On the surface, it seems that American voters have made their will clear. Poll after poll shows that they are calling for a major overhaul of our health care system. But when you look closer, their responses bristle with contradictions and discrepancies that I think the reform-minded presidential candidates will have to consider when deciding how to approach health care reform.
In a poll reported in Health Affairs at the end of last year, sixty-nine percent of respondents rated the US system as “fair” or “poor.” Yet in the same survey, when asked about their own experience with receiving medical services or with their own physician, 80 percent who had received care in the last year ranked their care as “excellent” or ”good.”
Other polls reveal the same pattern.
According to a survey released by Greenberg Quinlan Rosner in July, voters express doubts about the quality of the American health care system (with 49 percent dissatisfied), while 74 percent were dissatisfied with the cost. Yet, “at another, more personal level,” the pollsters note, “a slightly different picture emerges. Fully eight in ten (82 percent) describe themselves as satisfied with the quality of the health care they receive personally. This number jumps to 90 percent among seniors (64 percent very satisfied), but includes impressive majorities of nearly all groups…”
Nevertheless, when the pollsters asked the same group about health care reform, three-quarters called for “major changes” or “completely rebuilding” the system.
If they are satisfied with the care they are receiving, why would they want radical change? Because they don’t feel secure that they will be able to keep what they have: “There’s a precariousness to Americans’ contentment with their own health insurance coverage,” the Kaiser Family Foundation reported after looking at a number of polls at the end of last year. “Among the insured, six in ten are at least somewhat worried about being able to afford the cost of their health insurance over the next few years, and nearly as many (56 percent) said they worry that by losing a job, they or their family might be left without coverage.”
This, then, is why so many Americans want universal health care: it would guarantee that they and their families would always be covered.
Read a little more of the Greenberg Quinlan Rosner report and you find that the ambivalence deepens. On the one hand, many Americans believe the system is broken–or at least badly damaged. “There is a deep and powerful belief that costs are out of control and real ambivalence about the quality of the system overall,” the pollsters explain. “But people’s personal experience is better, particularly among the middle class and affluent, which potentially tempers broad demands for reform…”
How can so many Americans question the quality of the system as a whole, but believe that the care they are getting is more than satisfactory? For the same reason that many American believe that most politicians are corrupt, but that their own Congressman is honest. This is the magical thinking that leads the majority of Americans to distrust most doctors—but to put great faith in their personal physician. As I’ve argued on this blog, we trust our doctors because we must. Who would go under the knife, or submit to any painful or invasive procedure if he didn’t trust the doctor? For the transaction to go forward, the patient must believe in his doctor’s competence and his professionalism.
Reform-minded presidential candidates understand that many Americans like the health care they have—or at least they think they like what have. (Since most Americans are not seriously ill, they haven’t had a chance to find out whether what they believe about their coverage and their doctor is true.) Nevertheless, what voters believe is most important. This is why none of the leading Democratic candidates has proposed a single-payer system. All three have designed proposals that let insured Americans keep the private-sector insurance that makes them feel safe—at least for the moment. (Meanwhile, they are offering a public sector alternative so that, over time, Americans will have a chance to see how the public sector insurance stacks up against for-profit insurance.)
But what many reformers haven’t quite faced up to is this: Not only do most Americans want to keep what they have—they believe that, under reform, what they have should cost them less, even though they also believe that “the government” should spend more on health care.
As a study published in the Winter 2007 issue of the The American Heart Hospital Journal points out: “When Americans complain about [the cost of ] health care, it is generally not about the overall system but rather about personal outlays and the burden their health care bill places on the family budget. In 2006, 65 percent of Americans surveyed thought the average citizen spent too much on health care and that ‘the government’ should spend more. This is what it means when Americans consistently list ‘cost’ as the most important health care problem appropriate for governmental action, but it may be more accurate to think of it in terms of personal affordability rather than overall costs, despite the fact that the two are clearly linked.”
Here, it’s worth pausing to ask: when Americans say that “the government” should pay more, who exactly do they have in mind? Presumably most understand that “the government” equals taxpayers, and so it seems safe to assume that they are saying that other, wealthier taxpayers should pick up a larger share of the tab. If you earn $80,000 a year, you believe that those earning over $100,000 should show a little more generosity. If you bring home $100,000, on the other hand…(Does anyone remember Russell B. Long’s definition of tax reform: “Don’t tax you. Don’t tax me. Tax that fellow behind the tree”?)
Moreover, most Americans do not object to the fact that, as a nation, we are spending well over $2.2 trillion on care—or that at some point, if health care inflation continues to outstrip economic growth, spending on health care will squeeze out outlays for education, the environment, national security, or anything else that we might want to do. Most of those polled see the problem from an individual, rather than from a collective, perspective.
This, then, is the first problem that an incoming, reform-minded president will have to face. While Americans strongly support national health reform, many believe that “reform” will (or at least should) automatically cut their own health care bill without crimping the amount of care that they receive. And while they would like to see universal coverage, the majority may well resist any tax increases.
In fact, as I have argued elsewhere, there is enough money sloshing around in our health care system to provide affordable, high quality care for everyone—but only if we cut back on the waste. This means eliminating the unnecessary tests, unproven procedures and over-priced “bleeding edge” drugs and devices that are spurring health care inflation. In other words, $2.2 trillion is enough to give everyone the health care they need. But what they “need” may not be what they think they want.
The polls show that many Americans like what they have; if there is excess in our system, they embrace it. They find comfort in the idea that, when they consider their medical options, they have a long list of choices, including the newest and the most expensive drugs, devices, tests and procedures. Most subscribe to the American creed that newer is almost always better. And, as the latest ABC News/ Kaiser Family Foundation/ USA Today poll shows, only 30 percent of those surveyed see unnecessary treatments as a problem in our system, while just 28 percent say that the “increased use of expensive new drugs, treatments and medical technology” is driving rising costs, “even though,” the pollsters note, “this is the factor most often named by experts.”
When it comes to public opinion, this is the second major obstacle that a reform-minded president will encounter. The average American doesn’t like to feel that she or her doctor are part of the problem. The polls show that most of us are far more comfortable assuming that people they we already dislike—insurers, malpractice attorneys, or drug-makers—are responsible for excessive costs. We certainly don’t want to entertain the possibility that many of the treatments our own doctors are prescribing for us are, in fact, unnecessary, unproven or simply futile.
Of course, up to a point, the polls are correct: profits made by insurers do add to our health care bill. But if I were elected czarina tomorrow, waved my wand, and eliminated the entire for-profit insurance industry, that would cut the nation’s health care bill by just 4.5 percent (That is the share of our health care dollars that goes to cover insurers’ administrative costs, executive salaries and profits.) And it would be a one-time savings.
As for drug-makers, the problem is not just the blockbuster pricing needed to sustain double-digit earnings; the truth is that doctors are prescribing, and patients are demanding, more and more pills. From 1994 to 2005 the number of prescriptions purchased climbed by 71 percent while the U.S. population grew by only about 9 percent. As a nation, we’re over-medicated.
Over the long run, we can afford high quality, universal coverage—if we just wring the waste out of the system. But that will take time, more research into the “comparative effectiveness” of various products and procedures, and an enormous public relations campaign to convince the public that “more care is not always better care.”
Finally, the polls show that widespread “distrust of government” could block change. As the Greenberg pollsters warn, the last seven years have done little to build public confidence that government is either competent of honest:
“In our accountability research, we noted that voters are pulled between a desire for a more activist government than they are getting and a deep cynicism about whether or not government can function efficiently and effectively,” the pollsters write. “Not surprisingly then, voters identify ‘government run programs are wasteful and inefficient’ as the most pressing concern about health care reform (37 percent). Among independent voters, this concern jumps to 49 percent.”
These are the obstacles that I think presidential candidates should anticipate. I don’t have the answer as to how a president should handle these problems. Much will depend on the economic circumstances at that moment: the temper of the times, the number of seats progressives have won in Congress, and just how many more employers have stopped offering health insurance. But at this point I am convinced that, when it comes down to it, a large share of the public may be more ambivalent about reform than it seems.
In the past, I’ve been keen on the idea of “educating” the public. If a strong leader explains what’s wrong with health care in America, patiently and carefully, I have argued, eventually the public will understand that in our profit-driven system, “over-treatment” can be as much of a problem as “under-treatment.” After all, Al Gore did eventually manage to persuade us that global warming is a serious threat. Though admittedly, it did take years—and people listened only after deep dissatisfaction with the Bush administration turned into a longing for what might have been.
Today, I’m beginning to wonder if we really need a Great Educator: If reformers try to point to the excesses in our system, will people listen? Or will they just feel that much more frightened and insecure? The fact that the three leading Democratic candidates have proposed such similar plans suggests that if you sit down, read the research, and study the problem, there is a fair consensus about what needs to be done. But do most Americans really want to study the problem?
I’m beginning to suspect that “leadership” will be the key to health care reform—leadership combined with a conviction that inspires trust.
Here, I can’t help but recall what Carl Schneider, a Professor of Law and of Internal Medicine at the University of Michigan writes near the end of his exceptional book, “The Practice of Autonomy: Patients, Doctors and Medical Decisions.” Schneider is not convinced that Americans need so many choices. He thinks it may be time to move “away from [the emphasis on] patient choice and toward changing the medical system so that it delivers a better product. To put the point provocatively, it may be time to think about giving patients what we think they want, but have not been able to secure for themselves. We might even consider giving patients what we think they would want if they thought about it.”
Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and Institutional Investor. She is the author of “Money-Driven Medicine: The Real Reason Why Healthcare Costs So Much,” an examination of the economic forces driving the health care system. A fellow at the Century Foundation, Maggie is also the author the increasingly influential HealthBeat blog, one of our favorite health care reads, where this piece first appeared.