After last Friday’s missive had been up on the Internet for a little while, I got a question from an interested reader who lives nearby and frequently walks with me. He wrote:
Gene,
Do I know the person you walked with? Peter’s video is amazing. Oh, and I couldn’t be sure where you stand on what the policy should be…
I have always considered it to be the speaker’s responsibility to be understood. If my reader was not sure what I said, it was my fault. It’s also my responsibility to offer clarifications.
The sense of my answer to my friend was that so far I do not favor one plan over another, and I do not have a favorite candidate. We walked over the weekend and continued our conversation. What I told my friend on the walk that did not come through so clearly in what I wrote was that it is too early to offer a specific plan or solution. I think it is too early to select one solution. I think it is too early to be debating solutions. We need to do a lot more reflecting on where people are and what people think. Here is what I said:
My concern for some time has been that the debates demonstrate one big effort to “jump to solution.” Democrats captured the House in 2018 and made great progress in blocking the damage being done to healthcare by the Trump administration and Republicans in Congress. Now Democrats seem convinced that in 2020 they must sell the public on the complete answer to what comes next when they should be emphasizing why we need to be continuing to move as quickly as possible in our efforts to insure that we make sustainable progress toward a better system of care for everyone. I understand that politicians are not senseis who are capable of leading us in a process of continuous improvement. They may well be right about where our programs should be heading and feel that they know enough to try to sell “if we [do] x, then y will happen,” but voters lack a deep understanding of the issues that are barriers to the Triple Aim…
Later on in the letter I wrote:
- There is widespread misunderstanding about how our system of care actually works. The majority of Americans are well and the few personal experiences that they have with the system do not require them to think much about the complexities that exist. The minority of voters who are forced by an event to seek care lack awareness about how the individual inconveniences and complexities they encounter add cost and avoidable errors and inconvenience in their care and are multiplied across the whole system…
- There is not much recognition that if the system doesn’t work for everyone, including the disadvantaged, it is quite possible that the day will come when it doesn’t work reliably for anyone, no matter how advantaged they might be. That day may already be here for you if you live in rural America or a disadvantaged neighborhood in one of our cities.
- The status quo, the so called medical-industrial complex, is producing huge profits. Bernie Sanders is speaking to the profits of the drug industry and insurance companies, but other supporting industries from high tech suppliers to specialty groups, and many academic medical centers, are prospering in the current environment and see little short term benefit in having their businesses disrupted by a change in finance. It is highly likely that the charges paid by government sources will not completely replace the largess of commercial payers.
- There is a continuing distrust of the government’s reliability and fear that a government payment system will add constraints to business plans and force recipients to meet standards of transparency and performance that will be onerous.
- Many providers are so stressed that they have little time and no motivation to speak up for the necessity of changes that might turn out to require more of them than they have the energy or desire to invest. Adaptive change is hard. No one is eager to submit to it.
I finished by saying:
The potential list of barriers to any change is much longer. I do not think the Democrats are wrong to be fearful of enabling the president’s reelection by their continuing disharmony, attempts at one upmanship, and lack of an inspiring centrist leader. Would it not be better to focus on the need for change and why the discussion should begin with a more analytical and informative description of “what is” and the projections from reliable sources of the chaos that will occur if we continue to focus primarily on our individual concerns without much empathy and concern for the experience of others?…
Over the weekend, I have continued to think about why the debate among the Democratic candidates about what sort of program is best is premature. The Democrats made huge political gains in 2018 by talking about “healthcare principals.” Just because a majority of voters in 2018 seemed to accept the progressive idea that healthcare should be an entitlement does not mean that we have considered all the questions that need clarification or that there is a consensus about the way forward. My suggestion that more study was needed before arguing the specifics of new healthcare legislation seems confirmed by a collaborative study entitled “Americans’ Values and Beliefs About National Health Insurance Reform” done earlier this year by researchers at the Harvard T. H. Chan School of Public Health, the Commonwealth Fund, and The New York Times. Their findings were published in a 48 page paper that was posted on the Internet in October.
If you type “Americans’ Values and Beliefs About National Health Insurance Reform” into Google you will get the PDF but you will also get a raft of other documents coming up under the same inquiry. The first click reveals the current report, and articles from 1994, 2008, 2009, 2016, and 2017. A quick overview suggests that like our attitudes regarding marriage and whether it should be limited to a contract between a man and a woman, our collective attitudes about healthcare are evolving.
Physicians for a National Health Program describes itself as “a single issue organization advocating a universal, comprehensive single-payer national health program.” It boasts that it has more than 20,000 members and chapters across the United States. That sounds like a huge number of doctors, but I would remind you that the AMA boasts more than 200,000 members and there are over 950,000 practicing physicians in the country. Despite the fact that they count only about 2% of doctors in their number, the members of PNHP are an effective voice in the conversation to advance the vision of single payer universal healthcare. They published a review of the collaborative paper written by the Commonwealth Fund, The Harvard T.H Chan School of Public Health and the NYT.
The PNHP summary, “Harvard survey on beliefs about health insurance reform: Americans’ Values and Beliefs About National Health Insurance Reform” is under 2000 words. I will add my thoughts to the highlights of the PNHP review. The original Harvard paper begins by acknowledging the point that makes much of the discussion among the candidates a waste of time and perhaps counter productive. I have bolded key points.
Reforming the U.S. health insurance system has become a major issue in the upcoming presidential election, both in primaries and likely in the general election. There are a number of different health care reform proposals that have been put forth by candidates and parties, but prior studies show that voters in the general public are often not aware of the details of these plans. This suggests that the differentiation voters make between one plan and another is likely based on underlying values, beliefs, and life experiences. This report addresses specifically adults’ views in these three areas, as they relate to health insurance reform proposals supported by the public.
One of the issues that has emerged in recent polling on health insurance reform is that people often report they support more than one type of plan, even though these plans are often very different from each other from a policy perspective. This poll seeks to examine this issue by asking people who are interviewed to choose the plan that they most favor among the three major plans that are being debated currently: (1) Medicare-for-all, (2) improving the existing Affordable Care Act (Obamacare), or (3) replacing the Affordable Care Act with a new law that would give taxpayer funding to states to design their own health insurance systems with fewer federal rules.
The basic purpose and structure of the study is designed to describe the range of attitudes that exist among a group that was chosen to reflect a statistically accurate picture of the population that will be voting in the primaries and in the general election. I would urge you to remember that attitudes are in evolution and where they were in the summer of 2019 may not be where they will be in November 2020. They continue:
This report examines Americans’ current beliefs, values, and experiences, according to their preferences on three major proposals for national health reform. The results point to significant conclusions, which are timely given the importance of health care as an upcoming issue in the Democratic primaries and the 2020 presidential election.
We polled Americans’ values and beliefs across seven different areas: the preferred role of government generally, the preferred role of government in health care, attitudes toward the current U.S. health care system, views on equal treatment in health care, personal experiences with health care, views on the future desired direction of health insurance reform, and public trust in groups trying to improve the U.S. health care system.
The summary jumps to the bottom line before going back to report the details. There is no one structure of the three questioned that is statistically identified as a preferred outcome. Before you become distressed, the study does reveal preferences and shared opinions that may reveal opportunities for bipartisan participation in achieving shared goals. The paper continues:
Notably, none of the three policies received a majority of Americans’ support as their most-favored plan, suggesting major divisions in preferences on the future of health insurance reform. We found the greatest differences in public opinion are the preferred role of government in health care, attitudes toward the current U.S. health care system, and views on increasing taxes so everyone can have health insurance. Proponents of all three plans showed the greatest similarities in shared values for equality in health care and trust in similar groups trying to improve health care, as well as their personal experiences.
Overall, Americans who prefer Medicare-for-all and those who prefer improving the existing ACA share similar views in several areas that lie in contrast to the views of those who favor replacing the ACA with state health plans. However, proponents of Medicare- for-all and improving the existing ACA also differ in important ways. They are split in their views of the economy, where a slight majority of adults who favor improving the existing ACA have a positive image of capitalism, while a majority of adults who favor Medicare-for-all have a positive image of socialism. Meanwhile, two-thirds of Medicare- for-all proponents prefer more federal government involvement in health care, compared to only a slight majority of proponents of improving the existing ACA. In addition, about two-thirds of adults who favor improving the existing ACA hold favorable opinions about private health insurance provided by employers, compared to only about half of adults favoring Medicare-for-all who share this view.
The study does specifically ask about “Medicare for all.” It does not specifically ask about “Medicare for all who want it” because it predates the evolution of that term. The second category, “improving the existing Affordable Care Act” is a surrogate for the combination of Medicare for all who want it plus strengthening and improving the ACA without a public option. I assume that the final category, “replacing the Affordable Care Act with a new law that would give taxpayer funding to states to design their own health insurance systems with fewer “federal rules” is a placeholder for repealing the ACA and substituting it with some of the alternatives that the Republican Party was offering in 2017 when their chant was “Repeal and Replace.”
The first surprise is that the interviewed individuals sorted out almost evenly into the three groups. 32% favored Medicare for all, 28% favored the refurbished ACA, and 29% favored the abolition of the ACA and return of healthcare to the jurisdiction of state programs. Discovering that split is not what makes the study important. We need to look into the attitudes in each group to really understand the opportunities and barriers for universal coverage.
Among all three groups, there are dramatic differences in views on the preferred role of government involvement in health care. While more than eight in ten adults who favor Medicare-for-all and more than seven in ten adults who favor improving the existing ACA say they think it is the responsibility of the government to make sure all Americans have health insurance coverage, only one in five adults who favor replacing the ACA with state health plans say this. More than seven in ten adults who favor Medicare-for-all and a majority of adults who favor improving the existing ACA prefer a health insurance system run mostly by the government, while only about one in seven adults who favor replacing the ACA with state health plans prefer this approach.
For emphasis, let me restate that important information. A very large majority of both those that favor Medicare for all and the revamped ACA do believe that it is the responsibility of the government to make sure that all Americans have health insurance coverage. An even bigger surprise for me is that 20% of group three, the people who want to do away with the ACA, still want government to make sure that all Americans are covered. There are more shared opinions within the first two categories. Group three (the abolish the ACA group) holds some positions that are not so surprising. Read on:
Americans are also divided in their attitudes toward the current U.S. health care system, by their preferences for health reform. While large majorities of adults who are proponents of improving the existing ACA and Medicare-for-all hold favorable opinions of the Affordable Care Act, three-quarters of adults who are proponents of replacing the ACA with state health plans hold unfavorable opinions about it. This suggests major divisions in public opinion, both in how the U.S. health care system is currently operating, as well as the path forward.
Americans also hold opposing views according to their preferences for health reform about increasing taxes so everyone can have health insurance. While large majorities of adults who favor Medicare-for-all and improving the existing ACA favor increasing taxes so everyone can have health insurance, seven in ten adults who favor replacing the ACA with state health plans oppose tax increases.
Developing any element of bipartisanship requires finding some commonly held views. The challenge is whether or not any of the current candidates has the approach or skill that can capture the benefit of this consensus. The next quote is the most surprising statement of all, and should be the origin of bipartisan opportunity, or if not that, the path that could lead undecided and independent voters to vote for Democrats, if they they can focus on the “why” of healthcare reform, and hold their horses in their premature eagerness to focus on the fine points of “what.”
When it comes to equal treatment in U.S. health care, large majorities of adults favoring all three approaches to health reform share views that while equal treatment is not a current reality, it is an important goal. Americans generally share views on the importance of equal treatment, regardless of income or race.
The next report of consensus should be a wake up call for doctors, healthcare administrators, insurance companies, big pharma, and politicians. Voters trust nurses much more than they trust any other group. I am not so surprised. I rarely hear physicians or hospital administrators talking about the challenges that patients face in our current dysfunctional system. They are very vocal about their own concerns. I hear concerns about reimbursement and the potential problems for hospital and health system finance if Medicare for all is passed, but I don’t hear much concern from doctors and administrators about the continuing problems and concerns that patients experience as they try to navigate their way through the current system, or find the money to cover their costs. I can’t remember hearing many conversations that begin with genuine empathy or even superficial concern about the inconvenience and cost of care, or deep distress about the plight of the underserved or unserved. The fact that only 2% of physicians are members of PNHP may be a manifestation of this self interest. I once facetiously said that unless doctors learned to be less obviously self interested, they would eventually be compensated like public employees, and fall to a level of esteem in the eyes of the public below Wall Street’s most greedy operators. This data suggests doctors have lost the trust, if not the esteem, of many Americans.
When it comes to public trust in various groups trying to improve the U.S. health care system, Americans favoring all three plans generally do not trust any interest major groups, with the exception of nurses. This suggests that if outside groups are to play an important role in shaping the future of health reform, they will need to coalesce around a shared vision of what it should look like.
I know the next finding is true, but I just can’t understand it. Is it true that we all love our healthcare? Does the frog love water that is gradually coming to a boil? I think this is more a measure of how much people hate change of any kind rather than how satisfied they are with their current care. One of my son’s works as a social worker in the public schools of Albuquerque, New Mexico. He and his wife have coverage that is becoming more and more expensive with each new school year. He has required a few surgeries and their out of pocket costs are enormous. They have “flex spending accounts” but there are huge administrative barriers to accessing those funds. Most Americans seem oblivious to the reality that their employer based insurance changes every year, and the biggest change is the reality that their out of pocket costs go up every year. There is an accelerating transfer of risk from employers and the insurance industry to consumers. I am the “moderator” of my congregation. I know from the responsibility that I share with others for the finance of the church that our health insurance premiums for our ministers and employees will be increased over 9% for 2020. Our rates have gone up faster than inflation for a long time. I just do not understand the “satisfaction” that most people reported with their current plans. Do they look at their pay stubs?
In addition, we found that people’s personal experiences, though important to individuals, do not generally drive opinions about preferences for health reform. While a greater share of adults who favor Medicare-for-all express concerns about health care costs and health care access compared to those who favor improving the existing ACA and those who favor replacing the ACA with state health plans, large majorities of adults preferring all three plans say they are satisfied with their current health insurance coverage.
The conclusion is consistent with my concern that debating Medicare for all versus Medicare for all who want it may excite policy wonks, but the voters who are still trying to make up their minds are more likely to embrace shared principles over defining the fine points of policy differences among the Democratic candidates. It may well be that over the next few years under the leadership of a Democratic president and with a Congress that has large Democratic majorities, Democrats will be able to marginalize Republicans and write another new healthcare law that is not bipartisan. I hope not. Such a law would just be a wedge that divides us more than we are currently divided. What we need is a focus on increasing the consensus of public opinion that enables a bipartisan support of reform.
You may counter tmy “Pollyanna” opinion that long lasting reform must be bipartisan by pointing out that a large majority of Americans want stricter gun laws and nothing is happening. I would then counter that change that lasts requires much more than a plurality, and I believe that the day is coming when Martin Luther King, Jr.’s dream will come true, and it is also true that we will eventually have universal healthcare that is equitable as well as better laws that address our national affliction with gun violence. It is up to us to continue the conversations and actions that will make those dreams come true.
Finally, the report is most informative when it emphasizes that Americans’ views on healthcare are driven by basic beliefs and values. The challenge is to continue the effort to create greater consensus around the basic values and beliefs that will support the empathy and concern for one another that is consistent with universal coverage and the Triple Aim. As The Commonwealth Fund, Harvard T.H. Chan School, and the NYT report emphasizes:
As we look ahead to the debate over national health insurance reform, it is clear that Americans’ viewpoints on health care issues are heavily driven by their basic beliefs and values. Medicare-for-all is a powerful issue in the Democratic primary, but for Americans who are Republicans or Independents, this approach to health insurance reform does not resonate the same way. These Americans are split in preferences between improving the existing ACA and developing other alternatives.
I urge you to download the whole report and examine its great graphics for the enlightenment that they offer.
