In my recent post on the issue of quality in health care, I spoke a little about how public opinion can be a poor guide when it comes to understanding the full scope of our health care problems. I noted that, according to Gallup polls, 85 percent of Americans report being satisfied with the quality of care they receive—despite the fact that patients get, on average, just 55 percent of the care that experts recommend for most major medical conditions. The lesson here is clear: if you really want to improve health care in the U.S., you need to look beyond superficial preferences and into the nitty-gritty of how health care is delivered in our system.

This holds true for the issue that Americans care about the most when it comes to health care: making their own care more affordable. But it’s not the public that’s at fault here; when it comes to questions of cost and affordability, people just aren’t being asked the right questions.

Consider the Gallup poll mentioned above, which asked how people felt about the cost and quality of health care. 45 percent of those polled said they were dissatisfied with our health care system’s performance in terms of quality; just 15 percent said the same of their personal experience. In contrast, a whopping 80 percent of respondents said they were dissatisfied with the system’s performance in terms of cost, and 40 percent said the same of their personal experience. Simple enough, right?

Here’s the problem: polls like this reinforce the notion that health
care is compartmentalized, that different health care priorities are
unrelated to each other. In asking people to report separately on cost
and quality, pollsters suggest that the two are discrete issues. But in
reality, they’re inextricably linked: how much I pay for my health care
is a factor of the kinds and volume of care that the system delivers to
patients.

According to an analysis
by PriceWaterHouseCoopers, 33 percent of your health care premium goes
to physician services (doctor’s visits, surgeries, diagnostic tests,
vaccinations, etc) and 35 percent goes to hospital care. Another 16
percent of your premium goes to prescription drug spending. Taken
together, this means that a full 84 percent of your premium goes to the
utilization of health care (the rest goes to administrative costs). The
affordability of my care depends on how—and how often—everyone else
receives care.

Clearly we can’t expect polls to be the only—or even the central—way of
educating the public on the relationship between care delivery and
cost. But they could do a much better job at exploring if and how the
public understands this relationship. Precious few polls address the
how of health care reform—people’s understanding of the relationships,
trade-offs, and strategies that will be the real-world mechanisms for
achieving public priorities.

More often than not, we get polls that present an over-simplified vision of health care. Check
out the Kaiser Family Foundation’s (KFF) June 2008 election tracking poll
on health care below.

Here respondents are asked to pick only one priority that they want to hear about, and personal affordability and national spending are broken apart into two separate categories. But as we’ve seen, how I spend my health care dollars depends on how the country spends it’s health care dollars.

Consider the straightforward example of prescription drugs. Since our government doesn’t negotiate with pharmaceutical companies for lower drug prices, health care purchasers pay about 60 to 70 percent more for drugs than the average for OECD countries, even when controlling for the fact that the U.S. is the wealthiest country in the world. Because manufacturers charge more, providers pay more, and that extra cost is passed down to you and me. According to data from Kaiser, drug retail prices increased by an average of 7.5 percent per year between 1994 and 2006—almost triple the average annual inflation rate. The reason why you pay more for a prescription has a lot to do with the fact that our heath care system pays drug companies more in order to be able to get you that prescribed drug. Worse still, according to PriceWaterHouseCoopers, 14 percent of your health care premium goes to covering prescription drugs: so as the system spends more on pharmaceutical products, your premium increases as well.

In other words, there’s something extremely misleading about a poll whose conclusion is that leaders should be talking about personal costs and not national spending. Health care is not an either/or proposition; in the real world, it’s all about the interaction of different aspects of the system. More helpful would be polls that gave a better sense of context as to cost issues–questions that reflected the actual choices that people will face as health care reform moves forward.

Some polls already do this. In the same June report, KFF asked registered voters what changes they thought
would go a long way helping reduce their personal health care costs.
The results? 66 percent said reducing fraud and waste in the health
care system, 53 percent said healthier living and preventive medicine,
and 41 percent said reducing the amount of unnecessary care. What’s good about this poll is that it explores how people understand the relationships behind their concerns. Similarly helpful are polls
saying that Americans are willing to pay higher taxes for health care. Here again the focus is on the interdependencies that make health care work–in this case, paying taxes to fund change–and not on overly-pat categorizations.

Perhaps no issue could benefit by being more thoroughly addressed by such substantive polls than over-treatment, which is a key factor in making health care affordable. By some
estimates the U.S. system spends $500 billion—a full one-quarter of its
total health care bill—on unnecessary care. Such excessive
over-treatment drives up costs for individuals and families: since most of our premiums go toward health care utilization, a glut of care means that premiums go up. And as the volume of care
increases, insurers will be forced to cover a smaller proportion of the
care available, resulting in higher out-of-pocket expenses for many
people.

This fact—combined with the Kaiser finding that 41 percent of people
think unnecessary care makes care more expensive—suggests that it’s
time for polls asking practical, contextual questions about how quality and cost come together in over-treatment.
Instead of asking people if they’re satisfied with their health care
costs, let’s ask them how they feel about more consistent best
practices guidelines. Or let’s find out what people think about
comparative-effectiveness research. Let’s inquire as to people’s
treatment preferences: is there some threshold of scientific validity
that people want in their treatments? Are they familiar with the risks
of over-treatment? Is getting as much care as possible really as
important to people as pundits always assume?

In other words, let’s learn more about how people understand the crucial relationship between the kind of care we receive and how much they pay for health care. Health care polls that emphasize cost without really delving into the
practical measures that will do the most to control costs—and improve
the quality of care—miss out on a big opportunity to engender informed
discussion. And history shows that an incomplete health care debate can
cause problems down the road.

Look back at health care polls in 1993-94, and they look remarkably
similar to the numbers we see today. In a 1993 poll by the Roper
Organization, only 40 percent of respondents thought that the price
they paid for care was reasonable. Another 1994 poll found that 85
percent of Americans thought that the U.S. health care system needed to
either be completely rebuilt or had to undergo fundamental changes.

Yet despite these favorable numbers, President Clinton’s 1994 health
care reform effort famously flopped. Why? Because it’s architects never
delved beyond the most superficial levels of public sentiment before
crafting its plan. As Ezra Klein put it
in a January American Prospect piece, the Clinton Administration seemed
to think that and that all it needed to do was to tell the public:
“trust us.”

People wanted reform, but they weren’t in the loop as to what form the
necessary changes would take. When Clinton rolled out his plan,
conservatives slammed it—and a lot of their criticism stuck because
people hadn’t heard much else. Recall the infamous “Harry and Louise”
television advertisements; one
ad suggested that community ratings, i.e. a system where everyone in
the same community pays a single premium, was an unfair rip-off.

The Harry and Louise became iconic examples of special interest spin at its best, and much of their punch came from the fact that they were discussing issues that hadn’t been talked through before the reform process began. Perhaps the advertisements would have been less effective if reformers had known more about how people felt about about the way health care should
work in practice, as it related to structure of their specific plan. How do
people feel premiums should be paid? How do they feel risk should
spread? What do people think is fair in health care? After all, everyone wants an affordable, high quality system
that helps as many people as possible—the devil is in the details.

This is not to say that we’re headed for a Harry and Louise-style
meltdown in 2009. In fact, prospects for health care reform look
healthier than ever, not least because the conservatives who sabotaged
Clinton’s efforts are now reeling. But no matter what form health care
reform takes, we’re going to have to address health care delivery if we
want to address health care affordability.  It’s the different moving parts of health care–and not the high-level intentions–that are going to be the true challenges of reform. So let’s start exploring public opinion on those choices that we know we’ll have to face, especially for that issue which is so key to making health care affordable: over-treatment. Indeed, over-treatment is not going
to go away by itself–and health care polls would be a much more valuable resource for reformers if they helped to familiarize the public with its options sooner rather than later.