s p e c i a l r e p o r t

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Two recent government reports show substantial short-term improvements in the financial out-look for Medicare and in the federal budget def-icit.1,2 However, these forecasts also suggest the need for further action brought about by a wors-ening of the financial situation after 2015 as the number of Medicare recipients increases from 52 million to 73 million in the decade following.1-3 This issue is likely to receive considerable atten-tion in the upcoming debate about the federal budget deficit and the national debt.

As we reported in the Journal in 2011, there has been little public support for major policy changes aimed at reducing Medicare spending to lower the federal deficit.4 This article goes further and seeks to document the underlying beliefs that may shape the public response to future efforts to substantially slow projected Medicare spending. Our thesis is that there ex-ists today a wide gap in beliefs between experts on the financial state of Medicare and the pub-lic at large. Because of the potential electoral consequences, these differences in perception are likely to have ramifications for policymakers addressing this issue.

We examine this thesis by analyzing data from six public opinion polls conducted in 2013 with 1013 to 2017 U.S. adults, plus historical data, in a project supported by the Robert Wood Johnson Foundation (see box for polls). We also compare public-opinion data to published re-ports on the status of Medicare today. The find-ings are presented around five issues: public views about Medicare spending and the budget deficit; perceptions of the performance of Medi-care; reasons seen for the rising costs of Medi-care; views about the future of Medicare; and implications of these beliefs for future elections. Because of the possibility that generational views may differ greatly, most of the data are presented for the total adult population and for

four commonly used age groups. For compari-sons between age groups, a P value of less than 0.05 was considered to indicate statistical sig-nificance. All P values are two-sided. Sampling variation and weights are accounted for in the calculation of statistical significance.

MEDIC ARE SPENDING AND THE BUDGET DEFICIT

Medicare spending has slowed during the past 5 years,5 but most of the public is unaware of this. As shown in Table 1, more than 6 of 10 respon-dents (62%) believe Medicare spending is rising faster than it was 5 years ago. Despite this belief, multiple polls show a low level of support (10 to 36%) for major reductions in Medicare spending to reduce the deficit (KFF–RWJF–HSPH, 2013; CBS, 2013; HSPH–SSRS, 2013; see box for poll-name abbreviations). This has not changed sig-nificantly since 1993, when 19% of respondents were found to support Medicare spending cuts in order to reduce the federal deficit (Time–CNN–Yankelovich, 1993). The most recent poll shows that the only age group that supports reductions are respondents 18 to 29 years old (HSPH–SSRS, 2013).

This lack of support may relate to beliefs that might not be factually correct. Although Medi-care is the third largest item in the federal bud-get,6 many Americans are unaware that it is one of the largest budget items (53% believe it is). In addition, most respondents do not see Medicare spending as a major contributor to the deficit today (31% believe it is a major cause of the def-icit; HSPH–SSRS, 2013). One reason that many people believe Medicare does not contribute to the deficit is that the majority think Medicare recipients pay or have prepaid the cost of their health care. Medicare beneficiaries on average pay approximately $1 for every $3 in benefits

The Public and the Conflict over Future Medicare SpendingRobert J. Blendon, Sc.D., and John M. Benson, M.A.

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they receive.7 However, approximately two thirds of respondents believe that most Medicare re-cipients get benefits worth about the same as (27%) or less than (41%) what they have paid in payroll taxes during their working lives and in premiums for their current coverage (HSPH–SSRS, 2013).

MEDIC ARE PERFORMANCE

Added to these perceptions is the widespread popularity of Medicare. For example, the major-ity of Americans (72%), including nearly 9 of 10 seniors (88% of adults 65 years of age or older), have a favorable opinion of Medicare (HSPH–SSRS, 2013). Medicare has been popular since before it was enacted into law in 1965. In Octo-ber 1964, a total of 61% of Americans approved of the proposed Medicare program (Gallup–IISR, 1964). In addition, 60% of the public, in-cluding 80% of seniors, currently believe the existing Medicare program is working well for most seniors (KFF–RWJF–HSPH, 2013). The val-ue of Medicare to seniors can be seen in the finding that, in spite of their higher levels of ill-ness, they are less likely than Americans 30 to 64 years old to say they are very or moderately worried about not being able to pay their costs for normal health care (Gallup, 2013).

However, there are concerns about Medicare today and current cost-containment efforts. Most respondents see Medicare in some cases already withholding treatments and prescription drugs to save money, including 63% who believe this happens very often or somewhat often. Also, the public sees the bigger problem for Medicare beneficiaries as not getting the health care they need (61%) rather than as receiving unnecessary care (21%) (HSPH–SSRS, 2013). Medicare pays about half the total personal health care expenditures for beneficiaries,8 but many people are confused about what propor-tion is paid by Medicare, whether it pays for most of recipients’ bills or substantially less (HSPH–SSRS 2013).

Although Medicare is popular, it is not seen as better run than private insurance plans, nor is it seen as particularly different from private coverage with respect to quality of care or ac-cess to physician care. Despite occasional re-ports of people wanting “government to keep

out of their Medicare,” the overwhelming major-ity (74%) recognizes that Medicare is a federal government program (HSPH–SSRS, 2013).

REASONS FOR RISING COSTS OF MEDIC ARE

As shown in Table 2, when given a dozen pos-sible causes for rising Medicare costs that have been suggested either by experts or in the me-dia, the majority do not identify any one of them as the most important. However, the three most often cited reasons relate to poor management of Medicare by government, fraud and abuse in the health sector, and excessive charges by hos-pitals. The lowest ranked reason was the cost of new drugs and treatments being offered to se-niors (HSPH–SSRS, 2013).

FUTURE OF MEDIC ARE

Of importance to note, the responses of the pub-lic vary when it comes to the reasons that future

Opinion Polls on the Conflict over Medicare Spending

Bloomberg–Selzer poll February 15–18, 2013 (http://media.bloomberg.com/bb/avfile/rnyKSyGsiatk)

CBS News (CBS) poll March 20–24, 2013 (www.cbsnews.com/8301-250_162-57576433/ poll-80-of-americans-unhappy-with-washington/?pageNum=2)

Gallup poll April 4–14, 2013 (www.gallup.com/poll/162239/middle-aged-americans-worried-finances.aspx)

Gallup–Institute for International Social Research (Gallup–IISR) poll October 1964*

Harvard School of Public Health–Social Science Research Solutions (HSPH–SSRS) poll May 13–26, 2013 (www.hsph.harvard.edu/horp/files/2013/06/HSPH-Medicare-Topline.pdf)

Kaiser Family Foundation–Robert Wood Johnson Foundation–Harvard School of Public Health (KFF–RWJF–HSPH) poll January 3–9, 2013 (http://kff.org/health-reform/poll-finding/the-publics-policy-agenda-for-the -113th-congress)

Pew Research Center for the People and the Press poll February 13–18, 2013 (www.people-press.org/files/legacy-questionnaires/ 02-22-13%20Topline%20for%20Release.pdf)

Time–CNN–Yankelovich Partners (Time–CNN–Yankelovich) poll August 4–5, 1993*

* Available from the Roper Center for Public Opinion Research, Storrs, CT.

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Table 1. Public Beliefs and Values about Medicare, According to Age.*

Issue All Respondents 18–29 Yr 30–49 Yr 50–64 Yr ≥65 Yr

percent

Medicare spending and the federal budget deficit

Do you think Medicare spending is rising faster, slower, or at about the same rate as it was 5 years ago?†

Faster 62 56 62 72द 57

Slower 9 18§¶‖ 7 5 6

About the same rate 24 25‖ 27‖ 16 27‖

Please tell me whether you favor or oppose major reductions in future spending on Medicare to reduce the federal budget deficit†

Favor 36 56§¶‖ 34¶ 30¶ 22

Oppose 60 42 62‡ 66‡ 73‡§

To the best of your knowledge, is Medicare one of the largest items in the federal budget, or is it not?†

Yes 53 45 51 58‡ 59‡

No 36 48§¶‖ 36 32 27

Do not know or decline to answer 11 7 13 10 14‡

Do you think Medicare spending is a major cause, a minor cause, or not a cause of the size of the federal budget deficit?†

Major cause 31 31 32 30 31

Minor cause 41 44 40 43 36

Not a cause 23 19 24 22 27

People who receive Medicare have paid payroll taxes for much of their work-ing lives and pay premiums for their current Medicare coverage. Do you think most people receiving Medicare get benefits worth . . . ?†

More money than they pay into the system 24 20 21 29§ 30‡§

Less than they pay into the system 41 51¶‖ 45¶ 37¶ 28

About the same 27 24 28 26 31

Performance of Medicare

Do you have a favorable or unfavorable opinion of Medicare?†

Very favorable 36 19 33‡ 41‡ 59‡§‖

Somewhat favorable 36 42¶ 38¶ 34 29

Somewhat unfavorable 12 19¶‖ 14¶ 8¶ 3

Very unfavorable 7 6 9¶ 8¶ 4

Would you say the current Medicare program is working well for most seniors, or not?**

Medicare is working well 60 57 49 62‡§ 80‡§‖

Medicare is not working well 28 28¶ 33¶ 29¶ 15

Do not know or decline to answer 12 14¶ 18¶‖ 9 5

Please tell me how concerned you are about not being able to pay medical costs for normal health care (% very or moderately worried)††

44 39 48ঠ51ঠ35

Thinking about people who have Medicare today, how often do you think Medicare withholds high-cost prescription drugs, medical care, or surgical treatments from people who might benefit from them in order to save money?†

Very often 20 15 25 19 15

Somewhat often 43 51¶ 46¶ 39 34

Not too often 24 28 21 25 24

Not at all 6 3 3 7 15‡§‖

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Table 1. (Continued.)

Issue All Respondents 18–29 Yr 30–49 Yr 50–64 Yr ≥65 Yr

percent

Which do you think is the bigger problem for people on Medicare today?†

They do not get the care they need 61 67¶ 66¶ 62¶ 43

They get care they do not need 21 18 20 21 27‡

Neither‡‡ 5 3 4 5 12‡§‖

Both‡‡ 6 8 6 5 4

For the average person >65 yr old, do you think the Medicare program pays for almost all, most, about half, or only a little of their health care costs?†

Almost all 15 11 13 14 23‡§‖

Most 26 22 25 29 28

About half 35 43¶ 32 36 29

Only a little 21 19 27¶‖ 19¶ 13

Which do you think is better run?†

The federal Medicare program 15 12 14 15 22‡§‖

Private health insurance plans that people get through their jobs 41 52§¶‖ 41¶ 39¶ 30

About equally well run 39 33 41 42 40

Do you think patients with Medicare receive better or worse health care than patients with private health insurance plans, or is it about the same?†

Better 5 3 8‖ 3 5

Worse 27 34¶ 26¶ 29¶ 14

About the same 66 63 63 65 75‡§‖

Do you think it is easier or harder for patients with Medicare than for pa-tients with private health insurance plans to get an appointment with a doctor, or is there not much difference?†

Easier 12 15‖ 14‖ 7 11

Harder 37 35 40¶ 43¶ 25

Not much difference 47 46 44 43 58‡§‖

To the best of your knowledge, is Medicare primarily a . . . ?†

Federal government program 74 60 76‡ 80‡ 81‡

State government program 15 22¶ 16¶ 14¶ 7

Private insurance program 4 6 4 3 4

* All questions were taken directly from the surveys. Percentages do not necessarily add to 100 because the percentage of “Do not know or declined to answer” responses is not shown unless it was 10% or more of the total responses.

† Data are from the responses of 1253 U.S. adults, reported by the HSPH–SSRS, 2013.‡ P<0.05 for the comparison with the group of respondents 18 to 29 years old.§ P<0.05 for the comparison with the group of respondents 30 to 49 years old.¶ P<0.05 for the comparison with the group of respondents 65 years of age or older.‖ P<0.05 for the comparison with the group of respondents 50 to 64 years old.** Data are from the responses of 1347 U.S. adults, reported by the KFF–RWJF–HSPH, 2013.†† Data are from the responses of 2017 U.S. adults, reported by the Gallup poll, 2013.‡‡ Response was not a choice provided in the poll but was offered voluntarily by the respondent.

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Medicare spending should be reduced. As shown in Table 3, the public is more supportive if the rationale is solely to improve the long-term fi-nancial position of the program (67%), rather than to reduce the federal deficit (36%) or pay for a tax cut (28%). The majority believe that the program will run out of funds in the next 15 years (77%) and see serious consequences for Medicare beneficiaries. This time period was chosen because it is just beyond the 2026 date when the Medicare trust fund is predicted to run out of money.2,3 The majority believe that Medi-care 15 years from now will either pay a lower level of benefits than it currently does (38%) or no longer exist (32%) (HSPH–SSRS, 2013). In ad-dition, 39% of respondents believe Medicare probably will not be there when they need it (Bloomberg–Selzer, 2013). A majority also be-lieve that because of budgetary problems, Medi-care in the future is likely to withhold prescrip-tion drugs, medical care, or surgical treatments from people who might benefit from them (77%) (HSPH–SSRS, 2013).

Despite this aggregate level of support for re-ducing Medicare spending to improve the long-term financial outlook of the program, it is not clear what major changes will be endorsed in the future. Policy changes relating to perceived excessive charges could garner future support, but many other policies may not. Most Ameri-cans support continuing Medicare with fee-for-service payments (65%) rather than changing to capitated health care arrangements (30%). A substantial minority (39%) report that they would face very serious or somewhat serious problems if the retirement age were raised. The majority (64%) believe that if in the future there are cuts in the payments doctors receive from Medicare, doctors will be less willing to see older patients (HSPH–SSRS, 2013). Medicare payment to physicians in 2010 was, on average, 81% of private health plan payments.9 Half the public (50%) is aware that doctors are paid less by Medicare than by private health insurance plans. The one area of clear support for the fu-ture is the growing preference for Medicare Advantage–type private health coverage among persons less than 65 years of age (HSPH–SSRS, 2013).

POLITIC AL IMPLIC ATIONS

Containing Medicare spending for deficit and sustainability reasons is likely to be an issue in future elections. As shown in Table 3, regardless of the potential seriousness of the problem, can-didates who favor major cuts in Medicare spend-ing to reduce the federal budget deficit could face negative electoral consequences. Few regis-tered voters (12%) say that they would be more likely to vote for a congressional candidate tak-ing this stand, whereas many more (58%) say it would make them less likely. This is especially true for registered voters 50 years of age or old-er, approximately two thirds (66%) of whom say they would be less likely to vote for such a can-didate (HSPH–SSRS, 2013).

In conclusion, two points are important. It would aid the long-term resolution of these is-sues if there were a nonpartisan, broad-based public education campaign launched focusing on how Medicare works financially. Second, it would be advantageous if discussions of the fi-nancial sustainability of Medicare could be sep-arated from public debates over reducing budget

Table 2. Public Views about Why Medicare Costs Are Rising.*

Reason

Respondents Saying This Reason Is One

of the Most Important

percent

Poor management by the government 30

Fraud and abuse by people, doctors, and hospitals 24

Excessive charges by hospitals 23

Excessive charges by pharmaceutical companies 20

More people are going on Medicare, and there are fewer people <65 yr of age to pay taxes to sup-port them

19

Excessive charges by doctors 18

Money that is being collected for Medicare is be-ing spent on programs other than Medicare

17

People receiving drugs and medical treatments they do not need

17

People do not get enough preventive care 16

People on Medicare are living longer so they cost the program more money

13

Malpractice lawsuits and settlements 10

New drugs, tests, and treatments being offered to the elderly

6

* All reasons were taken directly from the survey. Data are from the responses of 1253 U.S. adults, reported by the HSPH–SSRS, 2013.

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Table 3. Public Views about the Future of Medicare and Political Implications, According to Age.*

Issue All Respondents 18–29 Yr 30–49 Yr 50–64 Yr ≥65 Yr

percent

Future of Medicare

Please tell me whether you favor or oppose major reductions in future spending on Medicare for each of the following purposes†

Reduce the federal budget deficit

Favor 36 56‡§¶ 34¶ 30¶ 22

Oppose 60 42 62‖ 66‖ 73‡‖

Improve the long-term financial outlook of Medicare

Favor 67 75¶ 68¶ 68¶ 54

Oppose 29 23 29 29 37§‖

Pay for an income tax cut

Favor 28 39§¶ 31§¶ 21 17

Oppose 67 56 64 75‡‖ 75‡‖

If the President and Congress do not take action, do you think the Medicare trust fund is likely to run out of money in the next 15 years, or not?†

Likely to run out of money 77 78 79¶ 78¶ 69

Not likely 15 15 18 18 25‡§‖

Thinking about 15 years into the future, do you think Medicare will . . . ?†

Pay a higher level of benefits than it does now 8 13‡§¶ 6 8¶ 4

Pay about the same level 18 15 15 17 28‡§‖

Pay a lower level of benefits 38 32 41 40 36

No longer exist 15 years from now 32 35 34¶ 31 25

How likely do you think it is that because of budgetary problems Medicare in the future will withhold high-cost prescription drugs, medical care, or surgical treatments from people who might benefit from them?†

Very likely 33 25 40‖ 34 30

Somewhat likely 44 51 38 47 43

Not too likely 15 20 14 14 12

Not at all likely 5 2 6 2 11§‖

Here are two different ways Medicare could pay doctors. Which of these do you think would be better for you?†

Your doctor gets paid a fee each time they see you 65 54 65 73¶‖ 64

Your doctor gets paid a fixed amount of money so they can manage all of your health care for the year

30 42‡§¶ 31§ 21 27

Currently, the age of eligibility for receiving Medicare is 65. If you (had been/were) asked to wait 2 years longer before receiving Medicare benefits, would that (have been/be) a problem for you and your family, or not?†

Very serious 24 13 25‖ 30‖ 24‖

Somewhat serious 15 22§¶ 17¶ 13¶ 6

Not too serious 4 6 5 3 4

Not a problem 53 57 49 50 62‡§

If in the future there are cuts in the payments doctors receive from Medicare, do you think doctors will be less willing to treat elderly patients, or will it not make much difference?†

Less willing to treat elderly patients 64 48 66‖ 75‡¶‖ 60‖

Will not make much difference 35 52‡§¶ 33§ 24 35§

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Table 3. (Continued.)

Issue All Respondents 18–29 Yr 30–49 Yr 50–64 Yr ≥65 Yr

percent

Do you think Medicare pays doctors more, less, or about the same as private health insurance plans pay doctors for the same types of health care?†

More 13 20§¶ 16§¶ 9 6

Less 50 43 49 57‖ 52

About the same 30 32 29 27 32

Do you think Medicare pays hospitals more, less, or about the same as private health insurance plans pay hospitals for the same types of health care?†

More 16 21¶ 17 13 12

Less 46 35 46 53‖ 48‖

About the same 33 40§ 33 29 33

(When you retire,) If you had a choice, would you prefer to get your Medicare health insurance benefits from . . . ?†

The current government Medicare program 34 26 28 33 57‡§‖

A private health plan, such as a PPO or HMO offered through Medicare

56 65¶ 63¶ 57¶ 29

Do not know or decline to answer 10 7 8 9 13

Political implications

If a candidate for Congress supports making major cuts in Medicare spending to reduce the federal budget deficit, would that make you more likely or less likely to vote for that candidate specifically because of this issue, or would it not make much difference in your vote?**

Much more likely 6 4 9 5 5

Somewhat more likely 6 8 9 4 5

Would not make much difference 24 42‡§¶ 24¶ 19 16

Somewhat less likely 16 16 15 20 13

Much less likely 42 25 41‖ 46‖ 53‡‖

How important for you and your family is Medicare?††

Very important 54 38 47 63‡‖ 73‡§‖

Somewhat important 23 25 25 20 20

Not too important 12 21§¶ 14§¶ 8¶ 2

Not at all important 10 17§¶ 13§¶ 7¶ 3

How closely are you following the debate about Medicare spending and the budget deficit?†

Very closely 17 9 14 21‖ 29‡§‖

Fairly closely 25 16 22 32‡‖ 33‡‖

Not too closely 25 25 27 25 20

Not at all closely 31 47§¶ 36§¶ 22 17

* All questions were taken directly from the surveys. Percentages do not always add to 100 because the percentage of “Do not know or decline to answer” responses is not shown unless it was 10% or more of the total responses. HMO denotes health maintenance organization, and PPO preferred-provider organization.

† Data are from the responses of 1253 U.S. adults, reported by the HSPH–SSRS, 2013.‡ P<0.05 for the comparison with the group of respondents 30 to 49 years old.§ P<0.05 for the comparison with the group of respondents 50 to 64 years old.¶ P<0.05 for the comparison with the group of respondents 65 years of age or older.‖ P<0.05 for the comparison with the group of respondents 18 to 29 years old.** Data are from the responses of 1063 registered voters, reported by the HSPH–SSRS poll, May 13–26, 2013.†† Data are from the responses of 1347 U.S. adults, reported by the KFF–RWJF–HSPH, 2013.

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deficits or enacting tax cuts. Until these con-cerns are better addressed, the gaps in percep-tion are likely to remain.

The views expressed in this article are those of the authors and do not necessarily reflect those of the Robert Wood Johnson Foundation.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

From the Harvard School of Public Health, Boston (R.J.B., J.M.B.); and the John F. Kennedy School of Government, Cam-bridge, MA (R.J.B.).

1. Updated budget projections: fiscal years 2013 to 2023. Wash-ington, DC: Congressional Budget Office, May 2013 (http://cbo .gov/sites/default/files/cbofiles/attachments/44172-Baseline2.pdf).2. 2013 Annual report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insur-ance Trust Funds. Washington, DC: Boards of Trustees, Federal Hospital Insurance and Federal Supplementary Medical Insur-ance Trust Funds, May 31, 2013 (http://downloads.cms.gov/files/TR2013.pdf).3. Pear R. Report shows better outlook for Medicare. New York

Times. May 31, 2013 (http://www.nytimes.com/2013/06/01/us/politics/outlook-for-medicare.html?_r=0).4. Blendon RJ, Benson JM. The public’s views about Medicare and the budget deficit. N Engl J Med 2011. DOI: 10.1056/NEJMp1107184.5. Viebeck E. CBO: Medicare spending slowing faster than ex-pected. The Hill. February 5, 2013 (http://thehill.com/blogs/healthwatch/medicare/281241-cbo-medicare-spending-slowing -faster-than-expected).6. Office of Management and Budget. Fiscal year 2013 historical tables: budget of the U.S. government (http://www.whitehouse .gov/sites/default/files/omb/budget/fy2013/assets/hist.pdf).7. Parlapiano A. Getting back more from Medicare, less from Social Security. New York Times. April 3, 2013 (http://www.nytimes .com/interactive/2013/04/03/us/politics/getting-more-or-less-than -you-paid-for.html?_r=0).8. Multack M. The Medicare program: a brief overview. Wash-ington, DC: AARP Public Policy Institute, March 2012 (http://www.aarp.org/content/dam/aarp/research/public_policy_institute/ health/medicare-program-brief-overview-fs-AARP-ppi-health.pdf).9. Report to the Congress: Medicare payment policy. Washing-ton, DC: Medicare Payment Advisory Commission, March 15, 2012 (http://www.medpac.gov/documents/Mar12_EntireReport.pdf).

DOI: 10.1056/NEJMsr1307622Copyright © 2013 Massachusetts Medical Society.

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