By Trudy Lieberman

Much of the national press took a pass last week on another important “study says” story out of Massachusetts. This is the second time in the last month where the national media missed a story with implications for the success of health reform. The latest report, which came from the Harvard School of Public Health and the Blue Cross Blue Shield of Massachusetts Foundation, showed that Massachusetts residents have different views about what’s causing the high prices of medical care than do the state and national policy wonks who are framing the solutions. What a surprise! We have repeatedly reported that the public is disconnected from what the pols are saying. Why should we be astonished they are not in step with the policy community?

The study, says lead researcher Dr. Robert Blendon, found that the public generally believes the cost problem stems from excessive charges by drug companies, insurers, and hospitals. Why not doctors? “Doctors have managed to present a picture in the state that they are not the reason why costs are rising. It speaks to the efficacy of the physicians’ campaign that their fees are not high enough,” Blendon told me. Indeed, doctors around the country have mounted local media campaigns to build their case that Medicare’s fee cuts will result in patients not getting care. Furthermore, the state media have focused mostly on the duel between hospitals and insurers, and that’s the message the public has received.

The survey also asked Massachusetts residents to specifically identify the major culprits responsible for the state’s high costs. Nearly two-thirds of the respondents think that people who don’t take good care of their health are a major reason. About half of them also fingered big hospital and doctor groups—which are using their size advantage to command higher prices—along with malpractice suits, too much paperwork, people getting more tests than they needed, doctors charging too much, and Medicare and Medicaid not doing enough to keep prices down. Why do malpractice suits keep popping up in the public’s mind as a big contributor to high prices, when in fact they play a very small role? Simple, says Blendon: the docs’ PR campaign has succeeded in making the public think malpractice is a significant problem. “The public is sympathetic to that message,” he says.

Just because physicians have been successful in deflecting the cost problem doesn’t mean high costs are disappearing. They remain the key problem with the Massachusetts law, and could be a big problem for national reform, especially because the public sees the problem differently from those in charge of solving it. The Massachusetts survey showed that other villains—overuse of expensive, high-tech medical equipment and expensive drugs; overuse of expensive teaching hospitals for routine procedures; and consumers who fail to shop for lower-priced doctors and services—were not high on the public’s list. Yet many policy experts identify these factors as major drivers of the high cost, and these experts are framing solutions around those factors. These solutions include making consumers pay higher premiums for going to high-cost doctors and hospitals, making them pay more out-of-pocket, and promoting all kinds of ratings of providers to encourage comparison shopping, as if one could buy health care like a car. The results in Massachusetts foreshadow a looming battle over solutions aimed at trimming the high cost of care, and that should have been enough to propel the story from a local one covered by the Massachusetts media into a national one. Should we solve the cost problem by making out-of-pocket costs so high that consumers won’t use services? Or should we find a way to simply lower the price level to be more in line with what patients in other countries pay for their care? The country has fought this battle before, and the outcome of this one is far form clear. “The public is much more concerned about the price. They haven’t bought into the idea we use too much care,” Blendon explained.

The people of Massachusetts do not expect that the national reform law will do much to lower costs in the state. They do, however, want the state to do something. About three quarters of the respondents said it was very important for the state to take major action. The survey did not ask what actions, because researchers feared that the public didn’t know about the various proposals on the table. Such remedies as global budgets and accountable care organizations are so much gobbledygook to ordinary folks that researchers believed their answers would not yield much useful information.

So goes Massachusetts, so goes the nation when it comes to health care. Journos covering presidential politics need to think about the lessons from the Bay State whenever the political discourse between Romney and Obama dissolves into a pissing contest over who is responsible for the kind of reform in Massachusetts that became the model for the national law. The point is health reform is the law of the land and has been law in Massachusetts for nearly six years. What works and does not work in Massachusetts is the discussion the public needs to hear.

Trudy Lieberman, a journalist for more than 40 years, had a long career at Consumer Reports specializing in insurance, health care, health care financing and long-term care. She contributes to the Columbia Journalism Review where this post first appeared.