[Skip to Navigation]
Sign In
JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
JAMA Forum

Doing Health Reform Better: Listening to the Public

To hear politicians talk about it, there are very stark battle lines in the United States over health care. But what the US public has to say and how poorly politicians and policy makers listen drives much of that conclusion. And much of it is wrong.

Image: Steve Debenport/Getty Images

To achieve the health reforms worthy of the country, it is critical to pay attention to what the public is saying before jumping so conclusively to policy answers.

To hear Republicans tell it, the US public is deeply concerned about the role of government infringing on their choices and are seeking freedom from regulations. There are scant data that say this is a top health care concern. To listen to the early Democratic primary debate, one would think there are stark differences in the public’s mind about Medicare for All, single payer, and other forms of universal coverage. Although data suggest the public is strongly in favor of universal converge, there is little evidence of this.

A better conclusion is that people just want a health care system that works for them and their families—and expect policy makers to fix the parts that don’t—and they’re less particular about how that happens. About 82% of all registered voters said health care was important to their vote in 2018.

Most of people’s health care concerns are basic and existential. When someone in their family is sick, they want to be able to afford to take care of them. And they want to be sure that no one—whether an insurance company’s fine print, the government, the Congress, or a judge—has the power to change the rules and take their health care away.

It’s a far more primal topic than what taxes they pay. Take a top pocketbook issue, multiply it by matters of life and death, and you have health care.

The prime example of politicians not listening and getting it wrong was on display during and just prior to the 2018 US midterm elections. After backing a series of policies over nearly a decade that weakened preexisting condition protections, Republican candidates faced a significant public backlash at election time. Polls showed it and politicians across the country began to publicly (even if not in fact) back-pedal from this position. Minority leader Kevin McCarthy (R, California) blamed the Republican midterm losses squarely on this 1 issue—with good justification. In the summer of 2017, right after the House voted to repeal the Affordable Care Act (ACA), there was a well-documented lack of congressional representatives who voted for repeal who were willing to conduct town halls and listen to their constituents. A listening strike turned out not to work in their favor.

Perusing policy ideas without listening to the public is something Democrats must watch for, too. The Democratic 2020 primary is being set up as something of a referendum between single-payer insurance and other forms of universal coverage. Such distinctions exist, of course. But to most of the public, the policy details of how universal coverage works are in the weeds compared with their primary concern—certain and affordable care. Polls show virtually every solution put in front of people that increases health care security and affordability are winners and everything that causes them to lose that or makes them more insecure to be losers.

The health care skies are gray for the US public right now, with Republicans suing to declare the entire ACA unconstitutional. The trap for Democrats is an extended argument over whether they prefer the sky to be royal blue or powder blue.

Politicians not listening well is not a function of too few political polls. Politicians can often point to polls proclaiming that the public favors one certain policy proposal or another. But politicians and the public should be wary of polls taken to demonstrate support for their views. Instead, they should listen to the trade-offs people are willing to make and how they talk to each other around the kitchen table.

So what are people saying? One experiment shows how more than 200 people recently responded in their own words to a question on social media about what they believed were the health care concerns most common among their friends and families. The aim was not to be scientific but quite the opposite—to try to tap into the kinds of conversations people have when talking to each other around the kitchen table or in coffee shops.

About 70% of people expressed concerns about affordability and health insurance coverage. Prescription drugs topped the list of cost concerns. Cost sharing and deductibles were also frequently mentioned, and when combined with insurance premiums, insurance costs rank even higher than prescription drugs. One may be tempted to conclude this means that people are most concerned with the cost of all health care, but to the public, it shows up as flaws in insurance.

Specific cost concerns were diverse and followed people’s own specific personal experience, reflecting the breath and size of health care. About 13% of people who mentioned cost identified the affordability of dental care. Others mention long-term care, ambulance rides, emergency department bills, or hospital stays.

When listening to people, one should avoid the temptation of simply clustering their responses and instead pay attention to how specific and idiosyncratic people’s concerns are. Health care often represents the greatest financial uncertainty and stress people face and they expect solutions to help them. The lesson is an important one for politicians to digest. If a politician says they’re tackling the cost of prescription drugs, people won’t believe it until the cost of their own insulin is affordable.

Because people’s concerns are so fundamental and acute, they cross over party identity more than is often recognized. Nine out of 10 Republicans and Democrats believe surprise medical bills should be a top priority of their state legislature. Likewise, 9 out of 10 in both parties say the same for prescription drug costs. Pain and uncertainty trumps party identity.

Obviously much more needs to be learned. Policy makers would be smart to elevate the voice of patients and reduce the influence of lobbyists and other less-representative voices. The path the Republicans in Washington chose these last few years—drafting proposals behind closed doors, avoiding hearings, and limiting town halls—isn’t the right one. There are many choices to make to get health reform right. The best, most durable answers are going to come from an engaged public and paying attention to what problems we can solve.

About the author: Andy Slavitt, MBA, Founder and Board Chair of United States of Care, served as the Acting Administrator for the Centers for Medicare & Medicaid Services under President Obama from 2015 to 2017, where he focused on advances in health care coverage and accelerating health care delivery system transformation. He has 2 decades of private–sector health care leadership, both as a senior executive at Optum, a health services and innovation company, and as an entrepreneur. He tweets at @aslavitt. (Image: US Department of Health and Human Services)
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words