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Importance: The 2016 US presidential election brought national visibility to prominent economic issues affecting rural America, yet little has been done to examine serious health or economic problems in rural communities from the perspectives of rural US adults themselves., Objective: To examine views on the most serious health and economic concerns and potential solutions in rural communities., Design, Setting, and Participants: This survey study used 2 cross-sectional probability-based telephone (cellular and landline) surveys of adults living in the rural United States. The first survey was conducted June 6 to August 4, 2018, and the second survey was conducted January 31 to March 2, 2019. All results were weighted to be nationally representative of rural US adults. Data analysis was conducted in April 2019., Main Outcomes and Measures: The primary study outcomes were the prevalence of rural adults reporting their biggest community problems, problems with health care access and costs, ratings of the local economy, views on opioid addiction, and views on solving major community issues., Results: The 2018 survey included 1300 respondents (response rate, 12%; completion rate, 70%), and the 2019 survey included 1405 respondents (response rate, 8%; completion rate, 76%). Rural adults primarily identified as non-Hispanic white (78%), and more than half of respondents were 50 years or older (survey 1: 55%, survey 2: 53%). Rural adults identified opioid or other drug addiction or abuse (25%; 95% CI, 22%-28%) and economic concerns (21%; 95% CI, 19%-24%) as the most serious problems facing their local communities. Opioid or other drug addiction or abuse was reported as a serious problem in their local community by 57% (95% CI, 53%-60%) of rural adults, while 49% (95% CI, 46%-53%) of rural adults said they personally know someone who has had opioid addiction. Problems paying medical bills were reported by 32% (95% CI, 29%-36%) of rural adults, and recent issues with accessing health care were reported by 26% (95% CI, 23%-30%) of rural adults. Regarding financial and economic issues, 55% (95% CI, 52%-59%) of rural adults rated their local economy as only fair or poor, and 49% (95% CI, 44%-54%) of rural adults said they would have difficulty paying off an unexpected $1000 expense. On solving major community problems, 58% (95% CI, 54%-62%) of rural adults saw a need for outside help to solve major community problems, and among those who reported needing outside help, 61% (95% CI, 57%-66%) identified a major role for government., Conclusions and Relevance: These findings suggest that in today's economically stretched rural United States, opioid or other drug addiction or abuse has emerged as an equal problem with economic concerns. One in 3 rural adults still have problems paying their medical bills even after the passage and implementation of the Patient Protection and Affordable Care Act. Although rural communities have traditionally been self-reliant, more than half of rural adults are open to outside help to solve serious problems facing their communities, including major help from government.

Importance: Under the Affordable Care Act (ACA), more than 30 states have expanded Medicaid, with some states choosing to expand private insurance instead (the "private option"). In addition, while coverage gains from the ACA's Medicaid expansion are well documented, impacts on utilization and health are unclear., Objective: To assess changes in access to care, utilization, and self-reported health among low-income adults in 3 states taking alternative approaches to the ACA., Design, Setting, and Participants: Differences-in-differences analysis of survey data from November 2013 through December 2015 of US citizens ages 19 to 64 years with incomes below 138% of the federal poverty level in Kentucky, Arkansas, and Texas (n = 8676). Data analysis was conducted between January and May 2016., Exposures: Medicaid expansion in Kentucky and use of Medicaid funds to purchase private insurance for low-income adults in Arkansas (private option), compared with no expansion in Texas., Main Outcomes and Measures: Self-reported access to primary care, specialty care, and medications; affordability of care; outpatient, inpatient, and emergency utilization; receiving glucose and cholesterol testing, annual check-up, and care for chronic conditions; quality of care, depression score, and overall health., Results: Among the 3 states included in the study, Arkansas (n=2890), Kentucky (n=2898, and Texas (n=2888), there were no differences in sex, income, or marital status. Respondents from Texas were younger, more urban, and disproportionately Latino compared with those in Arkansas and Kentucky. Significant changes in coverage and access were more apparent in 2015 than in 2014. By 2015, expansion was associated with a 22.7 percentage-point reduction in the uninsured rate compared with nonexpansion (P < .001). Expansion was associated with significantly increased access to primary care (12.1 percentage points; P < .001), fewer skipped medications due to cost (-11.6 percentage points; P < .001), reduced out-of-pocket spending (-29.5%; P = .02), reduced likelihood of emergency department visits (-6.0 percentage points, P = .04), and increased outpatient visits (0.69 visits per year; P = .04). Screening for diabetes (6.3 percentage points; P = .05), glucose testing among patients with diabetes (10.7 percentage points; P = .03), and regular care for chronic conditions (12.0 percentage points; P = .008) all increased significantly after expansion. Quality of care ratings improved significantly (-7.1 percentage points with "fair/poor quality of care"; P = .03), as did the share of adults reporting excellent health (4.8 percentage points; P = .04). Comparisons of Arkansas vs Kentucky showed increased private coverage in the former (21.7 percentage points; P < .001), increased Medicaid in the latter (21.3 percentage points; P  < .001), and higher diabetic glucose testing rates in Kentucky (11.6 percentage points; P = .04), but no other statistically significant differences., Conclusions and Relevance: In the second year of expansion, Kentucky's Medicaid program and Arkansas's private option were associated with significant increases in outpatient utilization, preventive care, and improved health care quality; reductions in emergency department use; and improved self-reported health. Aside from the type of coverage obtained, outcomes were similar for nearly all other outcomes between the 2 states using alternative approaches to expansion.

This article presents what Americans think about the policies subsumed under the label of the "War on Drugs." It is based on an analysis of 47 national surveys conducted between 1978 and 1997. The major results are that most Americans rely on the mass media for information about the scope of the drug abuse problem; Americans do not think that the Wars on Drugs have succeeded, but they do not want to quit on these efforts; weak support exists for increasing funding for drug treatment; support for preventive education has increased during the 1990s; criminal justice responses remain very popular; for many, illicit drug use is a moral rather than a public health issue; the public supports allowing physicians to prescribe marijuana for severe illness, but opposes the general legalization of marijuana and other illicit drugs; and needle exchange programs are supported by a bare majority, but only when they are told that the American Medical Association supports these programs.

Objectives: To identify the core beliefs and policy preferences of the American public toward changing the welfare system and providing support for low-income families., Design: Results are presented from 19 telephone and in-person surveys of adults nationwide between 1937 and February 1995., Setting: At-home interviews with adults., Participants: Seventeen surveys; each survey involved 1000 to 2000 adults nationwide., Interventions: None., Measurements and Main Results: The results showed that the public supports strong welfare reform measures (eg, time limits and work requirements), but it is reluctant simply to cut off welfare benefits to people and leave them without some means of basic support. The surveys identified five underlying beliefs that shape the public's policy preferences: (1) welfare causes more harm than good because it discourages work and causes families to break up; (2) welfare should be a temporary transition to work, not a long-term subsidy for low-income families; (3) the country spends too much on welfare programs; (4) lack of economic opportunity as well as personal responsibility is the reason people need welfare; and (5) both government and people themselves have a shared responsibility for ensuring that people have a minimum standard of living., Conclusions: The outcome of the welfare reform debate will have a substantial impact on the 21% of the nation's children who now live in poverty. The jury is still out on what the public will support in the welfare reform debate. The Medicaid program is caught in the middle of the welfare reform debate, and its ultimate fate may rely on state rather than federal decision making.

Objective: To assess the long-term impact of trauma and confinement on the functional health and mental health status of Cambodian displaced persons living on the Thailand-Cambodia border., Design: Household survey of 993 adults randomly selected from household rosters. Household sample selection by multistage area probability sample., Setting: Site 2, the largest Cambodian displaced-persons camp on the Thailand-Cambodia border., Participants: Adults 18 years of age and older selected at random within households; 98% of eligible persons selected agreed to participate., Results: From 1975 through 1979 (Khmer Rouge regime), more than 85% reported lack of food, water, shelter, and medical care, brainwashing, and forced labor; 54% reported murder of a family member or friend; 36% reported torture; 18% reported head injury; and 17% reported rape or sexual abuse. During the refugee period between 1980 and 1990, 56% reported lack of food or water, 44% reported lack of shelter, 28% reported lack of medical care, 24% reported brainwashing, and 8% reported torture. Since 1980, reports of murder of a family member, head injury, and rape/sexual abuse have decreased to 5%. Reports of experiencing combat situations and shelling attacks have remained consistent between the two time periods, approximately 44% and 30%, respectively. From 1989 to 1990, 25% reported experiencing lack of food or water, and 5% to 10% reported serious injury, combat, and shelling conditions. More than 80% said they were in fair or poor health, felt depressed, and had a number of somatic complaints despite good access to medical services. Fifty-five percent and 15% had symptom scores that correlate with Western criteria for depression and posttraumatic stress disorder, respectively. Fifteen percent to 20% reported health impairments limiting activity, and moderate or severe bodily pain. Despite reported high levels of trauma and symptoms, social and work functioning were well preserved in the majority of respondents., Conclusions: Reports of extensive trauma, poor health status, and depressive symptoms of this population are of concern in predicting future morbidity and mortality. The health and mental health needs of Cambodian displaced persons and their impact on social and economic behavior should be addressed now that the Cambodians have been repatriated.

Objectives: The debate in Massachusetts over the repeal of the first state-based "pay or play" universal health plan is discussed using data from a survey of 1066 Massachusetts households. The survey attempted to measure the problems of the uninsured, to estimate the likelihood that they would buy insurance if offered, and to calculate the proportion of the uninsured who would be covered under an employer mandate., Design: A survey conducted in person and by telephone in 1066 households, with an oversample of uninsured households, using stratification, clustering, disproportionate sampling, and poststatistical weighting., Participants: Adults aged 18 years and older who were knowledgeable about the insurance status of persons in their household., Main Outcome Measures: Insurance status, employment status, access to and use of health services, and willingness to purchase health insurance., Results: First, the present system of hospital-based uncompensated care in Massachusetts is inadequate by itself to meet the needs of uninsured residents. Uninsured persons are less likely than insured ones to seek medical care for chronic health problems and serious symptoms requiring evaluation. Second, 83% of uninsured families and 24% of uninsured individual respondents would purchase one of several insurance options with 30% of the cost subsidized. Last, the employer mandate provisions of the legislation would cover 43% of the uninsured in Massachusetts., Conclusion: In the current economic climate, the political viability of the universal health care plan and similar national initiatives is uncertain given the intractable conflict between perceptions of the financial stability of small businesses that do not offer insurance and the health care needs of uninsured individuals.

The United States enters the 1980s beset with serious economic problems. The picture currently projected from long-term economic forecasts supplemented by national opinion polls for the early to mid-1980s suggests a downturn in our nation's economy and a sharp decrease in monies available for further growth or improvements in America's medical care system. These prospects have serious implications for many of America's most important health care institutions, their health professionals, and how plan for the future.

Since the increased efforts to improve medical care for Americans were initiated 15 years ago, it is generally believed they had little impact on the problems addressed. Review of national data suggests otherwise. American medical care and health status are getting better. We have improved the availability of physician services and largely eliminated the gap between visits made by rich and poor, or white and black citizens. We have greatly expanded the number of health professionals who provide medical care. Better organized programs to provide care to groups with special health problems have reduced both mortality and morbidity. Age-adjusted death rates, infant and maternal mortality, and death rates from coronary artery disease have fallen. While there remains an important agenda for the future, there seems room for cautious optimism about the abilities of American society to make forward progress.

A 1986 national survey of use of health services shows a significant deficit in access to health care among black compared with white Americans. This gap was experienced by all income levels of black Americans. In addition, the study points to significant underuse by blacks of needed medical care. Moreover, blacks compared with whites are less likely to be satisfied with the qualitative ways their physicians treat them when they are ill, more dissatisfied with the care they receive when hospitalized, and more likely to believe that the duration of their hospitalizations is too short.

A serious slowdown in the nation's economy has led to widespread agreement that the rate of escalation of medical care costs must be slowed. In responding to the pressures to cut costs, physicians need to be guided by the basic tenet of medicine: first do no harm. In recent years, this nation has made extraordinary progress in improving health and longevity. A recent study suggestively links reductions in mortality to increased expenditures for health. Thus, physicians should watch closely how the nation reduces medical care expenses. We suggest a series of yardsticks that might track the effects of the nation's cost-cutting efforts on personal health. Keeping a careful eye on where people receive care, how frequently they see a physician, trends in mortality, and the adequacy or timeliness of care could help us keep our sights set on the continuing improvement of the health of Americans.

An analysis of more than two decades of poll results has identified six major trends in public opinion likely to affect the health care system of the 1990s. Americans favor more rather than less health spending, at least as long as the economy remains strong, and they do not think the deficit problem requires cuts in medical care outlays. Should there be a serious economic downturn, however, the public would reverse itself and would favor reduced spending that relies on a different set of strategies than those favored by most health policy experts, particularly in regard to spending for care for the elderly. In either case, the poll results suggest that Americans may be less inclined to participate in newer forms of medical practice, such as health maintenance organizations or preferred provider organizations, than anticipated, and that the commercialization of health care is leading to a decline in public confidence in the leaders of medicine. This latter trend may result in a lack of trust in professionals' views concerning the quality of care and may presage more stringent government involvement in and regulation of health services.