Nearly 46 million persons in the United States did not have health insurance in 2004,1 and more than 31 million of America’s workers are underinsured.2 Numerous studies recently summarized by the Institute of Medicine have shown that being uninsured translates into serious health consequences, including a higher risk of death.3
In addition to the growing numbers of uninsured, rising health care costs4 and concerns about the quality of health care have focused public attention on reforming the health care system.5–8 A wide range of physicians’ organizations have been active in discussing the problems of the health care system and proposing solutions9–13 for “universal coverage.”
Recent studies suggest that many physicians support dramatic health care reform. A national survey found that 49% of U.S. physicians supported governmental legislation to establish national health insurance, while 40% opposed it.14 In a survey of Massachusetts physicians, almost two-thirds (63.5%) of respondents indicated that a single-payer system would provide “the best care for the most people for a fixed amount of money.”15
Medical students’ views about universal health care and other issues of health care policy are not well-known. Understanding the views of medical students is important, because these individuals will constitute the next 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 school curricula and faculty members are conveying to future physicians.
Previous studies have examined medical students’ views of the health care system and perspectives on various reform options,16–20 but to our knowledge no such studies have been published since the last major health care reform debate of the early 1990s, and those that were done were limited in scope and sample size. We therefore surveyed a nationally representative sample of first- and fourth-year medical students to determine their views about health care policy and universal health care in the United States. We hypothesized that support for universal health care would decline over the course of the medical training process, and would be reflected by higher rates of support among first-year students compared with fourth-year students.
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-year and fourth-year medical students. We oversampled fourth-year students to ensure their adequate representation in the sample due to an expected lower rate of returns. After excluding students with incorrect addresses, 1,363 eligible participants remained. Our responding sample could provide an accurate estimate, with 95% confidence, of U.S. first-year and fourth-year medical students’ views, with a sampling error of 3.6%.
The Center for Survey Research at the University of Virginia administered the mail questionnaire between March and May 2002. An advance letter was mailed to the randomly selected eligible participants, followed by a mailing that included a cover letter, the questionnaire, a prepaid return envelope, and a $2 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, phone, or e-mail. The University of Virginia institutional review board approved the study protocol.
We developed the questionnaire* on the basis of a systematic review of the literature and the observations of a focus-group of current medical students. We chose final 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 health care 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 health care,” so these terms were defined for specific questions when the exact meaning was vital to understanding the question meaning and answer options. Some answer choices about health care 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 care systems. In response to the questions “Which of the following would offer the best health care to the greatest number of people for a given amount of money?” and “Of the following health care structures, please indicate your preference as well as what you believe to be the preference of doctors and patients in the United States,” the response choices were: (1) A “fee-for-service” system in a competitive marketplace (the predominant mode of coverage in the “old” American system); (2) a “managed care” system in a competitive marketplace (the predominant mode of coverage in the current system); (3) a “single-payer” system 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 also 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 about programs such as Medicare and care of the uninsured in the United States. Finally, we asked students about various academic and life experiences that had caused them to support or oppose universal health care. The survey questions used for this study were part of a larger survey that took approximately 15 minutes to complete.
The analysis required weighting of the data to accurately represent the population of first-year and fourth-year 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 represent estimates of the responses of the national population of medical students. We compared first-year and fourth-year students’ responses using chi-squared tests for categorical variables, and we considered two-tailed p ≤ .05 statistically significant.
We received 770 completed questionnaires, yielding a response rate of 56.5%.22 A total of 295 first-year (57.2%) and 475 fourth-year (56.1%) students completed the survey. Table 1 shows characteristics of first-year and fourth-year students responding to the survey, along with characteristics of the population of fourth-year medical students in the United States in 2002,23 the same year as the study. Fourth-year respondents were similar to the general U.S. fourth-year student population (as determined by the Association of American Medical Colleges (AAMC) graduation survey23) in terms of gender. A larger proportion of fourth-year respondents were white, compared with the general population of graduating students in 2002. However, the racial composition of the first-year respondents was very similar to the population of graduating students nationwide.
Prioritizing health care policy issues
More than four out of five first-year (82% ) and fourth-year (81% ) medical students indicated that expanding health care coverage for the uninsured was “very” or “extremely” important (versus “somewhat” or “not at all” important). Similar proportions of first-year (82% ) and fourth-year (78% ) students reported that it was “very” or “extremely” important to enact a patients’ bill of rights to protect patients against some abuses of managed care. In comparison, about half of first-year (53% ) and fourth-year (50% ) students noted that strengthening the public health system in preparation for future bioterrorism attacks was “very” or “extremely” important.
Health insurance and universal access to health care
For the following questions, students were asked to indicate on a Likert scale whether they agree or disagree with several statements. A total of 90%  of first-year students and 88%  of fourth-year students agreed or strongly agreed with the statement, “Everyone is entitled to adequate medical care regardless of ability to pay.” In contrast, 84%  of first-year students and 72%  of fourth-year students disagreed or strongly disagreed with the statement, “People without health insurance still have access to the care they need.” More than nine out of ten medical students (89%  of first-year students and 95%  of fourth-year students) said that receiving routine care in the emergency room was not an effective way for the uninsured to receive care. More than half of first-year (64% ) and fourth-year (58% ) 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-year students than first-year students agreed that “Medicare is an effective program that guarantees access to health care for all elderly persons in the U.S.” (64%  vs. 55% , p = .015).
The “best” system for providing health care
Figure 1 shows a summary of all students’ (first- and fourth-year 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 money?” Nearly two-thirds (64% [472 of 732 total responses for this question]) of all students identified a system with universal coverage as the best structure, with somewhat more support among first-year students (68% ) than fourth-year students (62% , p = .11). Just over half of students (51% [371 of 732]) selected “multi-payer” overall, and this type of system was most popular among those selecting a system with universal health care. A considerable proportion of students (19%  of first-year students and 21%  of fourth-year students) selected “don’t know” as their response to this question.
Figure 2 contrasts first- and fourth-year 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 note, students’ personal preferences largely differed from their perceptions of what doctors and patients would prefer. Large majorities of both first- and fourth-year students supported a structure with universal health care, but even more believed that the public supports a structure with universal health care. First-year students were more likely to support a universal health care structure (70% ) than fourth-year students (61% , p = .012). More first-year students (46% ) believed that the public prefers a single-payer system than any other structure. In contrast to students’ preferences and their beliefs about those of the public, similarly large percentages of both first-(78% ) and fourth-year (76% ) students believed that physicians preferred a fee-for-service/marketplace system.
The United States versus other industrialized nations
Students were asked to rate on a Likert scale whether the U.S. health care system was better or worse than the systems of other industrialized nations (Table 2). Majorities of both first-year and fourth-year students believed that the U.S. system performed better than other nations’ in regards to freedom-of-choice of physician, length of wait for treatments, provision of high quality care, and development of innovative medical technologies. However, majorities of both first-year and fourth-year students indicated that the current U.S. system did worse than other industrialized nations in regards to providing access to care for everyone, protecting patients from out-of-pocket costs, the amount of interference in physician decision making, the amount of paperwork and administrative burden placed onto physicians, and medical student debt.
Influences on attitudes about universal health care
Table 3 shows students’ perceptions of how various influences contributed to their attitudes about universal health care (answer choices were on a scale of “support” to “oppose,” midpoint “did not influence”). Substantial proportions of both first-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 opinion said that the direction was in support of universal health care, except for fourth-year students’ reports of influences by residents. The three influences that were most likely to create support for universal health care were extracurricular learning, elective coursework, and required coursework. The influences that were most likely to create opposition to universal health care were residents, faculty/attending physicians, and opinions of family who were health professionals.
A recent series of reports on the consequences of uninsurance from the Institute of Medicine culminated with a call for the nation to achieve universal health coverage by 2010.24 Our study documents widespread support among 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 as a very important issue 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 care reform was high among both groups of students, but fourth-year students tended to be somewhat less supportive than first-year students. Less support for universal health care among fourth-year students may foreshadow the continued erosion of support once they graduate, as noted in one recent national study of physicians.14
Medical students’ support for the expansion of health coverage to the uninsured might be 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 support for this concept was consistent with the data collected in another national survey of fourth-year students conducted contemporaneously.23 Second, medical students correctly identified that people have difficulty accessing the health care they need if they do not have health insurance and that the emergency department is not an effective way for the uninsured to receive routine care.3 Third, students indicated their beliefs that the United States can afford a universal health care system and that Medicare is an effective system that guarantees health care access for the elderly. Medical students’ favorable view of Medicare may indicate their receptiveness to other government-financed systems of universal coverage. Last, students recognized that other industrialized nations’ health care systems have fewer problems with access to care.
While majorities of both first-year and fourth-year students preferred health care reform that would create universal health care, they also tended to believe that practicing physicians desire a fee-for-service system in the marketplace. At the same time, most medical students perceived that patients preferred universal health care. This dichotomy suggests that medical students perceive that physicians’ interests may not always align with the best interests of patients. Whether students develop these perceptions as a result of their medical training or from other sources remains unknown. Both a formal and a hidden curriculum during medical school play a role in students’ education,25 and our survey results suggest this is true, evidenced by their frequent reports of residents and faculty physicians contributing to negative perceptions about universal health care.
Fewer students in our study supported a “single-payer” system than in a previous study,19 perhaps because our question offered the additional response options of “multi-payer” and “don’t know.” We thought these additional response options would better reflect the wide range of policy solutions, as well as students’ previously documented lack of knowledge about health policy issues.26
This study has several limitations. First, in several instances, complex policy terms were not defined in the questionnaire. In order to counter this problem, we provided short definitions for some terms and a “don’t know” response option, but phrases such as “single-payer” or “managed care” still may have conjured confusion or bias. Second, differences in responses between first-year and fourth-year students may be due to maturation and acculturation during medical school, but the cross-sectional design does not confirm these effects. A longitudinal study of medical students throughout their training and perhaps their early years in practice would help pinpoint where and why the erosion of their support for universal health care occurs. Finally, nonresponse bias may have influenced these results. It is possible that students with greater interest in health policy issues may have been more likely to respond, and these students’ views may not be representative of all medical students.
This survey demonstrates strong 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 not support universal health care could negatively influence their views over time. The negative influences on their perceptions of universal health care should be balanced by curricula that will contribute to maintaining their support for universal health care as students advance in their training and into practice. Medical school faculty may wish to engage in dialogues with medical students in a productive, educational exchange of ideas. Educational programs should teach students about health care systems in other nations and should provide learning experiences whereby medical students learn about health care reform primarily from the patient’s point of view. In order to achieve the goal of universal coverage by 2010 as recommended by the Institute of Medicine, medical students and physicians should strengthen collaborative efforts both within professional circles and together with citizens’ groups toward the common goal of achieving high quality, affordable health care for all.
Dr. Huebner had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The authors thank Ryan Hubbard, PhD, Center for Survey Research at the University of Virginia, for his role in conducting the study and assistance with statistical analysis.
This study was supported by a grant from the Robert Wood Johnson Foundation and by internal support from the American Medical Student Association/Foundation Jack Rutledge Fellowship, and was presented at the Annual Meeting of the American Medical Student Association Poster Session, March 21, 2003, Washington, DC.
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*The questionnaire is available from Joan Hedgecock, American Medical Student Association Foundation, 1902 Association Drive. Reston, VA 20191.