Tough Choices on Health Care–Ready or Not, Here They Come

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Remember Harrison Ford as Indiana Jones, running away from an enormous boulder, glancing over his shoulder, racing to avoid being crushed? For the Congressional Budget Office (CBO), health care is the boulder that could devastate the federal budget if we can’t figure out better ways to contain rising costs. Many experts see this issue as one of, if not the, most urgent budgetary threats we face. The federal government spent roughly a trillion dollars on health care in 2013, including Medicare, Medicaid, and the Children’s Health Insurance Program. With an aging population, more of us will be on Medicare. Due to The Affordable Care Act (ACA), more people are being covered by Medicaid and receiving government subsidies to buy their own insurance. According to the CBO, rising health care costs will “pose a challenge not only for the federal government’s two major health insurance programs, Medicare and Medicaid, but also for state and local governments, businesses, and households.” There has been some good news lately--health care costs haven’t been rising as quickly as in the past, and there’s vigorous debate among policy wonks over why this is happening and whether costs could start rising more quickly again. The White House Council of Economic Advisors, for one, believes that some reforms in the ACA are helping slow the growth in costs. But health care costs are still rising--by 3.7 percent in 2012. Polls repeatedly show broad support for “reducing health care costs,” and on the face of it, people do seem to grasp that the U.S. spends an awful lot of money on health care. But a deeper look shows that most Americans aren’t thinking about health costs exactly the same way experts do. In fact, new research from Public Agenda, in partnership with the Kettering Foundation, suggests that public understanding of the health care cost problem is piecemeal at best. As might be expected, study participants were understandably anxious about their own costs and often shocked by medical bills they had seen, even if they hadn’t paid them directly. But many simply weren’t aware of the magnitude of government spending on health care, nor had they absorbed or grappled with some of the chief options for containing it. Here are some highlights from the study, which asked participants to weigh a range of proposals for addressing rising costs:

  • At the outset of the conversations, relatively few participants voiced strong concerns that the country is spending more on health care than it can afford.
  • But after viewing graphs showing how much the federal government spends on health care and where that money goes, nearly every participant in the study was amazed.
  • Many were particularly shocked to see that federal government spends more on health care than defense.
  • Most were also startled to see how costs for treatment vary from one part of the country to another and how they compare between the U.S. and other advanced nations.

Not only were participants largely unaware of how much government spends on health care, many were skeptical of some key reforms suggested by experts. For instance: Physician Payment Reform: Some people wondered whether doctors might cut corners if they weren’t paid for each procedure, as is generally the case now. Others worried that doctors would figure out how to game any new system. Still others felt it was unfair to hold doctors accountable for outcomes that might be beyond their control. A New Jersey man liked the idea of paying doctors flat fees, but he added: “I bet you the doctors won’t like it.” More Patient Choice: Some people liked the idea of having more choice among insurance plans, but many seemed daunted by proposals that encourage patients to comparison shop for health care services themselves. “Quite honestly, I don’t want to have to do all that research. I am not going to be able to develop that kind of expertise,” said an Ohio woman. More Patient Responsibility for Costs: Many participants objected strongly to this approach, arguing that too many Americans are already having trouble making ends meet. As might be expected, participants were deeply and sometimes passionately divided on whether government should play a larger or smaller role. Some participants were highly mistrustful of government and wanted its role in health care sharply reduced. Others thought government might be helpful in reining in insurance companies or health care providers that get too greedy. Some participants struggled to absorb these complex proposals and think through what they would mean for themselves and their families. Hardly any left the room with firm opinions about what to do. Most were still mulling over what they had just discussed. As one New Jersey woman put it: “I don’t know what’s the right answer, but something has to change in America.” The research suggests that many people are just setting out on a long learning curve on this issue and that, left to their own devices, many will be dubious and confused about key cost containment ideas. That’s not the best formula for building the political will for change. But the study also shows that, in settings that encourage learning and deliberation, citizens can accept hard facts and wrestle seriously with tough choices. In commenting on the study, Public Agenda founder Daniel Yankelovich pointed to the public’s lack of understanding of “how the system really works and how it got that way.” But then he added: “I do not blame the public for its ignorance. . . . My personal view is that public engagement is needed to bring about the necessary reforms.”