purchase private insurance, the public supports the current system (65%) over a voucher (32%). The public is evenly split (49% favoring, 48% against) on the idea of enrolling “most” Medicare beneficiaries in Medicare managed care. But, 72% favor government incentives to enroll in managed care, and 55% favor raising premiums for those who stay in fee-for-service.
“Just as in health reform, the American people are leery of sweeping change, and generally opt for more modest incremental reforms. Medicare is no exception,” said Drew E. Altman, president of the Kaiser Family Foundation.
Support for specific program changes
Among policy changes the public most strongly supports to avoid Medicare bankruptcy:
Having those over 65 whose incomes exceed $70,000 per year pay a higher Medicare premium than other seniors (78%);
Having the government provide incentives to recipients to join less expensive managed care plans (72%);
Reducing Medicare payments to physicians and hospitals by 15% (68%);
Paying more in taxes or premiums (62%).
The policy options with the weakest public support to avoid Medicare bankruptcy:
Reducing Medicare benefits (16%);
Raising out-of-pocket payments of Medicare recipients (20%);
Raising payroll taxes (32%).
The perceived purpose behind slowing the growth of Medicare spending makes a big difference in the public’s willingness to see Medicare recipients pay more. When the purpose is to keep Medicare from going bankrupt and avoid raising taxes, a majority (54%) of Americans are willing to have Medicare beneficiaries pay higher premiums and copayments. But when the purpose is to balance the Federal budget and avoid raising taxes, only 35% are willing to see beneficiaries pay more. The public is not willing, however, to support the government raising payroll taxes either to avoid bankruptcy (32% support), or to balance the budget (25% support).
“The public appears to be willing to support efforts to solve the bankruptcy problem, but they do not want Congress to use Medicare savings to balance the budget or cut taxes,” said Robert J. Blendon, professor of health policy at Harvard University and director of the Kaiser-Harvard Program on the Public and Health/Social Policy.
Looking toward the Future
When asked what the Medicare program should look like in the year 2000, a substantial majority (60%) prefer to leave Medicare as it is today, with a fixed set of benefits and the government providing individuals with a single insurance card, while only 35% see Medicare as we know it no longer existing and being replaced by a voucher program.
More Americans would like to see Medicare remain a program that is run by the Federal government (58%) than turned over to private insurance companies for them to run (35%).
The public is divided on the issue of how much coverage should be provided by Medicare in the future if higher taxes are required. Although a plurality (42%) of Americans would accept more limited coverage under Medicare rather than pay higher taxes, 24% would pay higher taxes to preserve the current level of coverage and 28% would pay even higher taxes to provide additional benefits. A plurality (42%) of Americans think Medicare benefits should go to all retirees, but higher income retirees should pay more; but fewer than one in four (23%) would means test the program and require all those with higher incomes to buy their own health insurance. One third (34%) believe that if people have paid Medicare taxes, they are entitled to benefits when they retire no matter how well off they are.
The Medicare Generation Gap
The survey found significant differences in how people of different generations view the Medicare program. For example, support for a complete redesign of the Medicare program is higher among those under 50 (44%) than among those over 65 (23%). Over one-third of those over 65 (35%) want Congress to leave Medicare alone, while few people under 50 (8%) hold this view. Those under 50 are almost twice as likely to support turning Medicare into a voucher system (40%) as are those over 65 (22%).
When it comes to managed care, a majority of those under 50 (60%) favor encouraging the greater use of low-cost managed care plans to avoid bankruptcy and increased taxes, a position favored by less than half of those 65 and over (42%). In addition, while a majority of those under 50 (57%) favor having most Medicare beneficiaries enrolled in private managed care plans rather than traditional Medicare fee-for-service (41%), seniors by an overwhelming margin (70% to 23%) prefer having most beneficiaries remain in fee-for-service.
Although most seniors (56%) recognize that the program is in danger of bankruptcy, many are cynical about the motives of Congress in the current Medicare debate. By a two-to-one margin, seniors think that members of Congress are trying to gain political advantage from the issue (63%), rather than genuinely trying to respond to a crisis in the program (31%). By contrast, a majority (52%) of adults under the age of 50 think members of Congress are genuinely trying to respond to a crisis.
The survey also shows that, as a group, seniors are politically more active on Medicare and Social Security issues than other adults.
Medicare Knowledge
Most Americans blame rising Medicare costs on:
excessive charges by doctors, hospitals, and other health providers (80% say this is a very important cause for rising costs);
poor management by the government (70%), and fraud and abuse by doctors;
hospitals (68%).
Reasons often cited by Medicare experts for rising costs appear less important to the public, such as the increased number of retirees (50%)and new drugs, tests and treatments for the elderly (31%).
Most Americans (77%) are aware that Medicare is primarily a Federal government, rather than a state or private program; that the current Medicare program pays for doctor bills for individuals age 65 and older (75%); and, that Medicare is a program that principally serves the elderly (74%).
But the public is poorly informed about what Medicare covers. Fewer than half are aware that Medicare does not pay for long-term nursing home care (49%) or for prescription drugs (41%).
Public understanding of the current debate over the future of Medicare may be hampered by misconceptions about how large a share of the Federal budget is devoted to Medicare. Asked to choose among five items on a list (defense was excluded), the public ranked foreign aid and food stamps as the two largest items in the federal budget (picked by 63% and 42%, respectively). By contrast, the two items on the list that do actually constitute the largest areas of non-defense spending — Social Security and Medicare — were cited by 33% and 32% of respondents.
Methodology
The Kaiser/Harvard/Harris Survey was conducted by telephone with 1,383 adults nationwide between May 31 and June 5, 1995. The sample consisted of 1,076 adults selected randomly, plus an oversample of 307 people 65 years of age and older. Altogether 548 people 65 and older were interviewed, and their responses were weighted to the group’s proper proportion among the national adult population. The survey was designed by the Kaiser Family Foundation and the Harvard School of Public Health’s Department of Health Policy and Management and was conducted by Louis Harris and Associates, Inc. The margin of error in the national sample is plus or minus 3 percent. The survey is the latest conducted under the Kaiser-Harvard Program on the Public and Health/Social Policy, designed to monitor public knowledge, values, and beliefs on health and health-related issues.
The Kaiser Family Foundation, based in Menlo Park, California, is a non-profit, independent national health care philanthropy and is not associated with Kaiser Permanente or Kaiser Industries. The Foundation’s work is focused on four main areas: health policy, reproductive health, HIV, and health and development in South Africa.
