Voices unheard: barriers to expressing dissatisfaction to health plans.

Consumers dissatisfied with their health plan can either "exit" (switch service providers) or "voice" (complain to the current provider). Policymakers' efforts to help consumers voice their dissatisfaction to health plans or external mediators have been disappointing, in part because little is known about the determinants of voice. This article represents the first comprehensive assessment of voicing in response to problematic experiences with health plans. A national consumer survey from 1999 is used to test hypotheses about characteristics of problems, patients, and settings that might inhibit voice and assess state regulations intended to enhance voice. Although problems associated with plans led to more voice than exit, voice is circumscribed by several factors: certain groups, such as racial minorities, do not express their grievances as often; episodes with severe health consequences for patients are not reported as regularly. The findings suggest that even though regulatory initiatives have not increased the frequency of voice, they have made grievances more effective, at least in jurisdictions where citizens know about the laws.