By Robert J. Blendon, Sc.D., John M. Benson, M.A., and Caitlin L. McMurtry, S.M.
The New England Journal of Medicine, May 29, 2019
U.S. health care costs — and not merely prescription-drug prices — have risen to the top of the national agenda. More than two thirds (69%) of the U.S. public has said that reducing these costs should be a top priority for President Donald Trump and Congress in 2019, ranking it behind only strengthening the economy (70%) on a list of 18 possible priorities (Pew, 2019) (see table). Given a list of 13 possible health-specific priorities, about 9 in 10 Americans said both prescription-drug prices (92%) and lowering the overall cost of health care (88%) were extremely important (Politico–HSPH, December 2018). In addition, when asked how much of a problem each of 18 domestic issues was, respondents ranked affordability of health care first, with 70% saying it was “a very big problem” (Pew, September–October 2018). We reviewed 14 national public opinion polls from 2018 and 2019 to elucidate the public’s perspective on health care costs and possible solutions.
Although the United States spends 18% of its gross domestic product on health — more than any other industrialized country — that is not the focus of the public’s concerns. In fact, 69% of the public believes that the United States is spending too little on health (only 10% believes we’re spending too much) (NORC–GSS, 2018); 56%, too little on Medicare (10%, too much); and 42%, too little on Medicaid (17%, too much) (West Health–NORC, February 2018).
Instead, the driving force for concern is the belief that health care services are unreasonably priced and that what people pay for care harms their household’s financial situation. More than half (53%) of Americans say the cost of health care affects their own household’s financial situation “a lot” (Pew, March 2018). Forty percent say they’re dissatisfied with the total amount they pay for care (Gallup, 2018).
So why, according to the public, are health care costs so high? When given lists of 12 or more possible reasons identified by policy experts and the media, respondents focus on charges by pharmaceutical companies (78% in one survey, 79% in another), insurance companies (70%, 75%), and hospitals (71%, 74%) as the main causes (KFF, 2018; Politico–HSPH, 2019).
Unlike many experts, the public does not see overuse of services as a significant contributor to the cost problem that concerns them. Some 60% of Americans attribute high costs to unreasonably high prices for services and drugs; 23% believe that Americans are getting more health care and prescription drugs than they need; and 11% consider these two factors equally responsible (Politico–HSPH, 2019).
About three fourths (76%) of the public believes that Americans are paying too much for most care they receive, relative to its quality. A majority also believes that health insurance premiums are increasing primarily either to boost profits for insurance companies (47%) or to accommodate high prices for care (16%), not because care is better (21%) or coverage is broader (13%) (West Health–Gallup, 2019).
Numerous broad-based proposals for reducing U.S. health care costs have been put forth by experts and covered by the media. More than half the public supported five of the seven such proposals they were asked to consider: making greater efforts to prevent disease and ensure that people live healthier lives (84%), having the government facilitate competition among health care professionals and hospitals based on price and quality (67%), having the government establish limits on what health care professionals and hospitals can charge (65%), allowing people 50 to 64 years of age to buy into Medicare (61%), and changing our health care system so that most people have Medicare and there is little or no private health insurance (52%) (Politico–HSPH, 2019). Although experts see competition and government regulation as fundamentally different ways of controlling health care costs, Americans are nearly equally supportive of both.
The two proposals the public does not favor would restrict patient access to treatments and prescription drugs: allowing payers not to cover some services deemed by experts not to be beneficial enough to justify their high cost, and giving individuals tax incentives to buy high-deductible plans. Each proposal was favored by only 37% of the public (Politico–HSPH, 2019). The public’s opposition to allowing experts to make decisions based on cost-effectiveness was similar in 2019 (56%) to what it was in 2012, when 43% were in favor and 54% opposed.
When asked whether they thought the five proposals favored by the majority would greatly reduce health care costs, however, a preponderance of respondents said they didn’t think any of the five, including Medicare for All, would do so (Politico–HSPH, 2019).
A similar pattern can be seen in attitudes toward high prescription-drug costs. Shortly after May 11, 2018, when Trump released the outline of a plan to lower prescription-drug prices, the public was asked whether they favored or opposed four components of the plan. Although a majority supported three of the four proposals, they saw only one as likely to be effective: having the Food and Drug Administration approve more generic, over-the-counter, and biosimilar drugs to encourage greater competition. Sixty-six percent favored this proposal, and 56% believed it would lower drug prices (Politico–HSPH, June-July 2018).
A large majority (82 to 89%) favors allowing the federal government to negotiate with drug companies for lower medication prices for people on Medicare (West Health–NORC, August 2018; KFF, February 2019; HSPH–SSRS, 2019). A smaller majority (58%) believes that such negotiations would reduce prices (HSPH–SSRS, 2019).
When asked whether government or private health insurance companies would be better at controlling health care costs, nearly half (47%) of respondents said government, while 38% said private companies. Notably, 61% of Republicans were in the latter camp, and 65% of Democrats were in the former (Politico–HSPH, 2019). And when respondents who thought that government-set limits on what health care professionals and hospitals can charge would reduce U.S. health care costs were asked which level of government would do a better job of establishing these limits, there was a similar lack of consensus: 51% said the federal government, and 45% said state governments. Once again, a partisan split was evident: 69% of Democrats chose the federal government, whereas 63% of Republicans chose state governments (Politico–HSPH, 2019).
What can we conclude from these findings as we approach the 2020 election? First, health care costs are likely to be an important election issue. But unlike many experts and political leaders, most Americans are not particularly concerned about aggregate health spending, either overall or on the part of government. In fact, when asked about the possibility of the Medicare Part A trust fund running out of money in the next 10 years, only 25% of the public was very concerned that it would (Politico–HSPH, 2019).
The public sees the issue of health care costs primarily as a price problem, rather than one of overutilization. Thus, proposals focused principally on reducing overuse of care are likely to be less popular than those that address high prices directly. People are likely to support candidates who talk about increasing overall health spending, not reducing it. In addition, it’s important to recognize that the public has not reached a judgment about whether increased competition or government regulation is more effective in controlling health care costs.
This debate tracks with the partisan divide: Republicans generally believe that private health insurance and state governments would be more effective at reducing costs, whereas Democrats tend to support efforts by government, especially the federal government, to address the problem. Finally, given the public’s skepticism that any approach will greatly reduce health care prices, if they are to actively support particular cost-saving proposals, they will have to be shown that those approaches would actually reduce what they pay for care. And if the public’s view is going to converge with that of many experts, they will have to be convinced that overuse of services plays a greater role in high health care costs than they currently believe.
By Don McCanne, M.D.
This review of recent national public opinion polls on health care costs shows that the public is very concerned about high costs, and that they believe those high costs are due to high prices rather than overutilization of health care services.
They are less consistent in their views of what can be done about it, and that confusion is compounded by political polarization.
What they do want are approaches that would actually reduce what they pay for health care. If you could remove ideology and political bias from their thinking, and if they would look more carefully at the policy options, then support for the single payer Medicare for All model would certainly prevail.
If we could only figure out why so many cling tenaciously to the simplistic antigovernment rhetoric that expresses concepts that are not in the interests of the great majority of us – if we could understand that, then maybe we could improve our message beyond that of affordable health care for all (not that there is anything wrong with our message).
Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.