Unchanged Minds

A majority of Americans still believe the uninsured are doing just fine.

Click here for a guide to following the health care reform story online.

If you’re a political journalist and you want to stay sane, it’s best not to think too hard about whether your work is changing minds.

For more than a year the American media has devoted unprecedented resources to covering the crisis in American health care. As Harold Pollack, faculty chair of the University of Chicago’s Center for Health Administration Studies, wrote in an April 1 column for the New Republic: “Press coverage of health care reform was the most careful, most thorough, and most effective reporting of any major story, ever.”* That statement is obviously hyperbolic, but I second the underlying sentiment that the public was treated to a large volume of unusually sophisticated reporting and analysis from reporters and health policy experts (much of the analysis by Pollack himself). A Pew Research Center poll released April 7 found that nearly half the public said it was following the health care story more closely than any other, even though the topic has slipped off the front page.

It is therefore more than a little dismaying to read, in the latest issue of the journal Health Affairs, that the public still doesn’t understand what it means to go without health insurance. (A subscription is required to read the full text.) A team of Harvard researchers (one of whom, Tara Sussman Oakman, is now a program analyst at the department of Health and Human Services) compared poll data from 1999 and 2009 on the question of whether the uninsured were able to get necessary health care. In 1999, 55 percent said they were. In 2009, 58 percent said they were.

This perception is incorrect. The authors of the Health Affairs article point out that a series of reports released between 2001 and 2004 by the Institute of Medicine, a nonprofit health arm of the National Academy of Sciences, clearly established that. People who lack health insurance, one 2002 report found, are more likely to go without cancer screening; do not receive sufficient care for chronic diseases like diabetes to prevent blindness and amputation; do not acquire sufficient medicine to treat diseases like hypertension and HIV infection; and receive insufficient care following a heart attack or other traumatic event.

If these findings sound familiar, that’s because they were repeated time and again in press coverage of the health reform bill. One study calculated that nearly 45,000 annual deaths within the adult nonelderly population were associated with a lack of health insurance. Another put it, more conservatively, at 18,000. These estimates are necessarily imprecise, but even Megan McArdle, the Atlantic’s libertarian business and economics editor, had to concede at the end of a tendentious March column pooh-poohing such findings (“Myth Diagnosis“) that expanded health-insurance coverage “improves outcomes among certain vulnerable subgroups, like infants and patients with HIV.”

Anyone who believes the uninsured enjoy sufficient access to health care probably has not been paying much attention to the news. In December 2008, the New York Times quoted an emergency-room doctor in Denver’s public hospital system saying, “I am definitely seeing patients coming in presenting worse in their illness because they are further along.” In February 2009, the Washington Post counted 45 people showing up to compete for 30 slots at a free clinic in Arlington, Va. In November 2008, Reader’s Digest described Robin Flint, an uninsured piano tuner in Massachusetts, wheezing because she couldn’t spare $175 a month on asthma medicine until her husband signed up for the state’s universal health insurance program. When I enter the terms “health insurance,” “uninsured,” and “sicker” in the Nexis database, it returns 1,033 news articles from the past year.

Now let’s take a closer look at the Health Affairs data. A generous interpretation of the finding that 58 percent believe the uninsured are “able to get care” is that respondents nonetheless understand the uninsured can’t get all the care they need. Here is how the question was posed in the 2009 poll: “Do you think most people in your community without health insurance are unable to get medical treatment, or that these uninsured people are still able to get medical care they need from doctors and hospitals.” Bad wording! Medical care is one thing. Adequate medical care (“medical care they need”) is quite another. (Incidentally, in reviewing the source document, I discovered that the Health Affairs chart put this number, incorrectly, at 56 percent; I’ve corrected it to 58 percent in the accompanying Slate version.)

Even making that allowance, though, it seems remarkably stingy for nearly one-quarter of the respondents (22 percent) to say that it is “not too” or “not at all” difficult for the uninsured to get adequate treatment. (Here the question referred unambiguously to “the medical care they need.”) That’s only 2 percent more than in 1999. Where the hell have these Marie Antoinettes been? More encouraging is that a combined 68 percent understands that the uninsured are either unable to get health care (34 percent in the poorly worded question) or find it “somewhat” or “very” difficult (34 percent in the well-worded question). But this figure is essentially unchanged from 1999, when a combined 69 percent understood the uninsured were either unable to get adequate health care or found it “somewhat” or “very” difficult. A similar proportion (64 percent) grasps that the quality of health care available to the uninsured is “not as good” as that available to the insured. (Duh!) But nearly one-third (31 percent) stubbornly insist, in the face of overwhelming contrary evidence, that it is “as good.” Here there are no comparative figures for 1999, but the 2003 figures are nearly identical.

The lesson, I suppose, is that no matter how much information you throw at the public, some people are still going to believe what they want to believe. On the question of health care for the uninsured, Health Affairs found, that’s especially true for Republicans, for men, for the elderly, and for rich people. More receptive to recognizing the difficulties faced by the uninsured—i.e., acknowledging that the sky is blue—were Democrats, women, young people, and people with low incomes. I guess we can thank the latter group for health care reform. Recognizing a problem doesn’t necessarily mean you embrace any particular solution. But it’s a start.

Correction, April 9, 2010: An earlier version of this column misspelled Pollack’s surname as “Pollock.” (Return  to the corrected sentence.)

E-mail Timothy Noah at

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