Ask American adults to name the most serious problems facing children, and one answer overwhelms the rest: drugs. Crime and the breakdown of home life rank a distant second and third, respectively.
Concern about health care and the ability to pay for it hardly get mentioned. Injuries, the leading cause of death among children, doesn't even make the list. Nor does smoking, the leading cause of preventable illness in all Americans. The only disease mentioned by at least 1% of adults is AIDS.
When the Harvard School of Public Health reported its nationwide survey, "American Attitudes Toward Children's Health Care Issues," health care was conspicuously absent.
The findings suggest that the "family values" agenda has caught on with the public more than the "health care" agenda, said the study's director, Robert J. Blendon, professor of health policy and political analysis at both the Harvard School of Public Health and the Kennedy School of Government, who directed the study.
"Poverty, day care, health insurance--these are off the radar screen," he said.
Blendon said he was surprised that poverty didn't rank higher as a concern when one out of five American children lives below the poverty line. He was surprised as well that concern about crime rose sharply even as national crime rates fell.
At a time when states are trying to figure out how--and whether--to take advantage of a new federal law aimed at boosting Medicaid coverage of otherwise uninsured children, the results are troubling to health officials.
In the Harvard survey, only 29% were aware of the new law or the effort to expand coverage of uninsured children. Adults with uninsured children were no more aware of the new legislation than were other adults.
"We were sort of staggered by that," Blendon said. "What's clear is that people don't even know there's going to be a debate about this. There's just no public following of this legislation."
The nationwide opinion poll was designed by the Harvard School of Public Health and conducted by the Survey Research Center at the University of Maryland. About 1,500 randomly selected adults were interviewed by telephone during September and October.
When a 1986 Harris poll, using identical language, asked adults to name critical problems facing children, drugs were also far and away the top concern. But the other rankings have changed sharply since.
Child abuse and sexual abuse, mentioned as a top concern by 28% of adults in 1986, plummeted to 1% this year. Crime leaped into second place, mentioned by 24%, compared with just 4% in the earlier poll. Concern about breakdown of home and family life remained strong, but dropped from 46% to 22%. Alcohol fell slightly from 9% to 8%. Nearly twice as many adults mentioned education as an important concern this year compared with 1986.
Neither health care nor poverty made it into the Top 10 list of concerns in either the 1986 or the 1997 survey.
"Health care, poverty, alcohol and smoking didn't even make it onto the list," said Ruby P. Hearn, senior vice president of the Robert Wood Johnson Foundation, which funded the survey. "The public agenda as revealed in the survey is much narrower than we think it needs to be."
She expressed concern that the public, although clearly frightened by the dangers of illegal drugs, remained unworried about related health problems.
"Very few kids just start taking drugs," Hearn said. "They start drinking or they start smoking, and that's what leads them to drugs."
One in six eighth-graders, she noted, say they recently have gone on a drinking binge, according to the University of Michigan's latest national survey.
Like Blendon, she also worries that the public misunderstands the new federal initiative on children's health-insurance coverage.
"The federal legislation did not take care of the problem," Hearn said. "It created an opportunity for states to take care of the problem."
About 11 million American children lack health insurance. The bipartisan Balanced Budget Act passed by Congress and signed into law by President Clinton in August includes a $24-billion measure aimed at expanding health coverage for many of those children. The new law encourages states to increase their Medicaid budgets--and thus take advantage of higher federal matching funds--to expand coverage to families with annual incomes up to twice the poverty level, or more than $32,000.
"A lot of families in that range are doing without, because they have not a clue that they are eligible," said Sarah C. Shuptrine, founder and president of the Southern Institute on Children and Families, a nonprofit organization focusing on the disadvantaged in 17 Southern states and the District of Columbia.
"The ball is in the court of the states now," she said. "The federal government has acted. It's an incredible opportunity for the states."
But the latest survey suggests that the public still misunderstands Medicaid, the federal-state health program for low-income families. People tend to think of Medicaid as aimed at only the poorest families, Shuptrine said, when in fact it may cover children in working-class families well above the poverty line.
"We need to uncomplicate those messages for parents," she said.
Blendon said, "What this means is that if a big push isn't made to increase public support for children's health care, any hope of extending coverage to the majority of the 11 million uninsured children could fizzle out at the state level."