Cost Containment Need Not be a Dirty Word to the Public

With the right kind of help, Americans can confront the challenge of addressing health care costs, suggests a new study


NEW YORK CITY -- While cost containment is a top priority for health care providers, insurers and state and federal governments, experts often assume that the public is disinterested, if not angered or alienated, by the issue. Yet a new qualitative study from Public Agenda and the Kettering Foundation suggests that, under the right conditions, Americans may be able – and willing – to consider complicated cost containment proposals and bolster policy efforts to control costs.

Because insurance shields people from some of the actual costs of their care, many experts believe that insured Americans are unconcerned about cost effectiveness. Many also assume that Americans will automatically object to any effort to control costs. However, all participants in this study – even those with insurance – were deeply anxious about rising personal costs. Furthermore, when given the opportunity to learn about and deliberate over various policy proposals, focus group participants became willing and eager to consider these suggested efforts.

"Patients have the potential to contribute a great deal to policy discussions around this issue, and given the right kind of information and support, they are able to do so," says Will Friedman, president of Public Agenda. "The question is whether or not their voice will be a thoughtful one. Without an effort to engage citizens, policymakers could encounter broad pushback on many of the reforms experts are recommending."

Participants were intrigued by a number of approaches to controlling costs that many experts consider quite technical, including payment reform. Reforming the ways physicians and hospitals are paid is part of every serious cost containment proposal, but it is rarely brought up outside of policy circles. However, study participants discussed in detail how payment reform could affect their and their families' care – for better and for worse.

At the same time, this research suggests that the public's current understanding of the health care cost problem for the nation as a whole might be piecemeal at best. Participants entered the focus groups anxious about their personal costs yet mainly unaware of the magnitude of government spending on health care. Many arrived uninformed about the extent of domestic and international variations in cost and outcomes. Nor did they know that most physician reimbursement is currently fee-for-service. After learning this information during the focus groups, participants were eager to learn and talk more about health care costs.

This small yet suggestive study is based on four three-hour deliberative focus groups around the country with a total of 44 insured and uninsured Americans ages 40 to 64. Participants looked at a series of graphs showing the scope and impact of health care costs and participated in a moderated discussion examining the pros and cons of some major options for containing costs. Findings are detailed in the report, "Curbing Health Care Costs: Are Citizens Ready to Wrestle with Tough Choices?" While modest in scope, the research provides important clues to health care leaders, policymakers and experts looking to better communicate with and engage the public on cost containment.

Participants Keen on Improving Coordination of Care; Divided on the Role of Government

Focus group participants were introduced to a number of approaches to health care cost containment and deliberated over the pros and cons of each. "Many of the proposals being considered to contain costs are complex, leading us to wonder whether participants would be interested in and able to consider them," said David Schleifer, senior researcher with Public Agenda and lead author of the report. "While our participants struggled a bit, they ultimately engaged with the proposals and worked to make sense of them. At the end of the groups, they were actually eager to talk more!”

Key findings from these focus groups include:

Eagerness for Better and More Effective Coordination. After considering proposals, participants supported policies that would encourage providers to work together more effectively. "This is perhaps the most encouraging finding from the entire exercise, because the delivery system reforms built into the Affordable Care Act and the Health Information Technology incentives from the 2009 stimulus bill are already having a noticeable impact on care coordination," said Nancy Metcalf, senior editor at Consumer Reports, in a commentary about the research.

Receptivity to Payment Reform. Experts believe that high health care costs and usage are in large part due to the current fee-for-service system, in which providers charge for every service they provide. Participants in the study were generally unaware of the format of the current payment system. But once they learned about it and discussed potential reforms, they saw pros and cons. Many participants felt that charging flat fees per year or episode could reduce overtreatment and help them better understand their own costs. However, they were concerned that payment reform could lead physicians to skimp on patient care.

Skepticism About Price Transparency and Prevention Efforts. Many insurers, state governments and other organizations are developing cost calculators so that people can more effectively shop for health care. For participants, increased choice among insurance plans held appeal. But the idea of shopping around for health care seemed challenging, disconcerting and unrealistic to many. "Quite honestly, I don't want to have to do all of that research. I am not going to be able to develop that kind of expertise," said a woman in Ohio. Participants also did not expect or want their physicians to have price information. They understood that figuring out prices under insurance plans is very difficult and preferred their doctors to focus on care rather than prices.

While the focus groups were universally concerned about unhealthy food, lack of exercise and other lifestyle choices that lead to disease, participants did not typically think that prevention efforts alone could do enough to bend the cost curve.

Division Regarding Role of Government. Participants often seemed to be calling for some form of government action to address health care costs, but their views on the proper role of government were complex, often divided and in flux. "Do I want socialized medicine? Hell no, I don’t think that's the answer. But there's got to be some regulatory system," said a man in New Jersey. "You're going to come up against a million people that say no, but it's going to be the ruination of this country. People cannot live the life they need to live if they've got to pay eight hundred dollars a month on a fixed income," he continued.

Some government actions were uncontroversial, including limiting annual increases in insurance premiums, getting generic drugs to market more quickly and restricting marketing to physicians by pharmaceutical companies. But even those who favored a stronger government role in health care worried that out-of-pocket costs could increase and that they would wait longer to see doctors. In each focus group, a few participants spontaneously raised single-payer, universal, government-provided insurance. Some found it appealing while others viewed it as unacceptable.

Information Not Enough to Bring Consumers into the Cost Control Conversation

The findings from "Curbing Health Care Costs" suggest that Americans' views on health care may still be inconsistent, misinformed and rooted in an individual perspective. But people do have a capacity to engage more substantially with the cost problem and to seriously discuss potential solutions. "Average Americans have played a scant role in shaping public policy in health care," said Dan Yankelovich, founder of Public Agenda and expert in public opinion. "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."

While participants found the information they were introduced to powerful and said it provoked thoughtful consideration, information alone was not enough to elicit stable views toward a variety of cost-containing approaches. Rather, the process of deliberating with each other on the pros and cons of various approaches enabled participants to reach a better understanding of viewpoints that were different than their own. "These results, along with other similar findings, need to bolster the efforts now underway – funded by both federal agencies and private foundations – to engage consumers and patients in cost payment reform at a variety of levels," said Thomas Workman, principal communication researcher and evaluator at American Institutes for Research, in a commentary about the research.

Many participants said their experiences discussing this issue with peers led them to believe that civil conversation was possible among health care leaders and policymakers. They saw this deliberative approach as one way for our country to make progress on solving our health care spending problem. "There were some differences but I think ultimately everybody was willing to compromise. Now, why the government can't come to that consensus, I have no idea," said a man in Alabama.


More Information

The full report, key findings and implications, and a summary of participant responses to proposed reforms are available at Charts, graphics and key facts shared with participants and the discussion guide used during the deliberative portion of the focus groups are also available for download at the link.

Join the conversation on Twitter with the hashtag #CurbCosts.

About the Research

Public Agenda, in partnership with the Kettering Foundation, used an innovative qualitative methodology called Learning Curve Research with Americans aged 40-64 in 4 cities around the country. In this exploratory research, participants first engaged in open discussions about their views and experiences with the health-care system. Next, the groups were presented with key facts about the nation’s health-care spending and listened as they asked questions and worked through what those facts meant. Participants then engaged in facilitated deliberation, during which they considered and discussed three different approaches to getting health-care costs under control. Then in small surveys and one-on-one follow-up interviews, participants reflected on the deliberations and talked about their views. For a more detailed description about the methodology for this report, please visit

About Public Agenda

Public Agenda is a nonprofit organization that helps diverse leaders and citizens navigate divisive, complex issues. Through nonpartisan research and engagement, it provides people with the insights and support they need to arrive at workable solutions on critical issues, regardless of their differences. Since 1975, Public Agenda has helped foster progress on K-12 and higher education reform, health care, federal and local budgets, energy and immigration. Find Public Agenda online at, on Facebook at and on Twitter at @PublicAgenda.

About Kettering Foundation

Kettering Foundation is a nonprofit operating foundation rooted in the American tradition of cooperative research. Kettering's primary question is: what does it take to make democracy work as it should? Kettering's research is distinctive because it is conducted from the perspective of citizens and focuses on what people can do collectively to address problems affecting their lives, their communities and their nation.

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