Program on International Policy

Americans on Health Care Policy

FINDINGS
August 30, 2000

10. Limits on Treatment

Another source of resistance to accepting health care limitations is derived from a broader belief, prompted by moral concerns and self-interest, that every person should receive the maximum level of care, irrespective of their ability to pay. Majorities resist most specific options for limiting treatment, though support becomes stronger if the consumer has a direct financial benefit. A strong majority does say that, if the savings were passed on in the form of lower insurance premiums, it would be willing to sign a living will limiting life-extending efforts when death is imminent.

A variety of poll questions reveal another key factor that contributes to Americans’ resistance to accepting limits on health care. This could be described as "maximalism" – the belief that there should be virtually no limitations on the availability and types of treatments for all patients. This tendency may be more marked in the US where there is widespread availability of the latest medical technology, access to experimental treatments, access to specialists on demand and immediate treatment, even for elective procedures. This is contrast to Europe and Canada, where there has been greater emphasis on universal coverage than on maximal treatment.

Several poll questions demonstrate the US public’s maximalist tendencies. In June 1998, an NBC/Wall Street Journal poll asked:

Do you think that the government should or should not guarantee everyone the best and most advanced health care that technology can supply, knowing that we will have to find a way to pay for it?

Sixty-six percent felt the government should guarantee access, while only 27% believed it should not.122 Similarly, when asked in an August 1997 ABC News poll to choose between two statements, 70% wanted to "provide any treatment that might help, regardless of its cost, even if it means raising insurance costs for all people." Just 24% wanted to "limit the use of expensive medical treatments that might help, in order to hold down health insurance costs for all people."123 A June 1994 Gallup survey reported that 66% thought it "unacceptable" for "the health care system in general to limit the availability of treatments" ("acceptable," 32%).124 In July 1994, a Harris poll found that 62% agreed, "Health plans should pay for any treatments which will save lives, even if it costs a million dollars to save one life" [emphasis added]. Only 34% opposed that statement.125

When respondents are presented specific options for limiting health care provisions to cut costs, those options usually are rejected. A 1998 NBC/Wall Street Journal poll asked whether it is an acceptable or unacceptable way to control the cost of health care to "Limit expensive medical procedures for people over eighty-five years of age," and 65% rejected the idea. A June 1998 Harvard/Robert Wood Johnson poll found 70% opposed the idea of "Certain expensive treatments like transplants and hip replacements not being covered for people over the age of 80." Eighty-one percent rejected "Having to wait a very long time for certain expensive treatments like transplants and hip replacements." Sixty-seven percent rejected "Having to wait a month for elective medical procedures." Seventy percent rejected "Having a limit on choice of doctor." A June 1994 Gallup poll also found 54% rejecting "limit[ing] the choice of doctors and hospitals."126

However, in each case, the benefit of accepting such limits was not specified beyond a general effort to create savings, which may or may not be passed on to the consumer. The COPA survey, however, added a new twist to find out whether people would be more willing to make compromises if they were certain of some kind of offsetting benefit. Respondents were told:

To cut medical costs, some people have suggested that health insurance companies could offer savings if an individual would agree in advance to accept certain inconveniences or limits on the treatments that the insurance company would pay for. Now, I'm going to read you some examples. For each one, I'd first like to know if you think it would be acceptable for insurance companies to offer such an option; and second, I'd like to know if you think you might choose such an option for yourself if it were offered and the savings were substantial.

One option was rejected by a majority. Asked if it would be acceptable for an insurance company to "offer savings if the individual would agree in advance that the company would not pay for new treatments if the demonstrated success rate was less than 25 percent," a 54% majority said it was "not acceptable for insurance companies to offer such an option," while 40% thought it "acceptable." An even larger majority (57% to 38%) said it was not an option they "might choose for [themselves], if it would substantially lower [their] health insurance costs."

Another option elicited a divided response. Asked if would be acceptable to offer savings if individuals "would accept waiting longer for treatment that is not urgent, or traveling a greater distance for specialized care," 50% rejected the idea, while 48% found it acceptable. Asked if they would choose such an option for themselves, once again 50% rejected the idea, while 47% said they would. In both cases, this is a much greater level of acceptance than in other survey questions about restricting access to new technology or waiting or traveling – as noted above, about two-thirds or more rejected the ideas in other questions.

Living Wills

One option did receive strong majority support in the COPA poll. Asked about the idea of offering savings to "individuals who have made living wills stating that they do not want extreme measures used to keep them alive when they are terminally ill and unconscious and not expected to ever regain consciousness," 72% said this would be acceptable, with just 24% saying it was not acceptable. Similarly, a strong 69% said they would take advantage of such an option themselves.

The idea of allowing insurance savings for people who chose to write living wills was extremely well received in the focus groups – it was seen as not simply a way to save money, but as a way to be more humane.

I agree with the living wills. There is a lot of cost to keeping people alive… I don’t think anybody would want to be kept alive, it doesn’t make sense. (Woman, Cleveland)

I think a lot of people are taking advantage of living will situations [by writing them]. If the insurance companies would give you a discount for that, that would be great. (Man, Cleveland).

I think we should be moving more and more to not forcing people to stay alive. Those costs are unbelievable when somebody is a vegetable. The doctors knew he had no chance of living. So, I think that’s an area of savings that we should be moving towards as a society. I would opt for that and think it should be an option for all of us. (Man, Richmond)

A 1994 Gallup poll also found a readiness to limit care in the terminal phase of life. It found that a slim majority (51%) would find it "acceptable for the health care system in general to require that no extraordinary means be taken to extend life" in an effort to "control health care costs" (44% found the idea unacceptable). Not surprisingly, support is lower than in the COPA question as it does not spell out that the individual would have the choice of limiting such treatment and would also financially benefit for it in advance.127

This does not mean, however, that most Americans are ready to limit treatment in the late stages of life in general. A June 1998 NBC/Wall Street Journal question found that just 32% found "acceptable" a proposal to "limit advanced and expensive medical procedures for people who are near the end of their life," even though it made clear that this is "when the majority of health care dollars are consumed."128 Fifty-eight percent thought the idea "unacceptable."

Findings Continued >>

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