Americans 'aren't looking for big structural changes in health care' - STAT

Voters on Tuesday sent several messages, including a key one about health care.

Big ideas on health reform have dominated the Democratic primaries and been the focus of Congressional efforts. A “repeal and replace” effort threatened to uproot the Affordable Care Act (ACA) and turn Medicaid into lump-sum payments to states, disrupting insurance coverage for millions. Medicare for All proposals would insure nearly everyone but abolish private health insurance. Many states and the Trump administration are pursuing a lawsuit that would overturn the entire ACA, slashing public funding, while other states and candidates for president are advocating new public option insurance that could increase public funding.

Americans may not agree on one approach to health reform, but the positions of some political leaders suggest that we are hungry for a big change in health care.

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The message from voters on Super Tuesday was that we aren’t looking for big structural changes in health care.

Health care is top of mind for American families — it is the number one policy issue for many voters. Millions of people in the United States are uninsured and millions more are underinsured. The news is filled with stories of people who couldn’t afford to seek care, received whopping bills, or even died because they did not want to risk their family’s finances.

According to a recent survey by The Commonwealth Fund, nearly half of Americans are dissatisfied with the cost of health care. In this survey, we asked questions that would help us understand how people’s values and experiences shape their opinions about health care, especially the kind of overhauls that policymakers and candidates are proposing. What they told us could have big implications for whether it makes sense to pursue big ideas or to try for modest reforms.

A clear message was that people are happier with their health care than the news implies. Despite concerns about affordability, most Americans have favorable views of each of the three major insurance pillars of our current health care system: employer-sponsored insurance, the health insurance millions of Americans receive through their work; Medicare, the government health insurance for seniors; and Medicaid, the government program for those too poor to afford health insurance.

The survey also suggests a high level of support for programs that protect the elderly, the sick, and the poor. These government programs respond to core values that Americans hold almost universally when they think about health care. Most believe that everyone has a right to health care regardless of race, income, or the ability to pay. They believe that the health care system should treat all people equally. And they believe that people with preexisting conditions should be able to get health insurance and not be penalized for being sick.

If Americans like government insurance — Medicare and Medicaid — so much, won’t an expansion of this form of health insurance get a hero’s welcome? That is unlikely.

Our survey showed that people don’t have a great deal of faith in big new government programs. That isn’t new: Medicare was controversial when it was signed into law and Medicaid — a crucial part of the fabric of the American safety net since 1965 — has remained controversial to this day.

Over time, though, Americans have grown to accept these programs, as millions have experienced them directly or indirectly. Medicare has now insured elderly Americans and people with disabilities for more than 50 years. And when the Trump administration tried to roll back Medicaid, Americans rallied nationwide to save it because they have seen it help their families and communities for decades. A new government health insurance program won’t arrive with this positive history.

So what does all of this say to those who want big reforms to today’s health care system?

When it comes to health care, Americans want good care for themselves and their neighbors with good insurance coverage. In general, most are willing to support a government role for health care, but most appear to favor gradual steps, expanding on what is familiar, rather than pursuing giant leaps that might jeopardize the insurance they have.

This is not to say that larger changes cannot be achieved, or that new ideas for reforms are unwelcome. Nor is it to say it’s fruitless to continue an active debate about paths to achieving a high-performing, affordable health system for all Americans. But those who favor giant steps may find they are swimming upstream against an American public that is unsettled by the cost of care but reluctant to gamble on losing today’s health care system even if the giant steps might bring about a future system that is better and less costly.

Eric Schneider, M.D., is senior vice president for policy and research at The Commonwealth Fund.

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