Background and Methodology

A series of 12, two-hour focus group discussion sessions was held between September 30 and October 3, 1991. A total of 119 people participated in the sessions, which were held in six geographically-dispersed markets across the U.S. including:

  • Potomac, Maryland

  • South Bend, Indiana

  • Gainesville, Georgia

  • South San Francisco, California

  • Suburban Dallas, Texas

  • Phoenix, Arizona

While we made an effort to recruit participants who, in the aggregate, reflect a cross-section of the American public, the resulting sample of 119 people is not a precise representation of the population. This is an inherent aspect of focus groups since this type of research is qualitative, not quantitative in nature.

The resulting participant profile is somewhat higher in socio-economic status than the nation as a whole, a variance which is common in focus group research. In addition, the total sample of participants includes somewhat more older baby boomers (35-44 years of age) and somewhat fewer senior citizens (65 and older) than found in the entire population. Participants were divided nearly equally between males and females. Roughly one in five represented a labor union/teachers’ association household. The mix of liberals, moderates and conservatives nearly mirrors the country as a whole: one in three are conservative, two in five are moderates, and one in five are liberal. Well over half of the participants were married, somewhat higher than the national average. Three quarters are employed, slightly higher than the national average, but consistent with being more highly educated. Less than one in ten participants represent farming households.

In terms of their health care coverage, a larger proportion of our sample of participants are covered by private, non-HMO insurance. One in five participants have HMO insurance, on target with the nation as a whole. The proportion of uninsured and Medicare/Medicaid insured participants was somewhat lower than the national average, which is again consistent with a slightly younger and higher socio-economic group of participants. Two of five participants claimed they had been uninsured at some point in time.

Recognizing the need to encourage open, honest discussion, the moderators utilized various techniques including asking participants to write down top-of-mind ideas, as well as asking them to dial in their responses to selected questions which subsequently would be discussed. This report summarizes the responses obtained in the written verbatim comments, the dialed responses captured through the Perception Analyzer’s (TM) hand-held dials, and the discussion comments.

Executive Summary/Implication


After reviewing more than 1,500 polling questions on health care in the public domain, and conducting 12 focus group sessions around the nation, it is clear that basic American human values are at stake in the health care debate now facing the nation.

Choice and personal control (freedom), security, honesty, equity, truth, and goodness are viewed as having been threatened, and in some cases attacked, by imposed changes in recent years. These unintentional assaults on the values of Americans more than anything else explain their frustration with the current health care system.

Future changes, if they continue the assault on these basic values, will likely only exacerbate the animosity people have toward the current system. Change which will return control, choice, equity and security to the system will be welcomed.


The findings of this research underscore the overwhelming importance of choice. or personal control, in the context of health care. Many of the likes and dislikes about one’s health care and the current health care system reflect a basic desire to choose one’s own doctor and hospital. Cost is the primary mitigating factor when it comes to choice. In situations where people do not perceive themselves able to afford adequate health care, only then are they willing (reluctantly) to yield their ability to choose, assuming the more cost effective alternative still provides them with quality health care. HMOs become a reasonable alternative if a person selects this option rather than being forced into it (particularly if a family has several children who require rather frequent visits to the doctor).

The desire for choice is evident across all demographic and geographic segments of the country.

Choice in one’s health care is underscored in the following examples and situations:

  • When HMOs limit people to a particular medical facility or hospital, they do not feel they can seek out the best possible care.

  • People want to deal with a doctor who is compassionate and cares about them, and will take the time to talk with them. Further, they want a doctor who will consider their particular illness from the standpoint of their whole body. Once they find a doctor with these characteristics, they are very reluctant to consider going to another one. Many people say they will pay extra to ensure they can maintain this relationship.

  • Diminishing health care benefits (e.g. fewer services and procedures covered, and the introduction of pre-existing condition requirements) and an increasing cost burden on people (e.g. higher co-payment amounts and higher deductibles), both frustrate consumers in that they feel they are losing control and being limited by their health care coverage. They basically feel their security is being threatened.

  • In situations where people have had a serious illness (e.g. cancer), the perception is that the person has no choice but to pay extremely high premiums for a minimal level of health care coverage. These people feel they are being unfairly discriminated against.

  • The perception is that the elderly are being shoved to the back of the line in terms of receiving health care. To the extent the elderly are able to receive adequate care (and not be abused and neglected like many people suggest), they are lucky. Older middle-aged people (45 to 64 years or so) are very concerned about their future because of the problems they see with the care of the elderly today. Baby boomers also are extremely concerned for the welfare of their parents who are entering their sixties and seventies. This means that concern about the elderly is not just limited to those in this segment, rather, it is wide-reaching across all segments.

To the extent that a person who changes his/her job is subject to pre-existing conditions or exclusion or fewer covered services in this new job, this represents a threat to their freedom and security.

The self-employed of America represent the ultimate example of free enterprise. However, it appears that many of the self-employed feel they do not have a choice with regard to health care–it is simply too expensive. But, by virtue of the fact they remain self-employed and forego health insurance, freedom to these individuals means more than health security.

People favor the continued development of medical technology. They want to be able to find the best medical care available.

In underscoring the importance of choice in health care, these situations and others suggest that the American public will reject any "solution" to the health care problem in the United States which threatens their ability to choose.


Basic marketing theory which American businesses utilize every day essentially says that you need to listen to the consumer and either develop a product or service to meet their unmet needs, or position an existing product or service by creating demand for it (but only if the propositions posed to the consumer are in concert with their basic attitudes about the product or service). The situation with the health care problem in the U.S. is no different in terms of the approach the policy makers should take. Specifically, it is important to listen to what people say about the health care system and become sensitive to their definitions and interpretations of various facets of health care. For example:

  • When people talk about the "quality" of health care, they are usually talking what satisfies them as users of the health care system. They talk about health care in very personal, emotional terms, not technical terms. Specifically, they talk about health care providers being compassionate and caring, treating them as individuals, and being available when they need help or care. They rarely talk about whether the doctor or hospital has specific technologies or equipment.

  • When people talk about "increased control" of the health care system they are talking about establishing order and structure to the current system. They are not talking about the government administering the system–an idea they fully reject, even though they look to the government to bring order to the system.

Further, when they talk about "radical reform" of the health care system, they are talking about overhauling selected aspects of the system, and fine-tuning other aspects. . Most people believe there is hope for the current system with this type of "radical reform." They are not advocating the development of a new system.

With regard to the portability of health care, particularly in job change situations, people want the freedom of choice in their health care, but they also want the security of a comprehensive plan which is associated with being part of a group plan. People’s desires for freedom and security in this context were not resolved. Future work needs to be done in this area to listen to what they have to say.


Many of the solutions of the past 10 years (HMOs, co-insurance, co-payments, higher deductibles, pre-existing conditions, exclusions, etc) appear to have inadvertently reduced choice, control and security for the public, and thus are the manifestations of the problems with the system today. (This is not to say that if those changes had not occurred that all would be well today).

This research has clearly shown that the American public will be unlikely to accept any solution which does not address the bottom line "causes" for the health care situation in the U.S. This means the solution will have to address the primary reasons for high and increasing costs in health care as well as the threat to basic values. As for cost, people point to the doctors themselves, hospitals, insurance companies, and lawyers.

The universal perception is that things have gotten out of hand with regard to malpractice: doctors have to test and re-test to protect themselves, and lawyers encourage people to sue in virtually any situation. The insurance companies are doing nothing to change this situation because it results in higher premiums for them.

Many people support the idea of "caps" on malpractice awards, suggesting that this will discourage claims. Further, they support the use of arbitration boards as a means by which to expedite malpractice claims. The caveat is that doctors serving on arbitration boards must be encouraged to not "stick up for one another." A solution to discourage lawyers is to limit their payment to a flat fee instead of a percentage of the settlement in a malpractice case. Further, some people argue that patients should be able to sue for a doctor’s license as a means by which to permanently remove incompetent doctors. Under no conditions are people willing to give up their right to sue–this is viewed as the ultimate weapon against bad doctors and hospitals.

In addition to malpractice, people also have well-formulated opinions about other causes for high costs in health care. These include too much paperwork for the insurance companies, inefficient hospital administration, and the need to test new drugs for years before FDA approval.

It is also the case that the American public is critical of the amount of money that flows out of the U.S. for aid to foreign countries, as well as defense spending. In virtually every group, someone suggested that minimal cuts in these two spending items could easily pay for health care coverage for those who are uninsured today. The general perception seems to be that in terms of the order of magnitude. the amount of money required to "fix" the health care system is relatively low in comparison with that spent on our foreign aid and defense agendas.

With regard to Medicare being a "solution" to the problem of the elderly not receiving health care coverage, the vast majority of participants in this research felt that this system has not yielded adequate care for the elderly. In fact, the perception is that it has created more problems for the elderly than it has solved: the elderly must worry about supplemental coverage; they are often neglected and abused when treated under Medicare; and they are forced to worry (often alone) about paperwork associated with claims.


There are several common messages in the health care debate:

  • Everyone must be able to get affordable health care.

  • We cannot just "give" all people some level of health care because it will be abused much like welfare, Medicaid and Medicare are seen as being abused. The perception is that people have to "wants health care and need to pay something for it to be considered valuable to them.

  • A "safety net" needs to be provided for those who cannot afford reasonably price health care. Generally, this safety net is perceived to cover emergencies and catastrophic situations which could "wipe a person out."

Most people feel that giving everyone some basic level of health care would result in the system being abused. much like the welfare and food stamp systems. Several participants talked about the problem of "giving people something they do not necessarily want." Their point is that even if health care was more affordable, not everyone would obtain health care insurance. For example, some young people are just not worried about health problems. Other participants believe in holistic approaches to health care. By giving health care coverage to people who do not place a high value on it, the perception is that it may be abused.

While people do not deny that the government will need to play a prominent role in fixing the health care system, they are very reluctant to turn the situation over to the government and lawmakers. The perception is that the government and lawmakers are partially at fault for the problems with other social welfare programs. and the current health care mess.


People see the health care situation as an example of failed market systems and failed government systems. They think the problem is so large that they cannot envision anyone other than the government being capable of addressing it but have no model in government they would like to see applied as a solution.

The combination of the inadvertent attacks on personal human values and the frustration of not being able to find any hope for a solution have led to a belief that radical reform is needed while people simultaneously demand preservation of most attributes of the current system. Their own aging and that of the society, coupled with perceived degradation of the health care system, compounds their fears of the future as they (the 87% with existing coverage) admit high satisfaction with their current doctors, hospitals and insurance while expressing profound concern for the health care system.

What is it that people like about their health care?

In terms of what people like about their health care, the most frequently mentioned items are related to:

  • The ability to choose their own doctor and hospital

  • The quality of the health care provider (doctor)

  • The perception of health care being relatively inexpensive to the consumer (especially among HMO users)

  • The breadth of the coverage in terms of the services covered

  • The convenience and accessibility of health care

Regarding the ability to choose one’s own doctor, many people have invested a significant amount of effort in the search for a doctor they like and with whom they feel confident: "I’ve been with my doctor for 22 years and wouldn’t change now." People do not feel that doctors are equally competent and they want to be able to shop around to make sure their doctor will provide quality care: "If my doctor doesn’t take good care of me, I want to be able to switch."

Another example of the importance of choice is illustrated in the case of the person suffering from a terminal or life-threatening illness. A person in this situation will seek out the best provider in that field as long as they can afford it. As one participant (a cancer patient) put it, "my doctor saved my life. He is the best and I will go to him as long as I can afford his fees."

Regarding the quality of the doctor, people talk about the attitude of the doctor toward them ("he treats me with respect; he listens to me") and the perceived competence of the doctor ("I need to have total confidence that my doctor knows what he is doing"). The concept of quality is related to two issues: 1) Does my doctor listen to me and treat me like a human being? and 2) Does he know what he is doing? The importance of quality is especially evident among people who want to choose their own doctor: "I want to be able to choose a doctor who will give me good quality care."

Regarding the perception that health care is relatively inexpensive, people with private, non-HMO insurance, as well as HMO insured people, talk about their employer paying the premium, the employer paying all or a significant part of the deductible, and low-cost ($2-$5) prescriptions. HMO users, especially the younger and unmarried person who doesn’t visit a doctor very often and has the entire premium paid by their employer, are more likely to be satisfied with the cost of their health care. The HMO user who has a family is somewhat happy with the cost of HMOs because the payment structure of the HMO helps them to identify all associated costs. There are no unknown costs like exclusions, deductibles, co-payments, etc. There is only a fixed user fee which is known. However, as will be discussed shortly, HMOs have considerable draw backs.

Regarding the breadth of their coverage, people talk about their coverage for dental and vision care, as well as general health care. Further, they say their plan requires them to pay only a few dollars for prescriptions. The coverage by unionized companies seems to be most extensive with the result that these people tend to be the most satisfied with their health care.

Regarding the convenience and accessibility of health care, HMO users like the idea that all of their health care needs are being taken care of in one facility. Further, HMO users don’t have to worry about the number of visits they make, even on the spur of the moment: "with children, you’re always running to the doctor"; "I can see a doctor for check-ups or when I need something without worrying about the cost"; and "I pay only $5 per visit so I don’t worry about how many times I go to the doctor." People with private, non-HMO insurance who have established a relationship with a doctor, also believe that they can see the doctor on short notice. Or at a minimum, drop in to a walk-in clinic or the emergency room.

Although mentioned somewhat less often than the above, people also talk about the peace of mind or "security" associated with knowing their health care coverage will take care of them in the case of a serious illness. These people essentially view health insurance in the same way they view home or auto insurance: They guard you against major expenses that could potentially wipe you out.

Some positive comments also were heard about the speed with which their insurance company reimburses them when they file a claim: "it takes 3/4/6 weeks to get reimbursed which isn’t too bad."


What are the problems with health care today?

In terms of what people perceive as problems with health care, they comment most often about:

  • The perceived expense of health care

  • Limited choices in health care

  • A lack of empathy or caring on the pan of health care professionals

  • A lack of ethics in the medical profession

Regarding the perceived expense of health care, people talk about the cost in absolute terms (how much they have to pay) and in relative terms (how costs are ever-increasing). Regardless of the group, cost was the universal concern about health care. In the absolute sense (what they pay), people talk about the high cost of health insurance when they are self-employed ("It’s too expensive for a self-employed person so I go without") or when they are retired ( "I had to get a job after I retired just so I could pay for my health insurance"). Others talk about the high cost of office visits which may not be covered by health insurance (particularly for preventive health maintenance): "I don’t go to the doctor because I can’t afford it, even though I have insurance."

When people talk about the thigh costs of health care, they are also referring to changes they have begun to notice over the last few years. For many people, employers are beginning to require employee co-payments and the amount of their yearly deductible continues to escalate. Many people could cite the exact amount covered by their insurance company (e.g. 90%, 80%, 70%) and how this percentage had changed in recent years. It appears to be the case that more than one aspect of their health care coverage has changed in recent time. In addition to a decreasing proportion of the medical expense covered by the insurance, there has been an increase in the annual deductible. In light of these trends, people are expecting more increases in what they have to pay for health care.

People also are concerned about health care costs because they believe them to be rising faster than their salaries and inflation. They believe that unless costs are controlled, there will be a time in the future when they can’t afford health care. The concern about cost was greater among older participants who were either retired or considering retirement in the near future. Older people have a greater need for health care and a diminished ability to earn income.

Regarding limited choices in health care, many people described feeling that they were losing control of their heath care in terms of what is being offered and the cost. The idea that an employer and/or the insurance company could cancel their insurance or double their co-payments or deductible, makes the health care consumer feel helpless. For the minority of people who are chronically ill or have suffered a serious illness like cancer, the general attitude is "if you are very sick, you could be canceled by the insurance company and become uninsurable." Still others talk about premiums which "doubled overnight," leaving them with no choice other than to accept the increased expense.

Regarding a perceived lack of empathy and caring in health care, many people comment that their doctor will not take the time to "talk to me." People believe that doctors "think of patients as profits rather than people." On the other hand, many of those people who feel their doctor is caring, often describe friend relationships with their doctor that have developed over time and often exist outside of the patient-doctor relationship.

HMOs were cited as being very impersonal, giving people the impression of "being processed."

On a related dimension of personal service, people are divided in their perceptions regarding the ability to receive medical treatment on short notice. Some believe there is no problem gaining access to quality health care. In some of these instances, people mentioned long-standing relationships with family doctors and that their the doctor would see them right away. Others believe that there are problems gaining access to quality care, citing difficulties getting an appointment with a doctor or having, as one man said, to wait at HMOs "only to be seen two and a half hours later by an obstetrician–for my ear infection."

Regarding a perceived lack of ethics in the health care industry, the feeling is that the health care system has lost credibility. As the cost of health care increases, it becomes very difficult for people to believe the increases are necessary. Many people believe one of the main causes for rising costs is corruption and consequently feel that costs can only be controlled if the excesses are curbed.

In discussing a lack of ethics or "greed" (a word used by participants), there are frequent anecdotes about hospitals charging $8 for an aspirin, prescription drugs which cost $1.65 for each pill, as well as charges on hospital bills for services that were never received (the most often mentioned being doctor visits that never occurred).

Another dimension pertaining to ethics in the health care industry deals with abuses of the elderly, most notably by long-term care facilities that neglect or abuse many of the elderly in their care.

In terms of other problems with health care, some people talk about diminished insurance coverage (in terms of the number of services being covered) and too much paperwork associated with filing a claim (and re-filing a claim as is oRen the case with some insurance companies).


Are people satisfied with their health care?

With the exception of those who are currently not covered by health insurance, most people are satisfied with their health care today. The uninsured, most of whom in our groups are self-employed, are very dissatisfied. Their primary complaint is that they are being denied health care insurance because it is too expensive; most of the self-employed said they could not afford the $800-$1000 monthly premium. It is interesting to note that some of the self-employed appear to have resigned themselves to the fact they can only hope that they will not be faced with a major health care problem. These people say they will be at the mercy of a hospital emergency room if something bad should happen.

Even though they pay deductibles and their employer requires co-payments, people who are members of labor unions appear to be rather satisfied with their health care coverage. These people know that their union works on their behalf to secure as comprehensive a plan as possible. Despite this positive view, unionized workers are also extremely concerned about the high cost of health care because the perception is that every year their insurance covers fewer services and the co-payment and deductibles increase.

Based on the responses entered through the dials, it appears that it someone has gone without health insurance at some time in their life, they appear to view their current health care coverage more critically than those who have never gone without health coverage.

There is some indication that people who use HMOs are slightly more likely than those who have private, non-HMO insurance or Medicare/Medicaid to be satisfied with their health care coverage. Notably, it appears that when a person chooses an HMO, they are selecting it because of greater access to health services for their families. This indication is based on their dialed responses and verbal comments.

Even people employed in the health care field are somewhat critical of the health care system today. They feel that:

  • There is too much paperwork

  • Doctors are overburdened with patients

  • Doctors perform unnecessary tests to minimize the chance of incorrect diagnoses (to guard against malpractice)

  • Doctors have bad attitudes as a result of the above situations

  • The price of health care services rendered (which this group is viewing from inside the system) is viewed as being too high with limited coverage

What are the primary dimensions of health care quality?

In light of the previous discussions, it is not surprising to learn that the primary dimensions of "quality" include: 1) accessibility (e.g. being able to call up your doctor in the middle of the night and have him there meet you at their office, or being able to get an appointment without waiting very long); 2) compassionate doctors; and 3) correct diagnoses. People define quality in very personal, emotional terms, not technical terms (such as particular specialties or the availability of particular high-tech equipment or services). Most often, people talk about the caring attitude of health care providers and their ability to compassionately view patients as individuals. Quality is not a sterile assessment of, for example, the number of correct diagnoses per 100 patients seen. Rather, it is a softer, qualitative measure which reflects the dimensions of customer satisfaction with their doctor and their hospital.

How do people feel about the future?

Among those who are currently happy with their health care today, most express skepticism about the future. The only positive comments related to the idea that things were already so bad that something would be done to improve the situation in the near future.

A primary concern about future health care pertains to dwindling benefits (fewer and fewer services covered each year) with people being asked to pay more and more for health care as employers require increasing employee co-payments. Another concern of people is that they are uncertain about their ability to keep up with the increasing health insurance premiums.

Older participants tend to be more worried than younger participants about the future because they were either retired or considering retirement and their income is or will be on a fixed basis. Younger people were only mildly concerned about their future, because they do not expect to be having health problems for quite some time.

As evidenced in the following comments, some people are concerned about larger social issues related to health care:

"There are too many homeless/uninsured for existing facilities to handle."

"I’m worried about care for the elderly. More and more doctors don’t accept Medicare patients."

"There will be a larger older population to support."

"Jobs are less secure while the cost of health care is rising."

"I am concerned about retiring and possibly getting sick and totally wiping out all my assets." (elderly person)

"The uninsured have the least amount of political clout to affect change"

The feeling of several people is that the middle class currently "is suffering" in terms of health care–the very poor and the very rich are taken care of (the poor receive Medicaid and the rich can afford it). The expectation is that this situation is going to continue into the future. According to these people, it is the middle class’ needs that need to be addressed in the health care debate.

How important is the issue of health care?

As previous research has shown, Americans are very concerned about health care as an issue facing the country. Both their comments and their responses entered through the dials highlight the perceived extreme importance of the issue. More interesting than this confirmation is the finding that women express somewhat greater concern about health care than men–a finding which is consistent with the general "gender gap" conclusion that women are more concerned than men about social issues.

It also appears that those who have never gone without health care coverage are somewhat more likely than those who have, to say that health care is an extremely important national issue. Perhaps these people are reflecting more on health care as a social issue or perhaps those who have gone without health care coverage recognize this as a reality which must be accepted.

Does health insurance play a role when changing jobs?

Health insurance would have to be considered when changing jobs, according to many participants. The primary concerns associated with changing jobs as they relate to health care center on: 1) the perception that the new employer’s plan may not be comparable in terms of coverage; 2) a pre-existing condition may not be covered by the new health plan; and 3) the plans may not be comparable in terms of price (the employee may have to pay more for the new plan). There were some definite differences of opinion on this topic with younger people somewhat less concerned about health care benefits, compared to middle aged and older people who were much more concerned about health care in the salary/benefits equation. Notably, younger people are more likely to be concerned about salary, not benefits. Further, they believe they are healthy now and do not see a need to worry about health care insurance.

There is evidence that people are concerned about being "locked" into their job, being unable to change jobs because of fears that their new employer’s health care insurance may be more expensive in terms of the deductible and co-payments, or it will not cover pre-existing conditions. But, people generally have mixed opinions about the idea of buying their own insurance. One concern is that it would be difficult to acquire the same quality health care as they have under a group plan, without a significant increase in the cost of the coverage. While a few people recognized that insurance companies would be forced to compete for your business (with the result that prices may decline), many did not want to be bothered by the need to "shop" for health care coverage. Nor did they believe the insurance companies would actually become price competitive. The situation the Post Office offers its employees (described by two participants) was viewed as a more reasonable approach to offering people the ability to buy their own insurance from a choice of providers (14 or so plans offered by the Post Office).

These findings suggest that while on the one hand, people want the freedom to choose (being able to change their job with no worries), on the other, they want the security that being pan of a group plan offers. This research did not provide a clear answer with regard to these potentially conflicting desires. Further study of these trade-offs is warranted.

Are the elderly receiving adequate health care?

In general, the feeling is that the elderly are ant receiving adequate care. Both their comments and their responses entered through the dials support this contention. The basic reasons for this belief include: 1) the perception that Medicare does not pay enough of the medical expenses incurred by the elderly and the elderly cannot afford to pay the co-payment and charges not covered by the plan; 2) fewer and fewer quality doctors are accepting Medicare; 3) some people are not familiar with the Medicare system (primarily the Hispanic participants) and require education about the system (particularly in terms of helping elderly parents receive Medicare benefits); 4) the perception is that many elderly Americans are commonly neglected, abused and cheated by long-term care providers; and 5) the elderly are easily worried about bills that go unpaid and become easily frustrated when having to deal with the details associated with health care insurance (e.g. bills from doctors, forms from the insurance company, statements, etc). Many participants feel that having to deal with Medicare and health bills actually places a great deal of strain on the elderly and their health.

There also is the perception that the elderly are "shoved to the end of the line" with regard to health care. Notably, one woman described a situation in which her grandmother was told by her doctor that she did not have any lumps in her breasts. The doctor went on to tell the grandmother that even if she did have a lump, it wouldn’t matter since she wasn’t going to live long enough for it to matter.

How do people feel about HMOs?

For the most pan people who select an HMO for their health insurance are happy with this choice. Those who did not have a choice because their employer uses an HMO, or because it was all they could afford, tend to be more unhappy with their health care coverage. There is some indication that men, more so than women, are happy with an HMO relationship. Further families with small children who need to visit the doctor more frequently are happy with an HMO because R is cheaper than visiting a private practitioner. Those who are happy with HMOs also mention the access they have to a wide variety of facilities at one site. These findings regarding HMO satisfaction also are supported by responses entered through the dials.

The prevailing perceptions are that: 1) HMOs offer limited choices of doctors; 2) there are long waits for service; 3) HMO doctors may not be as good as those in private practice; 4) HMOs are impersonal–all they want is to get people in and out in a hurry; and 5) HMOs assign people to a doctor with no choice in the matter.

People want to have the ability to go to the "best person possible" for their health care. The perception is that HMOs limit this ability to choose and it is virtually impossible to have the same doctor for your entire adult life if you are a member of an HMO.

Some people applaud the preventative orientation of HMOs; they feel that private, non-HMO insurance does not encourage routine check-ups. On this topic of preventative medicine, many people believe that one way to contain health care costs is to emphasize health care education and to encourage people to be active, rather than reactive, about their health. In the end, they believe that the number of serious illnesses (and therefore the costs associated with treating these illnesses) could be reduced by early detection.

Who’s to blame and what can be done about it?

Some members of the more rural groups expressed the opinion that "too much emphasis on health care results in health care problems." These people had a holistic approach to medicine, commenting that people can control their health through their minds. They also believed that there are options other than drugs for curing many illnesses. The perception is that doctors are all to eager to please a patient by simply prescribing a medicine. This sentiment regarding easy access to prescriptions was echoed in many of the groups. These people further suggest that doctors concentrate on "parts" of the body: "they are not treating the whole body." If the doctors were not hurried to see as many patients as possible and actually spend time with a patient, the perception is that diagnoses would be accurate with many problems caught before they become severe. Further, these people believe that this would foster a more preventative orientation to health such that patients would be forced to consider their entire body’s healthiness.

A related discussion centered on the perception that doctors have become too specialized and are quick to refer a patient to another "specialist." This situation further highlights the perception that doctors are not treating the whole body. Further, it contributes to the high cost of health care. Finally, by virtue of their specialization and the competition for their time, specialists are viewed as "too professional," while a family doctor is viewed more often as "dedicated" and

According to participants, malpractice is the main culprit in driving health care costs up. Lawyers are viewed as contributing significantly to this problem. Many people believe that regulating or otherwise controlling lawyers could have a significant impact on the cost of health care. People feel that lawyers are encouraged to "chase ambulances" because of lucrative settlements in which they share with the patient. Putting a cap on malpractice awards would be one way in which to discourage lawyers. Another suggestion was that lawyers working on malpractice cases should be paid a fat fee rather than on contingency.

To the extent that doctors are also a part of the malpractice problem, most people feel that the doctors are not left with any choice than to test and re-test patients to avoid malpractice suits. According to the participants in this research, if there was a cap on malpractice awards, doctors might be somewhat less inclined to worry constantly about ways to avoid malpractice claims. (This reflects sympathy for the doctor’s dilemma)

Some people believe that the doctors are in "cahoots" with the insurance companies and the hospitals. This means that people end up working for doctors and hospitals when they earn a living to pay for their health care coverage.

Many people were intrigued with the idea of malpractice arbitration boards as a means by which to address the malpractice problem. Their only concern is that doctors on the board will stick ups for one another, thus limiting the effectiveness of the board. Generally, people favor a combination of limits on malpractice claims and the use of arbitration. A few people even suggested that another means by which to "keep doctors under control" is to allow patients the opportunity to sue for the doctor’s license in severe cases of malpractice. The feeling is that it is not enough to only penalize them once monetarily–they need to be penalized permanently.

Virtually every participant in this research indicated they would not be willing to give up their right to sue as a means by which to control health care costs (by driving down malpractice claims). The ability to sue is viewed as the ultimate weapon the consumer has against doctors who are incompetent or careless.

A significant amount of blame for high health care costs is also placed on the insurance companies. Many people call for greater regulation of this industry or greater restrictions on profits the insurance companies can make. Several people cited situations in which insurance companies use their health care premium profits to finance non-health care investments, which end up having an adverse impact on their health insurance business.

People are rather reluctant to put limits on doctors fees as a means by which to contain costs. They believe that this will deter qualified individuals from entering the medical field because doctors will have to pay off their education expenses over a longer period of time.

There is a great deal of reluctance to delay tests and procedures as a means by which to contain costs. People point out that Americans expect immediate gratification even in their health care and will not tolerate waiting.

What about the uninsured?

Interestingly, several people were able to cite the number of uninsured Americans as being between 30 and 40 million. However, most grossly overestimated the number of uninsured. (Recall that the demographic profile of the focus group participants somewhat under-represents the proportion of uninsured in the nation.) The reason for overestimating the size of the uninsured population is due, in part. to people knowing someone who is not covered by health insurance (usually because they are self-employed), or because they have heard that there are "a lot of people who are uninsured." Regardless of the reason, the perception is that there is a significant number of Americans who do not have health insurance.

People acknowledge that there will always be those who are occasionally uninsured because of a job change or other situation. However, the larger, more worrisome group includes those who are chronically uninsured, of which there are those who are trying to get health care insurance but cannot (because they cannot afford it or because they are uninsurable), and those who are not trying to get it. The former group, those making an effort to get insurance, is viewed as including the self-employed and those with pre-existing conditions like cancer. The latter group is viewed as including those who have very low incomes and/or those who expect to be taken care of by the system (much like they are being taken care of by welfare).

People who are uninsured, because they cannot afford it or because of a pre-existing condition, seem to feel abandoned. According to these people, their basic security is threatened in that they do not have something to fall back on (other than walk-in clinics or the emergency room which are viewed as "treating anyone’) in the case of an accident or disease. Those who are insured sympathize with the self-employed situation, saying that "the backbone of America is free enterprise and entrepreneurs–the high cost of health care does not foster this."

How do people view medical technology development and medical research?

The bottom line is that people favor the continued development of medical technology While on one hand people say that MRI and CAT scan equipment does not need to be installed in every hospital or doctor’s office in a city, they are quick to say that they would want it installed in their doctor’s office or hospital if they needed it. Clearly, these people recognize that better utilization of equipment would have an impact on costs in terms of keeping them down or slowing the rate of growth, but they are very reluctant to be inconvenienced by increased efficiency/utilization. Therefore, another aspect of choice pertains to the development of technology, wherein people are free to find the best medical help possible.

In a similar vein, people support the general idea of spending more wisely in terms of developing new technology to extend life, but are quick to point out that we cannot, for example, emphasize equipment to extend the life of premature newborns over equipment designed to extend the life of the elderly and infirm and vice versa. Someone with a premature newborn would want every effort expended to keep the baby alive, and similarly, someone with an elderly parent would also want every effort expended: "it depends on your own situation and perspective." Clearly, certain people would be very upset with any situation which prioritizes treatment.

When asked to indicate priorities for medical research spending among several types of research, the pattern was fairly consistent: a slight edge to cancer, followed by roughly equal spending for childhood diseases, AIDS, and heart disease. Alzheimer research and other research generally received lower levels of support. Several people became quite adamant about the "easy solution" for AIDS (avoiding the behavior that starts and spreads this disease) relative to more difficult solutions for the other diseases and illnesses.

What about a national health care plan?

Not surprisingly, many people initially are attracted to the idea of national health care, "like they have in Canada, Great Britain, Germany, and Sweden." However, it is clear that when people learn more about the tradeoffs that occur under these systems, they become less and less attracted to the idea of national health care. They are easily discouraged when they learn they may have to wait for health care, and when they learn their choices may be more limited.

Also, as soon as national health care is positioned as "socialized medicine" (as several people described it) there is an immediate negative reaction to the idea.

Participants agree that a minimum level of health care should be available for all Americans because ‘the haves need to take care of the have nots, otherwise this would be a sorry place to live.’ However, some people believe the existing system of county hospitals and welfare is adequate as the necessary minimum level of health care. The question seems to be. "what level .of care should be available to everyone?" Regarding this issue, people in virtually all groups talked about providing everyone with a "safety net" of basic minimum health care services. This safety net would most likely be paid for by the government, which translates into increased taxes. Although they do not like the idea of increased taxes, they recognize that we will pay for it "one way or the other." If we do not provide a basic level of care, then those without care will ultimately cost more because of increased illness and the acquisition of expensive care through emergency rooms, etc. If we provide a basic level of care, then we can keep people in better health and cover them in catastrophic situations.

Some people basically consider their own situation and express a desire to have the personal freedom to obtain the best possible quality health care, much like striving for a new and better car. Health care is perceived as a consumer product, with the best products being available to the most affluent. These people were not willing to give up anything in terms of their perception of quality as long as they have the money to pay for it. Their concerns begin when they foresee a time when they won’t be able to buy the best possible health care.

Most people argue the government should sat be the administrator of a national health care program due to a perception that this body would mismanage and corrupt the system. Most participants feel the government’s role should only be one of regulating costs. Further, discussions inevitably turned to reducing defense spending and aid to foreign countries as means by which to raise money for the safety net of health care services.

When people start talking about the funding for the safety net of services, they talk about having people contribute a percentage of their income with the wealthier people obviously contributing more in absolute dollars. The perception is that to the extent the poor also contribute, they will be encouraged to use the services instead of going without health care.

Some people also talked about developing "pools" of money to cover the uninsured, much like is the case with contributions (through insurance premiums) to pools for high risk drivers in some states.


What is the bottom line?

The bottom line is that with little exception, most people have not given up on the current health care system and favor bringing increased order and structure to the current system in lieu of starting from scratch with a new system. People want a "radical reform" of the current system which means over hauling selected aspects of the system, and fine-tuning of other aspects. Even though they use the words "national health care system," people are talking about a coordinated, ordered, structured system, which considers the needs of all Americans. They are not referring to "socialized medicine"–their view of a system which is administered by the government.

While people recognize that top-to-bottom changes are needed in the health care system, they reject the idea of having the government administer the system and the changes. They do however, look to the government to bring order to the current health care system. Some of the key reasons for this stance include:

  • The problems associated with longer waits for service in other countries do not appeal to them.

  • Giving all people some level of health care does not address the fundamental problems inherent in the current system. That is, this solution does not address the problem of upward spiraling health care costs. Most people believe that the spiral will only continue upward under a national health system. In essence, many people offer hope for the current system without the need for embarking on a national health care system. The hope lies in regulating or controlling the lawyers and the insurance companies, as well as finding ways to control malpractice cases and claims (which will help to keep the doctors and hospitals in line).

  • People believe that America is a land of choices–people want their choice in health care.

  • People also believe that America is a land in which free enterprise flourishes. A national health care system does not fit with this belief.

Most people feel that giving everyone some basic level of health care would result in the system being abused, much like the welfare and food stamp systems. Several participants talked about the problem of "giving people something they do not necessarily want." Their point is that even if health care was more affordable, not everyone would obtain heal care insurance. Some young people are just not worried about health problems. Others believe in holistic approaches to health care. By giving health care coverage to these people, the perception is that it may be abused. But, it is important to note that people are very concerned about the uninsured.

The basic premise among many participants is that everyone should be guaranteed access to reasonably priced health insurance. The theme, "make health care reasonably affordable and I will take care of myself was common across many segments. For those who cannot afford reasonably priced health insurance (e.g. those below the poverty line), then we as Americans have a responsibility to provide a Safety net of basic services. As to the services included in this "safety net" there is a fair amount of disagreement. Some people say it should cover basic wellness services like routine visits (to encourage preventative health maintenance) and cover minor illnesses. Others say it should only cover catastrophic situations which could wipe out a poor family.

People are very critical of the government and its ability to administer a national health care system. Many pointed out the numerous scandals and excesses created by bureaucracies. There was real concern that a government system would cost just as much as the current system and would be mediocre. Further, many people are pessimistic about the current Administration and Congress and do not necessarily believe they are committed to dealing with the health care problems of the country.

Many people felt that a national system would be expensive in terms of requiring tax increases and people would still have to pay for additional services through a private provider to receive the same quality of health care they are currently receiving. The net result is that there would be no cost savings in the end.