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To Curb Costs, We Must Engage the Public on Health Care

by Daniel Yankelovich

Thursday, January 23rd, 2014

This commentary offers reflection on the findings and implications from "Curbing Health Care Costs: Are Citizens Ready to Wrestle with Tough Choices?" Daniel Yankelovich is a public opinion pioneer and cofounder of Public Agenda.


Though the recent Public Agenda study on health care costs is small in scale, it leads to several far-reaching conclusions. I want to use my nickel to comment on one of them.

The study presented three strategies for health care cost containment to average, older adult Americans (ages 40 to 64): make the public pay more for services; hold doctors and administrators responsible for reforms in efficiency; and/or, have the government control prices. Frankly, I am surprised by how clear-cut the implications of these discussions were. For a variety of reasons, the first and third strategies seem hopelessly impractical, leaving only the second for consideration. I have spelled out below the reasoning behind this conclusion.

In an era of stagnant wages and rising health care costs, the public feels heavily burdened already. Being asked to pay even more for a system that functions so inefficiently will incite high levels of political resentment and won’t do much to pressure the system into greater efficiency. The public is not equipped to choose among alternative plans, because it doesn’t know how to evaluate the implications of each alternative. And average consumers are in no position to evaluate (let alone turn down) the advice of medical specialists.

Most important of all, the study reveals a staggering ignorance of how the system really works and how it got that way. In my more than 60 years of polling experience I am accustomed to seeing public lack of knowledge and information on issues. But even I am taken aback by the extent of public blindness and denial on this issue. I do not blame the public for its ignorance. Average Americans have played a scant role in shaping public policy in health care. From the perspective of experts, the public has nothing to contribute to strategic policy thinking and has been effectively left out of the conversation. It will take a huge amount of time and effort to bring the public into the picture.

"Public engagement is needed to bring about the necessary reforms. Effective public engagement is possible, but it will take a lot more research and experimentation to learn how to do it right."

People’s fears that government price controls inevitably mean that doctors will provide less care is a compelling political argument. Wide ideological opposition to price controls strengthens the argument. Government-based price controls are dead on arrival.

As soon as one turns to reforming the delivery system — Strategy Two — powerful reasons for doing so immediately present themselves. The doctors themselves are deeply dissatisfied with the status quo. They are angry, demoralized, and resentful even though they may benefit financially.

The lack of transparency in the system is its most bewildering feature. The system of employer coverage that hides costs from the public arose by accident in the early days of WWII. It is the source of many dysfunctions. An even greater (and less transparent) source of dysfunction is the federally mandated monopolistic role of the American Medical Association (AMA) in setting codes for pricing. Much of the lack of price sensitivity in the system can be tracked back to this source. The role of the AMA makes it easy to game some promising reforms, such as digital record keeping, with the perverse result that this innovation often adds to costs and confusion rather than reducing them.

My personal view is that public engagement is needed to bring about the necessary reforms. Effective public engagement is possible, but it will take a lot more research and experimentation to learn how to do it right.




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