This analysis of new and existing research on public attitudes illustrates the challenges of addressing the problems facing our health care system. In these groups, we heard significant frustration with a complex and expensive system, questions about the competence of the federal government and exasperation with politicians whom participants described as disconnected from the real health care system that their constituents must face.
The stakes in finding workable solutions are high. Millions of Americans face unaffordable premiums and out-of-pocket expenses, millions are uninsured and national health expenditures continue growing, reaching 17.9 percent of GDP in 2017.21 If left unattended, these problems will make Americans even more vulnerable to economic hardship and leave our government and businesses less capable of addressing priorities such as education, infrastructure and wage stagnation.
Despite this dark picture, our focus groups coupled with our reading of survey data suggest shared goals and some avenues for progress—as well as some remedies that could be a harder sell with the public at this point. Let’s start with the most obvious pillars of public support. What are the public’s shared goals and solutions as far as health care is concerned?
Participants felt strongly that all Americans should have access to health care. Their overriding concern with affordability may not be newsworthy but bears repeating and has implications for policy: Giving people more “skin in the game” in the form of deductibles, premiums, copayments and coinsurance left our participants feeling angry and ready for change.
Price transparency appealed strongly to participants in these groups—in fact, Public Agenda’s survey research has found that one in five Americans has tried to compare health care prices and that, by a variety of measures, most Americans want more clarity on health care prices.22 With so many people having “skin in the game,” it is no wonder they are trying to protect themselves from high out-of-pocket costs and determine what they have to pay for their care. But transparency has its limits, both because not all services are shoppable and because even people who do shop around are not guaranteed to find reasonable prices—especially in places without much competition among providers.23 Nevertheless, user-friendly information about what health care costs is something people want and could help them avoid disastrous hidden expenses. It deserves to be part of the conversation about solutions.
Simplicity was also an important goal for participants frustrated with the confusions and burdens of getting the care they needed. Insurers, hospitals and other health care providers who can design truly patient-centered systems stand a chance of pulling business away from their competitors. While the Amazon, Berkshire Hathaway and JPMorgan Chase health care partnership is relatively new as of the release of this report and innovative primary care practices such as One Medical do not treat the most complex types of care, the field is clearly ripe for approaches to delivering care that prioritize customer service and “user-centered design.”24
Our participants raised the idea of making lawmakers vulnerable to their own policies by mandating that members of Congress have the same frustrating, expensive insurance as their constituents. They reason that if members of Congress had to go to the same lengths and expense as ordinary Americans to get care for themselves and their families, everyone would end up having better options. While this idea may sound far-fetched, one could easily imagine a maverick lawmaker running on this idea or introducing legislation to this effect, forcing policymakers to experience the stress of a high deductible firsthand—just as the director of the Harvard Global Health Institute did when he chose an insurance plan for his family with a $6,000 deductible.25
Experts routinely describe government spending on health care as unsustainable, unaffordable and, ultimately, dangerous for future generations. This is an issue, however, on which experts and the public appear to be talking past each other. These groups indicate that people are not necessarily concerned about how much health care costs the government. In fact, cutting government spending on health care appears to be unpopular. Leaders who want to cut government spending on health care must be ready with arguments about why doing so would not be harmful to quality or access, would not increase individuals’ out-of-pocket spending and would free up money for other priorities.
Based on this research and others’ surveys, Americans are not necessarily against cost containment. They agree that prices are irrational and understand that higher prices do not mean better quality.26 But if cost containment is framed primarily as an initiative that saves government money, it will not sell well with the public. Cost containment must help the family budget as well as those of states and the nation.
Participants in these groups were intrigued by the idea of states doing more to control health care prices. While further research would be needed to truly gauge the depth of people’s interest in such state efforts, this finding is consistent with the relative comfort people have for state government solutions as opposed to federal ones. One could imagine more states experimenting with price controls, although federal efforts may not be so welcome. While some Democratic politicians and advocates have argued for a single-payer program such as Medicare for All, these groups indicate that a major hurdle would be skepticism about whether the federal government is too remote and inefficient to make such a program work. Medicare itself, signed into law by President Lyndon Johnson, was largely popular but was not enacted without controversy.27 Public opinion on a single-payer approach may evolve over time, but for now, at least, people have significant reservations.
Health care experts routinely call for shifting away from fee-for-service payment and toward various value-based payment approaches. We view public opinion as relatively uninformed on the question of value-based payment. Participants in our groups raised questions about whether value-based payment is fair to doctors, whether doctors would try to game the system or why doctors need incentives to do what they already should be doing—providing quality care. These questions echo public concerns about the accountability movement in K–12 education, where evaluating teachers based on students’ performance and even tying teachers’ salaries to students’ performance have proven controversial.28 As value-based payment gains steam in health care, it could prove controversial if people’s concerns about negative impacts on quality are borne out or inflamed by special interests or partisan infighting.
21Zac Auter, “U.S. Uninsured Rate Steady at 12.2% in Fourth Quarter of 2017,” Gallup Well-Being, January 16, 2018, http://news.gallup.com/poll/225383/uninsured-rate-steady-fourth-quarter-2017.aspx. See also: Sara R. Collins, David C. Radley, Munira Z. Gunja and Sophie Beutel, “The Slowdown in Employer Insurance Cost Growth: Why Many Workers Still Feel the Pinch,” Commonwealth Fund, October 26, 2016, http://www.commonwealthfund.org/publications/issue-briefs/2016/oct/slowdown-in-employer-insurance-cost-growth/. Micah Hartman, Anne B. Martin, Nathan Espinosa, Aaron Catlin and the National Health Expenditure Accounts Team, “National Health Care Spending in 2016: Spending and Enrollment Growth Slow After Initial Coverage Expansions,” Health Affairs 37, no. 1 (2018): 150–60, https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2017.1299. U.S. Centers for Medicare & Medicaid Services, National Health Expenditure Data Fact Sheet, 2016, https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html.
22Schleifer, Silliman and Rinehart, “Still Searching: How People Use Health Care Price Information in the United States, New York State, Florida, Texas and New Hampshire.”
23Amanda Frost and David Newman, “Issue Brief: Spending on Shoppable Services in Health Care,” Health Care Cost Institute, March 2016, http://www.healthcostinstitute.org/issue_brief/issue-brief-spending-shoppable-services-health-care/.
24Nick Wingfield, Katie Thomas, and Reed Abelson. “Amazon, Berkshire Hathaway and JPMorgan Team Up to Try to Disrupt Health Care.” The New York Times, January 30, 2018, sec. Technology. https://www.nytimes.com/2018/01/30/technology/amazon-berkshire-hathaway-jpmorgan-health-care.html.
25Ashish Jha, “I’ve Put My Family on a Health Insurance Experiment. It’s Been a Challenge,” STAT, February 6, 2017, https://www.statnews.com/2017/02/06/health-insurance-high-deductible-experiment/.
26Kathryn A. Phillips, David Schleifer and Carolin Hagelskamp, “Most Americans Do Not Believe That There Is an Association Between Health Care Prices and Quality of Care,” Health Affairs 35, no. 4 (April 2016): 647–53, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2015.1334.
27Kathleen Weldon, “Public Opinion and the Passage of the Medicare Bill,” Roper Center, February 22, 2017, https://ropercenter.cornell.edu/public_opinion_and_passage_of_medicare/.
28Thomas Dee and James Wyckoff, “Incentives, Selection, and Teacher Performance: Evidence from IMPACT,” National Bureau of Economic Research, October 2013, https://doi.org/10.3386/w19529.