The Challenge of Healthcare Reform

Do U.S. healthcare conditions warrant a major new governmental effort to reform the system? Recent Gallup research measuring Americans’ views of healthcare shows what I consider a complex picture, but there is enough evidence of perceived problems to suggest that continuing efforts to improve healthcare cost, coverage, access and quality are warranted. The challenge is how to go about it.
As my colleague Lydia Saad recently noted, for the first time in Gallup’s two-decade trend, less than half of Americans rate the quality of healthcare in this country as excellent or good. Americans’ ratings of the quality of healthcare coverage they personally receive are also at a new low. And a record-high percentage say that within the past year, they or a member of their family has put off medical treatment because of the cost they would have to pay.
Other trends are more stable. Americans’ views of the cost of healthcare and healthcare coverage, both nationally and personally, are roughly where they have been. Ratings of the healthcare industry per se are slightly above the two-decade average, although still well below the average for all other business sectors rated.
Few Americans (1%-3% over Gallup’s past seven surveys) mention healthcare as the nation’s top problem, and the percentage who say the U.S. healthcare system today is in a state of crisis or has major problems is no higher than it has been at previous points over the past two decades.
Gallup data show that Americans’ current ratings of their personal healthcare situations are on the positive side of the majority line, including a 72% excellent or good rating for personal healthcare quality, a 66% excellent or good rating for personal healthcare coverage, and 56% who are satisfied with personal healthcare costs.
Even though these are generally positive numbers, simple mathematics shows that substantial percentages of Americans remain concerned about their healthcare quality, coverage or cost. Plus, as noted, almost four in 10 Americans — a not-insignificant number — have put off medical treatment because of cost.
Additionally, Americans, as is the case across many domains, are clearly more negative when asked about healthcare “out there” across the country. For example, 76% of Americans are dissatisfied with the cost of healthcare in the U.S.; only 32% rate healthcare coverage in the U.S. as excellent or good; and the new low of 48% of Americans rate the quality of healthcare in the country positively.
Other measures signal continuing problems with U.S. healthcare. The U.S. spends more per capita on healthcare costs than any other developed country in the world, but objective measures of U.S. health quality are relatively low. As the Peter G. Peterson Foundation recently concluded, “Despite higher healthcare spending, America’s health outcomes are not any better than those in other developed countries. The United States actually performs worse in some common health metrics like life expectancy, infant mortality, and unmanaged diabetes.”
In other words, America’s return on its huge monetary investment in healthcare is suboptimal.
The COVID-19 pandemic, of course, engendered a major review of shortcomings in the American healthcare system, and healthcare access and quality remain inequitably distributed across subgroups of the population. Recent news headlines have pointed to problems with availability of pediatric hospital beds; nurses who are dissatisfied and have gone on strike; and the impact of respiratory syncytial virus, or RSV, on highlighting severe shortages in emergency room capacities.
Plus, although healthcare is not top of mind as the country’s No. 1 problem, Pew Research found that it was the fourth-highest-rated priority, out of 18, in U.S. registered voters’ vote for Congress last November. The Kaiser Family Foundation similarly found that healthcare and healthcare affordability, although dwarfed by concerns about the economy and inflation, were second on the list when Americans were asked to name the top priority for Congress this year.
One seemingly simple solution for healthcare problems is the single-payer, “Medicare for All” program advanced by such leaders as Sen. Bernie Sanders. We don’t find strong support for this remedy from the public, although the public’s attitudes are complex (and interesting to study).
As my colleague Megan Brenan recently reviewed, “A 57% majority of U.S. adults believe that the federal government should ensure all Americans have healthcare coverage. Yet nearly as many, 53%, prefer that the U.S. healthcare system be based on private insurance rather than run by the government. These findings are in line with recent attitudes about the government’s involvement in the healthcare system, which have been relatively steady since 2015.”
Putting responses to these two questions together, we find that only 38% of Americans adopt the position Sanders espouses — that the government’s role is to ensure that everyone has healthcare coverage and that the government should run the system. Another 35% of Americans adopt the opposite views, believing both that the nation should use a private insurance system and that it is not the government’s role to ensure healthcare for all to begin with. And 18% of Americans believe that the government should ensure that everyone has insurance, but that this should be accomplished through private insurance, not a government-run system.
The takeaway here: The majority of Americans recognize that government has a role in expanding health insurance coverage, but many are ambivalent about fulfilling that role with a government-run system.
Reforming healthcare is not a new idea. Efforts to fix healthcare have extended back for decades — including most significantly the creation of Medicare and Medicaid in President Lyndon Johnson’s administration.
Most recently, we saw the major focus on healthcare reform in the first years of the Barack Obama administration, culminating with passage of the Affordable Care Act (ACA) of 2010.
Public-opinion-wise, a slight majority of Americans continue to support the ACA, according to Kaiser Family Foundation 2022 tracking. Gallup has generally found the same pattern in recent years, although our 2021 survey found support evenly split. (Of course, Americans’ views of the ACA are intensely partisan).
And Gallup’s tracking shows only a very modest uptick after ACA enactment in Americans’ positive ratings of their personal healthcare coverage (68% excellent or good from 2001-2010 versus 69% from 2011-2022) and satisfaction with healthcare costs (58.3% satisfied in the years before ACA passage versus 59.6% afterward).
The Joe Biden administration certainly feels the ACA has been a success. A fact sheet from the Department of Health and Human Services argues that, “Since its enactment on March 23, 2010, the Affordable Care Act has led to an historic advancement of health equity in the United States. This landmark law improved the health of all Americans, including women and families, kids, older adults, people with disabilities, LGBTQI+ and communities of color.” And other reviews note that the ACA has been coincident with lower health insurance premiums and a decrease in the uninsured rate. The ACA’s effect on overall health spending (pre-COVID-19), however, is debatable.
Also of historical note is the major effort to reform healthcare in the first years of the Bill Clinton administration. Under the direction of first lady Hillary Clinton, the U.S. government put together a cabinet-level Healthcare Task Force that “… aimed to create a plan for comprehensive reform of the American health care system.” The Task Force’s Working Group involved more than 500 participants (meeting with “over 1,100 health care organizations”), and in the end promulgated a proposed 1,342-page Health Security Act. The law was immediately criticized by Republicans and industry groups, and by 1994 was declared dead, with no chance of passage in Congress.
There are presumably numerous causes of the Clinton administration’s failure to reform healthcare, including the health insurance industry-funded “Harry and Louise” commercials that succeeded in casting doubt on the proposal.
But of particular relevance to any future efforts to reform healthcare, well-known pollster Daniel Yankelovich argued that “President Clinton’s reform plan was not shaped by discussion with citizens about rising health care costs and what to do about them — a process whereby reform proposals are continuously adapted to the rhythm of public understanding. The plan was the product of experts and experts alone.”
Yankelovich’s insights provide important food for thought. If and when a new committee, task force, or advisory group is put together to grapple with healthcare reform in this country, a primary consideration should be to more directly involve the American people themselves in the process. This builds from the conclusion that major societal reforms ultimately must work in the real world. Theoretical justifications for healthcare reform fail if they don’t fly with the people of the society who are most directly affected. And, there is substantial wisdom in the collective views of the people, often outweighing the wisdom of presumed experts.
Any major effort to achieve societal goals must also have a well-defined objective. Two frequently cited examples of what a society can accomplish — the Manhattan Project in World War II that produced the atomic bomb and the Apollo space program in the 1960s that sent men to the moon — had extremely well-defined objectives (along with huge budgets and strong leadership).
The objectives for healthcare reform are less straightforward. But one major (and measurable) metric that can be used to measure success, it seems to me, is the views of Americans themselves, and how they feel about healthcare costs, coverage and quality. People are the end consumers of healthcare and the target toward whom all this effort is focused. Therefore, it makes sense to include the attitudes of the people themselves as a major objective or goal for any healthcare reform process.
Gallup CEO Jon Clifton in his book Blind Spot recently reviewed the importance of incorporating subjective measures of happiness along with economic indicators of GDP in measuring how countries across the world are faring. As he noted, “Absent from leadership dashboards is how people feel.” In parallel fashion, improving measures of how people feel about their healthcare can and, in my opinion, should become a significant objective for new efforts at healthcare reform.