There is little question about the kind of health care system people want—universally accessible, affordable and simple. But beyond partial solutions such as more price transparency, our research suggest that it will be hard to find strong public support for bigger ideas to reach these goals until the public works through its ambivalence about the trade-offs.
How, then, to help Americans move toward public judgment on health care? Three avenues appear potentially fruitful: a better-framed public and policy conversation; state-based laboratories to test innovative ideas; and community-based citizen engagement to strengthen health and health care locally.
There’s no need to convince people of the problems in our health care system. But it is clear that framing the issue in terms of government spending is a losing strategy and that doing so leads experts and the public to talk past each other. Recall that focus group participants saw the share of government spending on health care as a sign of well-placed priorities—unlike experts who have been sounding the alarm about such spending for decades.
But we believe the nation can have a productive public conversation about containing health care costs. As we saw in our focus groups, people view costs as out of control. And as we’ve seen in our earlier survey research, they do not automatically equate high cost with high quality. So long as the solution is not to raise copays or lessen quality, or focuses only on federal and state budgets rather than people’s wallets, the public is likely open to conversations about how to effectively contain costs. Skillful public engagement could help people understand that containing government costs may go hand in hand with containing their own costs—and could free up government funds for other priorities.
In our groups, people were intrigued by Maryland’s attempts to control costs in its hospitals. While people bristled at the now defunct individual mandate in the ACA, Massachusetts has an individual mandate that people there seem to have accepted.29 Overall, people appear to be more open to experiments at the state level, an important way in which ideas and solutions gain currency in American democracy. We suspect that more state-level experimentation, if fed into the national conversation, could be a good way to help the public continue to think through and come to grips with what’s workable and what trade-offs they’re willing to accept in health care.
People in these groups often spoke about the health care system in their communities, including local hospitals, businesses and families. Each of the communities where we held our groups has distinct challenges and assets. In rural Franklin County, Missouri, for example, people had few hospitals or other providers to choose from. Given that all health care is local and that communities vary, there is an opportunity to engage community members and local leaders in identifying and addressing health priorities in their own backyards. In health care, opportunities for public engagement at the community level are rare.30 Creating systems for sustained, meaningful public participation in health care at the local level, and enabling and encouraging community decision making, can go a long way toward repairing our nation’s health care system from the ground up. It can help people gain a fuller understanding not only of the problems their communities face, but also of the solutions they are willing to accept and support.
29Sarah Kliff, “Health Reform with a Mandate: The Massachusetts Story,” Washington Post, June 19, 2012, https://www.washingtonpost.com/blogs/ezra-klein/post/health-reform-with-a-mandate-the-massachusetts-story/2012/06/18/gJQAfohImV_blog.html.
30Tina Nabatchi and Matt Leighninger, Public Participation for 21st Century Democracy (Hoboken, NJ: John Wiley & Sons, 2015).