Is Universal Health Care Socialized Medicine Peer Reviewed

Nearly 46 million persons in the United States did not have health insurance in 2004,¹ and more than 31 million of America'south workers are underinsured.^two Numerous studies recently summarized by the Institute of Medicine accept shown that existence uninsured translates into serious health consequences, including a higher hazard of decease.^three

In addition to the growing numbers of uninsured, ascent wellness care costs^four and concerns near the quality of wellness care have focused public attention on reforming the health care system.^5–eight A broad range of physicians' organizations have been agile in discussing the problems of the health care arrangement and proposing solutions^nine–13 for "universal coverage."

Recent studies suggest that many physicians support dramatic wellness care reform. A national survey found that 49% of U.S. physicians supported governmental legislation to establish national health insurance, while twoscore% opposed it.¹⁴ In a survey of Massachusetts physicians, almost 2-thirds (63.5%) of respondents indicated that a single-payer system would provide "the best care for the well-nigh people for a stock-still amount of money."¹⁵

Medical students' views nearly universal wellness care and other problems of health care policy are not well-known. Understanding the views of medical students is important, because these individuals will constitute the side by side generation of practicing physicians and will have the potential to help shape future reform efforts. Furthermore, students' views on these topics may provide insight into the messages that medical schoolhouse curricula and faculty members are conveying to future physicians.

Previous studies have examined medical students' views of the health care arrangement and perspectives on various reform options,^16–twenty but to our knowledge no such studies take been published since the final major health care reform contend of the early on 1990s, and those that were done were limited in scope and sample size. We therefore surveyed a nationally representative sample of first- and 4th-year medical students to determine their views about health intendance policy and universal health care in the United States. We hypothesized that support for universal health care would refuse over the course of the medical training process, and would be reflected by higher rates of support among commencement-year students compared with 4th-year students.

Method

Participants

We surveyed a national probability sample of first- and fourth-year students about their views of universal health care and related health policy topics. We used the Masterfile of the American Medical Association to draw stratified probability samples of 1,600 first-yr and fourth-twelvemonth medical students. We oversampled fourth-twelvemonth students to ensure their adequate representation in the sample due to an expected lower rate of returns. Afterwards excluding students with incorrect addresses, 1,363 eligible participants remained. Our responding sample could provide an accurate estimate, with 95% conviction, of U.S. first-year and fourth-year medical students' views, with a sampling fault of 3.half-dozen%.

The Heart for Survey Inquiry at the Academy of Virginia administered the mail questionnaire between March and May 2002. An accelerate letter was mailed to the randomly selected eligible participants, followed by a mailing that included a cover alphabetic character, the questionnaire, a prepaid render envelope, and a $ii incentive. All recipients were assured that participation was voluntary and that their responses would be confidential. Those not responding were contacted up to three additional times by mail, telephone, or e-mail. The University of Virginia institutional review board approved the written report protocol.

Survey instrument

We developed the questionnaire^* on the ground of a systematic review of the literature and the observations of a focus-grouping of current medical students. We chose terminal questions for the questionnaire based on an iterative process that involved feedback from survey experts, health policy specialists, and medical students. Some items were original and some were variants or replications of items from previously published wellness intendance surveys. Participants in the focus-group were somewhat divergent in their understanding of the terms "fee-for-service," "managed care," "single-payer," "multi-payer," and "universal wellness intendance," so these terms were defined for specific questions when the exact meaning was vital to understanding the question meaning and reply options. Some answer choices about health intendance financing structures were based on a survey question used previously¹⁹ that we edited and pilot tested in order to provide both additional explanations and an additional answer choice ("multi-payer") in order to reflect the multitude of financing mechanisms in other countries' universal health intendance systems. In response to the questions "Which of the post-obit would offering the best health care to the greatest number of people for a given amount of money?" and "Of the following wellness care structures, delight bespeak your preference equally well as what you believe to be the preference of doctors and patients in the United states," the response choices were: (i) A "fee-for-service" organisation in a competitive market place (the predominant mode of coverage in the "one-time" American organisation); (2) a "managed care" system in a competitive marketplace (the predominant mode of coverage in the electric current arrangement); (3) a "single-payer" organization with universal coverage (publicly financed national health insurance); and (4) a "multi-payer" system with universal coverage (combination of publicly and privately financed national health insurance). We as well asked students to rate various health system features related to access, quality, and physicians' work in the United States compared to those of other industrialized nations. A series of Likert-style questions were asked to assess values and knowledge virtually programs such as Medicare and care of the uninsured in the U.s.a.. Finally, we asked students virtually various academic and life experiences that had caused them to support or oppose universal health intendance. The survey questions used for this study were part of a larger survey that took approximately 15 minutes to complete.

Statistical assay

The analysis required weighting of the data to accurately represent the population of commencement-year and fourth-yr medical students with regard to both gender and race, using current medical student population figures.²¹ All estimated means and percentages are weighted statistics and therefore correspond estimates of the responses of the national population of medical students. We compared first-year and quaternary-year students' responses using chi-squared tests for categorical variables, and nosotros considered 2-tailed p ≤ .05 statistically meaning.

Results

Sample

Nosotros received 770 completed questionnaires, yielding a response rate of 56.five%.²² A total of 295 offset-year (57.ii%) and 475 quaternary-year (56.1%) students completed the survey. Table one shows characteristics of first-year and fourth-year students responding to the survey, forth with characteristics of the population of quaternary-year medical students in the United States in 2002,²³ the same year as the report. Fourth-year respondents were similar to the full general U.S. fourth-twelvemonth educatee population (equally adamant past the Association of American Medical Colleges (AAMC) graduation survey²³) in terms of gender. A larger proportion of quaternary-year respondents were white, compared with the general population of graduating students in 2002. Nevertheless, the racial composition of the start-year respondents was very like to the population of graduating students nationwide.

Table 1:

Characteristics of First-Twelvemonth and 4th-Year Medical Student Respondents and of All Fourth-Year Students Graduating from U.Southward. Medical Schools in 2002

Prioritizing health intendance policy problems

More than 4 out of five first-twelvemonth (82% [242]) and fourth-year (81% [380]) medical students indicated that expanding health care coverage for the uninsured was "very" or "extremely" important (versus "somewhat" or "non at all" important). Similar proportions of kickoff-year (82% [243]) and fourth-yr (78% [366]) students reported that it was "very" or "extremely" important to enact a patients' nib of rights to protect patients against some abuses of managed intendance. In comparison, about half of commencement-year (53% [158]) and 4th-twelvemonth (l% [236]) students noted that strengthening the public wellness system in preparation for future bioterrorism attacks was "very" or "extremely" of import.

Wellness insurance and universal admission to health care

For the following questions, students were asked to point on a Likert scale whether they agree or disagree with several statements. A total of 90% [270] of kickoff-year students and 88% [424] of quaternary-year students agreed or strongly agreed with the statement, "Everyone is entitled to adequate medical care regardless of ability to pay." In contrast, 84% [249] of get-go-yr students and 72% [336] of fourth-year students disagreed or strongly disagreed with the statement, "People without health insurance still accept admission to the intendance they demand." More than ix out of ten medical students (89% [268] of kickoff-year students and 95% [457] of fourth-year students) said that receiving routine care in the emergency room was not an effective fashion for the uninsured to receive care. More than half of first-yr (64% [193]) and quaternary-yr (58% [276]) students disagreed with the statement, "The U.S. cannot afford a universal health care system."

Of those that registered an opinion, a higher percentage of fourth-yr students than first-twelvemonth students agreed that "Medicare is an constructive plan that guarantees admission to health intendance for all elderly persons in the U.S." (64% [296] vs. 55% [156], p = .015).

The "best" arrangement for providing health care

Figure ane shows a summary of all students' (commencement- and fourth-twelvemonth students combined) responses to the question, "Which of the following would offer the best health care to the greatest number of people for a given amount of coin?" Nearly 2-thirds (64% [472 of 732 total responses for this question]) of all students identified a arrangement with universal coverage every bit the best structure, with somewhat more support among commencement-year students (68% [195]) than fourth-year students (62% [277], p = .11). Simply over half of students (51% [371 of 732]) selected "multi-payer" overall, and this type of system was most pop among those selecting a system with universal health care. A considerable proportion of students (19% [53] of kickoff-yr students and 21% [92] of quaternary-yr students) selected "don't know" as their response to this question.

Figure 1:

Medical student responses to the question: "Which of the post-obit structures do you remember would offer the best wellness care to the greatest number of people for a given amount of money?" Measured in percentage (actual).

Figure 2 contrasts starting time- and 4th-twelvemonth students' assessments of their own preferences for health care financing structures, in addition to their assessments of the structures that would be favored by physicians or the public. Of notation, students' personal preferences largely differed from their perceptions of what doctors and patients would prefer. Large majorities of both starting time- and 4th-year students supported a structure with universal wellness intendance, but even more believed that the public supports a structure with universal wellness care. Start-year students were more likely to back up a universal health care structure (lxx% [205]) than quaternary-year students (61% [290], p = .012). More than first-year students (46% [134]) believed that the public prefers a single-payer system than any other structure. In dissimilarity to students' preferences and their behavior about those of the public, similarly big percentages of both commencement-(78% [229]) and 4th-year (76% [362]) students believed that physicians preferred a fee-for-service/marketplace system.

Figure 2:

Medical students' preferences and behavior about physicians' and the public's preferences for wellness care system.

The United states of america versus other industrialized nations

Students were asked to rate on a Likert scale whether the U.S. health care system was amend or worse than the systems of other industrialized nations (Table 2). Majorities of both first-yr and fourth-year students believed that the U.S. system performed better than other nations' in regards to liberty-of-choice of md, length of wait for treatments, provision of high quality care, and development of innovative medical technologies. Nevertheless, majorities of both first-year and fourth-twelvemonth students indicated that the current U.S. system did worse than other industrialized nations in regards to providing access to care for anybody, protecting patients from out-of-pocket costs, the amount of interference in physician decision making, the amount of paperwork and authoritative brunt placed onto physicians, and medical student debt.

Tabular array 2:

Medical Students' Perceptions of the U.S. Health Care System Compared to Other Industrialized Nations' Systems

Influences on attitudes about universal health intendance

Table 3 shows students' perceptions of how various influences contributed to their attitudes about universal health intendance (answer choices were on a scale of "support" to "oppose," midpoint "did non influence"). Substantial proportions of both showtime-year and fourth-year students reported that a wide range of sources influenced their opinions on this topic, including personal experiences, educational experiences, and exposure to the media. A majority of students identifying each source as an influence on their stance said that the direction was in support of universal wellness care, except for fourth-year students' reports of influences past residents. The three influences that were most likely to create support for universal health intendance were extracurricular learning, elective coursework, and required coursework. The influences that were most likely to create opposition to universal health care were residents, faculty/attention physicians, and opinions of family who were health professionals.

Table 3:

Influences on Medical Students' Support or Opposition to Universal Health Intendance

Discussion

A recent serial of reports on the consequences of uninsurance from the Institute of Medicine culminated with a call for the nation to achieve universal health coverage past 2010.²⁴ Our study documents widespread support amongst U.S. medical students for this goal. Students' support for the expansion of health coverage to the uninsured was shown in multiple areas of our study, including the belief that all individuals are entitled to adequate health care regardless of ability to pay, the rating of expanded health care coverage equally a very important consequence for the government to address, and the preferences for health care reform that would create a system with universal coverage. Support for expanded coverage and health intendance reform was high among both groups of students, but fourth-year students tended to be somewhat less supportive than beginning-year students. Less support for universal health care among fourth-twelvemonth students may foreshadow the connected erosion of support once they graduate, equally noted in one recent national written report of physicians.¹⁴

Medical students' support for the expansion of wellness coverage to the uninsured might exist explained by four other sets of results from our study. First, students' moral commitment was revealed in their strong and consistent support for the concept of health care as a right for all persons. The high level of back up for this concept was consequent with the data collected in another national survey of 4th-year students conducted contemporaneously.²³ 2nd, medical students correctly identified that people have difficulty accessing the health care they need if they do non have wellness insurance and that the emergency department is not an effective way for the uninsured to receive routine care.ⁱⁱⁱ Tertiary, students indicated their beliefs that the United States can beget a universal health care system and that Medicare is an effective arrangement that guarantees wellness care access for the elderly. Medical students' favorable view of Medicare may betoken their receptiveness to other authorities-financed systems of universal coverage. Last, students recognized that other industrialized nations' health care systems have fewer issues with admission to care.

While majorities of both commencement-year and fourth-twelvemonth students preferred health intendance reform that would create universal health care, they likewise tended to believe that practicing physicians desire a fee-for-service organization in the marketplace. At the aforementioned time, virtually medical students perceived that patients preferred universal health care. This dichotomy suggests that medical students perceive that physicians' interests may not always marshal with the all-time interests of patients. Whether students develop these perceptions as a consequence of their medical training or from other sources remains unknown. Both a formal and a hidden curriculum during medical schoolhouse play a role in students' education,²⁵ and our survey results propose this is true, evidenced past their frequent reports of residents and faculty physicians contributing to negative perceptions most universal health care.

Fewer students in our report supported a "single-payer" organisation than in a previous study,¹⁹ mayhap considering our question offered the boosted response options of "multi-payer" and "don't know." We thought these additional response options would improve reflect the wide range of policy solutions, too as students' previously documented lack of knowledge about health policy issues.²⁶

This study has several limitations. First, in several instances, circuitous policy terms were non divers in the questionnaire. In social club to counter this problem, we provided brusque definitions for some terms and a "don't know" response selection, but phrases such as "single-payer" or "managed care" nonetheless may have conjured defoliation or bias. 2nd, differences in responses between kickoff-yr and fourth-year students may be due to maturation and acculturation during medical school, but the cross-sectional design does not confirm these furnishings. A longitudinal study of medical students throughout their preparation and perhaps their early years in practice would assist pinpoint where and why the erosion of their back up for universal health intendance occurs. Finally, nonresponse bias may have influenced these results. Information technology is possible that students with greater interest in wellness policy bug may take been more likely to reply, and these students' views may non be representative of all medical students.

This survey demonstrates stiff support among U.S. medical students for expanding health care coverage to the uninsured. Although a majority of students expressed a preference for a system of universal health care, their perception that practicing physicians do non back up universal health care could negatively influence their views over time. The negative influences on their perceptions of universal wellness care should be balanced by curricula that volition contribute to maintaining their back up for universal health intendance every bit students advance in their training and into exercise. Medical school faculty may wish to appoint in dialogues with medical students in a productive, educational exchange of ideas. Educational programs should teach students about wellness care systems in other nations and should provide learning experiences whereby medical students acquire about health care reform primarily from the patient'southward indicate of view. In order to attain the goal of universal coverage past 2010 as recommended by the Plant of Medicine, medical students and physicians should strengthen collaborative efforts both within professional person circles and together with citizens' groups toward the common goal of achieving high quality, affordable wellness care for all.

Acknowledgments

Dr. Huebner had full access to all the data in the study and takes responsibility for the integrity of the data and the accurateness of the information analysis. The authors give thanks Ryan Hubbard, PhD, Center for Survey Research at the University of Virginia, for his function in conducting the study and assist with statistical analysis.

This study was supported by a grant from the Robert Wood Johnson Foundation and by internal back up from the American Medical Student Association/Foundation Jack Rutledge Fellowship, and was presented at the Almanac Meeting of the American Medical Pupil Association Affiche Session, March 21, 2003, Washington, DC.

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© 2006 Association of American Medical Colleges

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