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Where Americans See Eye to Eye on Health Care

May 8, 2018

About the Hidden Common Ground Initiative

It’s taken decades for our national politics to become as ideologically polarized and gridlocked as they are today, but it’s only recently that pundits and pollsters have started to converge on a narrative that blames the general public, instead of a flawed political system and culture, for this state of affairs. Especially since the 2016 election, a storyline has taken hold that portrays our dysfunctional national politics as a reflection of our profound divisions as a people. In this account, we’re an alienated society with no ability to understand one another, let alone find common ground or work together toward common ends.

For example, a 2016 series published by the Associated Press, Divided America, argued:

It’s no longer just Republican vs. Democrat, or liberal vs. conservative. It’s the 1 percent vs. the 99 percent, rural vs. urban, white men against the world. Climate doubters clash with believers. Bathrooms have become battlefields, borders are battle lines. Sex and race, faith and ethnicity…the melting pot seems to be boiling over1.

Such rhetoric about divisions among the public has proliferated, and surely it captures something important about the contemporary United States. We are fragmented in many ways, with consequential differences, divides and disagreements that are important to acknowledge and address. But our divisions are hardly the whole story, and this rhetoric can be dangerously self-reinforcing, exacerbating the divisions it chronicles, stunting our political imagination and playing into the hands of those who would manipulate and intensify our differences to their own advantage.

The Hidden Common Ground Initiative explores a different hypothesis and possibility— namely, that as far as the broader public is concerned, there is often enough common ground to at least begin forging progress on many of the problems we face. Moreover, with some nurturing quite a bit more common ground can emerge. The initiative is concerned with locating the common ground that exists on tough issues and giving it greater voice and currency in public conversations and policy debates. And it is concerned with generating insight into how more democratically meaningful common ground can be achieved.

We believe that dispelling the myth that we are inescapably divided on practically everything can not only help fuel progress on a host of issues, but also help us better navigate our real, enduring divisions, from differing philosophies of governance to racial tensions. Hidden Common Ground aspires to tell the story of what unites us by way of concrete, actionable solutions that can make a difference in people’s lives and the fate of their communities—and eventually, perhaps, in our national politics as well.

This report from the Hidden Common Ground Initiative focuses on hidden or otherwise underappreciated common ground in health care. How do people talk across party lines about the problems facing our health care system? What do people think should be done to make progress?

Finding Common Ground on Health Care

Health care has long been controversial and is certainly among the more partisan problems in American politics today—at least among political leaders. In 2017 alone, the American public witnessed endless debate among leaders over whether and how to repeal and replace the Affordable Care Act (ACA)2 and also witnessed Republicans’ inability to devise and pass new health care legislation—all part of leaders’ age-old ideological disagreements about how health care should work in this country.

Despite such a bleak picture, does the intense partisan division over health care among elected officials and pundits actually reflect partisan divisions among the public at large? Survey research does indicate continuing partisan divisions among the public on the favorability of the ACA. But despite these and other divisions along party lines on the direction we should go to improve health care in the United States, Public Agenda’s research and engagement experience over the past 40 years indicates that even seemingly divided groups may share or be able to find significant common ground.

When people from different walks of life sit down and talk about health care, how do they process the problem and think about solutions? Our approach to exploring the public’s views on the topic began with a review of existing survey data and proceeded to three focus groups in diverse locations with ordinary Americans, with roughly equal numbers of Republicans, Democrats and Independents in each group.3 This report concludes with implications and reflections on the solutions that are most and least likely to garner public support and with ideas for productively engaging the public on the topic of health care.

1Affordability was participants’ number one priority for health care. Unlike leaders, participants were not concerned about how much the government spends on health care, but they were angry about the costs they face.

In recent years, a majority of Americans, regardless of party identification, say making health care affordable to individuals and families should be the top health care priority for the president and Congress.4 This sentiment emerged immediately in our groups as people reflected on the health care system and their experiences with it. They shared stories about facing expensive medical bills, paying for pricey prescriptions and covering burdensome copays, premiums and deductibles. They were ardent and forthright about how the high cost of health care affected their lives and their families.

The prices keep going up and our paycheck stays the same.

Franklin County, MO; in her 30s; uninsured; Independent

My grandparents are retired and over half of their income goes to what Medicare can’t cover. My grandmother at 75 years old is looking for a part-time job to be able to cover Medicare copays. I think that’s absolutely ridiculous.

Hamilton County, OH; in her 30s; Medicaid; Democrat

I fell into a trap. I couldn’t get Medicaid, but I couldn’t afford the Obamacare. So it was kind of a double-edged sword.

Franklin County, MO; in his 50s; self-purchased health insurance; Republican5

Experts and public officials often cite excessive government spending as a reason to reform the health care system.6 But surveys have found that more Americans are concerned about lowering the amount individuals pay for health care than decreasing how much the federal government spends on it over time.7 While some of our participants voiced concerns about waste and inefficiency, most viewed high health care spending by government as of little concern—or even as a sign of well-placed priorities—rather than as a fiscal red flag.

Thus, when we presented focus group participants with information about how much their respective state governments and the federal government spend on health care, many were unconcerned about high levels of government spending. In fact, many viewed high spending favorably and were instead surprised by what they thought was a lower amount than they assumed. One man from Suffolk County, New York, went so far as to say that current federal government spending on health care is not enough:

Only 20 percent of the federal budget? That’s a low number. It should be higher. That’s the problem. Health care should be a right, but then the 20 percent has to go up significantly.

Suffolk County, NY; in his 40s; self-purchased health insurance; Democrat

In a similar vein, a respondent from Missouri added:

Our defense spends $615 for a toilet. They can find a way to pay for health care.

Franklin County, MO; in his 70s; self-purchased health insurance; Independent

One woman, also a political Independent from Franklin County, Missouri, said the government is already spending the taxpayers’ money, so it may as well spend that money on health care. An Independent from Suffolk County, New York, described health care as “such an important thing” that it merited public spending.

These findings are consistent with a 2018 Kaiser Family Foundation survey that showed very few Americans, regardless of political affiliation, support cuts to government health care programs—only 7 percent support such cuts for Medicare, and only 12 percent support such cuts for Medicaid.8

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2Simplicity and transparency were high priorities for participants.

“Simplicity” was a recurring word in our groups. Needless complexity—including inconsistent and opaque billing practices, mysteriously shifting drug prices and arcane administrative procedures—was viewed as extremely aggravating by participants in our groups. Goals for health care in the United States, our participants agreed, should include a streamlined, transparent, easy-to-navigate system that does away with unpleasant surprise costs and red tape.

The biggest thing I can tell you is they get these damn bills, and they’re all over the place. You’re talking about a dentist charging 110 bucks. Same dentist, $110 for you, $117 for you, $218 for you, $300 for you.

Franklin County, MO; in his 70s; self-purchased health insurance; Independent

I almost feel like I work in a doctor’s office. I’m emailing them, but you have to stay on top of them. You have to watch your bills as they come in so you reach that deductible. You have to be really organized in managing your own care.

Suffolk County, NY; in his 50s; employer-sponsored health insurance; Republican

My husband was in the hospital with some heart issues. They wanted to send him home on monitor for 30 days. And he said, “Well, what’s this going to cost me?” And they couldn’t give him a price. So, he said, “Get a social worker, or someone, an insurance person in here to call my insurance company to find out what this is going to cost me out of pocket, because last time it happened it cost $10,000 because the insurance didn’t cover it.” And all we got from the hospital was, “I don’t know, I don’t know, we can’t get you the information.” So he left the hospital without the monitor.

Franklin County, MO; in her 40s; employer-sponsored health insurance; Independent

The desire for transparency is consistent with findings from a Public Agenda survey in which most Americans—63 percent—say there is not enough information about how much medical services cost.9

Participants often described health care costs as not just too high but irrational or suspect.

I had a special pill they wanted me to take after my knee surgery, and when I went to pick it up it was $300. I called my doctor, I said, “Hey, I can’t afford that, and I’m paying all this insurance.” He said, “Well, let me get back with you. Call me back.” You know what that one pill cost after that? Three dollars and something. See, they playing games with these drugs.

Hamilton County, OH; in her 60s; Medicaid; Independent

All these drug companies are the ones setting the prices on all this stuff. And they just want to charge you whatever they think you’ll pay.

Hamilton County, OH; in his 60s; employer-sponsored health insurance; Republican

Overall, participants were adamant about the frustrations of deciphering and navigating the health care system, particularly payment. Their exasperations were evident in how they described the system, using terms such as “nightmarish” or “makes no sense.” Tired of being given the runaround by insurers, hospitals and providers, participants called for a simpler, more efficient and transparent health care experience.

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3People viewed prices as out of control and were intrigued by the idea of states doing more to control prices. But they were unsure about value-based payment.

A 2017 survey from Public Agenda revealed that 68 percent of Americans think insurance companies are mostly interested in making money, rather than having patients’ best interests in mind. Thirty-eight percent of Americans think hospitals are mostly interested in making money, and 27 percent think that of doctors.10 We often heard similar sentiments in our focus groups.

They charged me like $45 for a syringe. That’s why insurance is so high because they overprice everything and it just keeps on going up.

Hamilton County, OH; in his 60s; employer-sponsored health insurance; Republican

I got my arthroscopic surgery on my knee. I went to a surgery center and they charged my insurance company $32,000. And then six months later, it just so happened my husband had the same surgery. And because of convenience, he went to the hospital. And they charged $17,000. Same exact surgery.

Franklin County, MO; in her 60s; self-purchased health insurance; Democrat

They have to inflate [Medicaid and Medicare costs]. The doctor has to inflate because they’re getting, like nothing from the insurance company. The doctor’s receptionist said, “He’s getting $35. This is why he’s charging you $200.”

Suffolk County, NY; in her 60s; self-purchased health insurance; Democrat

Participants in our Suffolk County, New York, group framed the problem in terms of excessive profit, motivated by greed and perverse incentives, though they were of varying views on the pros and cons of for-profit vs. nonprofit health care:

The problem on the whole is because it’s all for-profit. Until the system becomes a not-for-profit, you’re going to have all these issues.

Suffolk County, NY; in his 40s; self-purchased health insurance; Democrat

It’s terrible that it is for-profit because it’s never going to change. It’s always going to be about money.

Suffolk County, NY; in her 50s; Medicaid; Independent

Everyone needs to make some money. I mean, if they’re overcharging that’s one thing, but that’s what makes them better is that they’re for-profit.

Suffolk County, NY; in his 50s; employer-sponsored health insurance; Republican

A lot of pharmaceutical companies do a lot of great work, and some have jerks like [Martin Shkreli]. But if it wasn’t for pharmaceutical companies, there would be a lot of cures that are not available today because they discovered them.

Suffolk County, NY; in his 60s; Medicare; Independent

There was general agreement in these groups that more oversight is needed with respect to high prices. When we asked participants about states doing more to control how much hospitals and medical facilities can charge insurance companies—and briefly explained to participants the example of Maryland’s global payment system for hospitals—the notion generally elicited support.11

Hospitals overcharge for a lot of things to where it’s ridiculous. I looked at my bill and it was $40 for a syringe. If there was like a board, they would see that right there and then say, “Hey, why did you charge $40 for that?”

Hamilton County, OH; in his 60s; employer-sponsored health insurance; Republican

One hundred percent better regulation is needed. There’s nobody watching. I went to the doctor the other day and she ran tests she didn’t have to.

Suffolk County, NY; in her 50s; Medicaid; Independent

If it’s Missouri people working for Missouri residents, then there’s a tighter ship there, and there’s accountability there. At least they’d have a vested interest in the people that they’re serving.

Franklin County, MO; in her 40s; employer-sponsored health insurance; Independent

Insurers and providers are also increasingly experimenting with “value-based payment” as a strategy for controlling costs and incentivizing quality improvement.12 This means transitioning toward a system that rewards quality and outcomes, of care rather than the quantity or volume of services provided.13 The only survey we are aware of that asks the general public about value-based payment found that, not surprisingly, most people are not familiar with the term or with terms such as “bundled payment.”14

We explained the concept of value-based payment to participants and asked for their perspectives on paying providers based on quality and outcomes rather than on quantity or volume. Generally, people were not familiar with the concept and found it confusing. They had many questions about how it would work.

I think there’s some merit to it, but I don’t think it’s as simple as that because some people need more care than other people.

Franklin County, MO; in her 40s; employer-sponsored health insurance; Independent

I think it’s a matter of integrity that they should always give quality.

Suffolk County, NY; in his 50s; employer-sponsored health insurance; Republican

Well, it could work because the doctor could give you the best test the first time.

Hamilton County, OH; in his 50s; self-purchased health insurance; Republican

They’ll do the least possible to get the best outcome. I don’t think that’s good for anybody.

Hamilton County, OH; in his 60s; employer-sponsored health insurance; Republican

Some participants likened value-based payment in health care to proposals that tie teachers’ pay to student outcomes, with one woman, an Independent from Hamilton County, Ohio, saying she had “a real issue” with such an approach.15 If value-based payment is to be adopted more widely, there is clearly a need to better engage members of the public on what it is and its pros and cons.

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4Everyone should have access to health care, according to participants. But they objected to the idea that people should be required to have coverage and were skeptical that the government could effectively run a single-payer system.

There was agreement among participants that everyone should have coverage or access to health care. A combination of fairness, compassion and pragmatism seemed to animate people’s views that no one should be denied access to affordable health care because of financial distress or preexisting conditions. An Independent from Suffolk County, New York, went so far as to say that health care is a “human right” that should be available to all.

Everybody’s entitled to have [health insurance]. So, the opportunity for insurance is welcoming.

Franklin County, MO; in her 40s; employer-sponsored health insurance; Republican

I would like for the poor people to get the same good care that somebody with a lot of money can.

Franklin County, MO; in her 60s; self-purchased health insurance; Democrat

I think it’s a good thing that everyone is entitled to get insurance.

Hamilton County, OH; in her 60s; Medicare; Independent

In the past, if you couldn’t afford insurance, you went to welfare and they would help people out that needed extra help. And it seemed like that worked in the past with some of the people I knew.

Hamilton County, OH; in his 60s; employer-sponsored health insurance; Republican

I like that we take care of our poor people. That’s important to me.

Suffolk County, NY; in her 60s; self-purchased health insurance; Democrat

Even before the Affordable Care Act, our governor had already put things in place with the Medicaid expansion and a couple other things to make sure that almost everybody got [coverage]. He seemed to care more about the people in this state getting coverage and expanding things like Medicaid. And that was an expense that helped everyone.

Hamilton County, OH; in her 60s; Medicaid; Democrat

Participants often specifically mentioned the Affordable Care Act’s rules that people with preexisting conditions cannot be denied coverage and that people under age 26 can stay on their parents’ insurance—two elements of the ACA that survey research indicates are quite popular.16

One woman made the case that everyone should have coverage because it’s not fair to those who are paying for insurance to subsidize the uninsured, but she was unusual in making that connection between universal coverage, costs and fairness.

Everyone should be insured because it’s not fair that I pay insurance and here’s somebody else going to the hospital to get all these good services. I think it’s good that we do have this thing where everybody is sharing the cost.

Hamilton County, OH; in her 60s; Medicare; Independent

Generally, participants seemed to feel that all Americans should have health insurance—if they want it. While a few had no issue with the individual mandate, participants often expressed discomfort with the idea of being required by the government to purchase health insurance coverage, viewing it as an encroachment upon freedom and choice.17

I do know a healthy young person that chooses not to have health insurance. Is she gambling? Maybe, but life’s definitely a gamble. You shouldn’t have to if you don’t want to. Freedom shouldn’t be penalized.

Suffolk County, NY; in her 60s; self-purchased health insurance; Democrat

I think the patient should have the choice, but with the understanding that with that choice comes personal responsibility.

Franklin County, MO; in her 40s; employer-sponsored health insurance; Independent

I don’t think somebody should be forced or demanded to have something that they don’t want.

Hamilton County, OH; in his 30s; employer-sponsored health insurance; Independent

Having health insurance should be a personal decision. It shouldn’t be demanded upon the company to provide that because some people could care less about it. As a business owner, I get penalized for that.

Hamilton County, OH; in his 50s; self-purchased health insurance; Republican

Survey research indicates an ongoing split among the public over the government’s role in health care. In 2017, 56 percent of Americans said the federal government should be responsible for making sure all Americans have health care coverage—comparable to the 59 percent who said so in 2000.18

We asked participants about the idea of letting all Americans join Medicare or even replacing private insurance with Medicare. Some were intrigued, citing their satisfaction with how Medicare was currently running and noting that it could help businesses by relieving them of the responsibility of purchasing health care for their employees.

From my experience so far with my husband, Medicare is working out just fine. Nobody told him he can’t go to any specific doctor. Everybody he looked at takes his insurance.

Suffolk County, NY; in her 50s; Medicaid; Independent

I like the idea because it takes burdens off of companies.

Hamilton County, OH; in his 50s; self-purchased health insurance; Republican

But participants also expressed concerns about Medicare for All. Generally, their questions and concerns were more practical than ideological, including skepticism that the government could efficiently implement and administer the program. They often referenced what they’ve experienced with other government-run health programs or their perceptions of health care in other countries.

The government manages veterans’ health care, they already manage the VA, and they’re not doing a stellar job. Why in the world would anybody think they can take on another program and do better?

Franklin County, MO; in her 40s; employer-sponsored health insurance; Independent

I’m Native American. My dad moved to Oklahoma because he would get free medical care [through the Indian Health Service]. But when he got really sick we had to move back here to Missouri, because they didn’t even have the doctors to take care of him. And that is government.

Franklin County, MO; in her 40s; employer-sponsored health insurance; Republican

If you go to a lot of these countries [with government-run health care], people die because they wait months because they can’t get a liver or the doctors aren’t getting enough pay.

Hamilton County, OH; in his 30s; employer-sponsored health insurance; Independent

A lot of people from Canada come to the States, and they just pay cash to get medical care because they are on wait lists.

Franklin County, MO; in her 40s; employer-sponsored health insurance; Independent

The sentiments we heard in these groups are consistent with survey research. A Gallup survey found Americans were almost evenly split in their preferences for a government-run health care system versus a system based on private insurance.19 A Kaiser Family Foundation survey found that public support for a single-payer system or Medicare for All is malleable: a slim majority supports such programs, but when survey questions present the trade-offs that may be required, opposition outweighs support.20 Overall, the discomfort we heard among participants about government-run health care suggests that people need time to mull over the trade-offs before they come to a stable judgment on the topic.

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5Participants were angry at politicians and politics. They felt that the odds for progress would improve if politicians had the same frustrating, expensive insurance coverage that their constituents do.

People in these diverse, multipartisan groups were united in their frustration with politicians and their inability and unwillingness to tackle health care with integrity. Almost all of our participants viewed politicians as caring more about special interests than the public interest.

I hate seeing health care as a political football being tossed around where we’re stuck in the middle of that.

Suffolk County, NY; in his 50s; employer-sponsored health insurance; Republican

The personalities and the politics keep getting in the way. It’s more of a game to them.

Hamilton County, OH; in her 60s; Medicaid; Democrat

I think the drug companies have more lobbyists in Washington than there are politicians.

Suffolk County, NY; in his 60s; Medicare; Independent

It’s all the lobbyists saying, “Wow, this pharmaceutical company will throw money towards you if you take care of us.” And it’s not just pharmaceutical companies.

Hamilton County, OH; in her 60s; employer-sponsored health insurance; Independent

Many firmly believed that members of Congress have excellent and free insurance—leaving politicians out of touch with the health care system that ordinary Americans experience.

All those senators and congressmen have their own little pocketbook of health care that’s different. They don’t have the same insurance that the rest of us have. That’s one of my bigger griefs.

Hamilton County, OH; in her 60s; employer-sponsored health insurance; Independent

We have 70-, 80-year-old people in Congress who are completely out of touch.

Suffolk County, NY; in his 40s; self-purchased health insurance; Democrat

They don’t have to pay for their insurance.

Hamilton County, OH; in his 60s; employer-sponsored health insurance; Republican

In every group, at least one participant raised the idea that politicians should be required to have the same health insurance as their constituents so that elected officials could experience firsthand the shortcomings of the current system. This suggestion inevitably elicited widespread and enthusiastic responses from fellow participants. Having the same insurance as their constituents, participants said, would compel lawmakers to act promptly and in the public interest.

If you want a health care plan passed tomorrow, make sure every senator and representative gets the same damn plan, no exceptions, no exemptions.

Franklin County, MO; in his 70s; self-purchased health insurance; Independent

I have no power to solve the world’s issues. But if the people making the laws had to follow the same laws, our health care system would be different.

Hamilton County, OH; in her 60s; employer-sponsored health insurance; Independent

Implications for Policy and Reflections on Public Engagement

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?

SHARED GOALS AND PARTIAL SOLUTIONS

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

EMERGING GOALS AND POTENTIAL SOLUTIONS

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.

Engaging the Public, Improving the Conversation

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.

A Better-Framed Public Conversation

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.

States as Laboratories

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.

Communities as Settings for Civic Engagement and Learning

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.

We convened three two-hour focus groups in September 2017, with a total of 30 Americans in three locations across the country. The groups were conducted in urban Hamilton County, Ohio, where Cincinnati is located; rural Franklin County, Missouri; and suburban Suffolk County, New York. Locations were identified based on several factors, including that Ohio and New York both expanded Medicaid under the ACA but Missouri did not. Locations were also chosen for their voting histories: Hamilton County is located in Ohio, which has historically been a swing state in presidential elections. Franklin County is located in Missouri, which has voted for the eventual winner of all but three presidential elections. Suffolk County, New York, supported Donald Trump in the 2016 presidential election after Barack Obama won the county in the 2008 and 2012 elections.

In all groups, participants were recruited by professional market research firms according to Public Agenda’s specifications to represent a cross section of the public in those counties in terms of gender, age, socioeconomic status, health insurance status, race/ethnicity and political ideology. During recruitment, potential participants were asked whether they or anyone in their household worked in the health care industry. People who answered affirmatively were not included in the groups. Focus groups took place in market research facilities, and all participants were compensated for their time. Senior Public Agenda staff moderated the focus groups. Focus groups were video recorded and professionally transcribed. Public Agenda’s research team collaboratively developed a coding scheme and coded the focus group transcripts using Dedoose qualitative analysis software.

Americans’ No. 1 priority for healthcare? Affordability
(Becker’s Hospital Review, Tuesday, May 22nd, 2018)