Medical Device Daily Washington Editor

WASHINGTON — The Nov. 14 briefing on public opinion regarding modern healthcare, sponsored by the publishers of the policy periodical Health Affairs, rendered a seemingly self-contradictory set of ideas among the American public. However, one panelist argued that those contradictions did not necessarily mean that John Q. Public is out of touch, but instead reflected a wide range in the preferences in healthcare delivery.

On the other hand, an Internet simulation involving lay citizens showed that when faced with the complexities of crafting healthcare policy, Americans see quite clearly that there are limits to growth, suggesting that as the national discussion of healthcare continues, the prospects for a national consensus are building.

Daniel Gaylin, the executive vice president of the National Organization for Research at the University of Chicago , said that his organization’s survey showed that “80% of respondents think that the system is in trouble.”

“A substantial majority want a system that expands coverage and increases choice, but does not increase cost,” Gaylin noted, but while roughly half of respondents say that mandatory enrollment is a good idea, only one in four of the uninsured are of the same opinion.

Another feature of the data that policy makers might find interesting is that roughly nine in 10 feel that the cost of insurance should not vary by healthcare status, but “the majority of respondents say smokers should pay more,” an attitude that was echoed when it comes to those who are overweight, Gaylin noted.

Despite the suggestions of political turmoil seemingly embodied in the just-completed congressional elections, “[t]here was surprising commonality between Republicans and Democrats” Gaylin remarked. The support for mandatory enrollment was at 48% for registered Republicans, and Democrats supported the idea by 63%. Independents came in last, but by a still-substantial portion at 43% (the data table indicated that only a yes or no answer was available to respondents, opening the question of how the numbers might have tumbled out if “don’t know” was an option).

Despite its reputation as a bastion for the laid back set, California provided survey numbers that are much stingier on the obesity/premium question than respondents in general. Residents of the Golden State backed higher premiums for the overweight by 43% as compared to the 30% in the rest of the country. Ironically, “rates of obesity in California are rising faster” than in most other areas of the U.S., Gaylin pointed out.

Gaylin argued that not all of the seeming contradictions automatically argue that respondents are exceedingly good at coping with cognitive dissonance. Some of the data suggest “levels of preference” that will be difficult to provide with the current configurations of healthcare insurance.

Marjorie Ginsburg, the executive director of Sacramento Healthcare Decisions (California), stated that her research into consumer preferences, which employed an Internet chat board, suggested that consumers are aware that simply expanding the current base of coverage to all residents of the U.S. “is going to be extremely difficult.”

She commented that in the project, designed to elicit some ideas about what sort of basic coverage consumers might opt for in a limited insurance scenario, “a number of values came to the fore.” The participants, after several rounds of virtual negotiations on the chat board, came to the conclusion that “some healthcare needs could not be covered,” including some quality of life solutions. Among these were treatments for impotence and infertility, the latter of which “got the most discussion,” Ginsburg said.

Many participants concluded that “the $100,000 cancer treatment” for a patient who seems unlikely to survive for a substantial period of time even with the treatment was not a compelling expense. However, “the most controversial of the 14 measures” discussed was a restriction of providers, and the controversy regarding this aspect of insurance “points to how we decide as individuals how we feel about healthcare” in contrast to how one might see an issue as a policymaker, Ginsburg said.

Francois de Brantes, the national coordinator for Bridges to Excellence , (Washington) a non-profit coalition looking into healthcare viability, said that “employers are between a rock and a hard place” regarding any changes to current healthcare plans because health plans are essential to recruitment and retention. However, the ever-ballooning costs and an entitlement mentality are putting an unsustainable amount of pressure on many firms, especially in industries that are unusually labor intensive.

Many firms have been dropping the retiree health benefit, de Brantes noted, but there is “a short window for exiting retiree health,” given that Baby Boomers are poised to leave the workplace en masse. Supply-side efforts to rein in costs are not having the desired effect, but demand-side management, such as health savings accounts, “are the beginning of turning around the entitlement problem,” he said. Still, even these measures are not having quite the impact needed to flatten healthcare spending in the U.S.

Mark Smith, president/CEO of the California HealthCare Foundation (Oakland), admitted that he too is “struck by the contradictions…when you hear the things that people want.”

Smith said that insurance now covers four elements of concern for the typical consumer. One is “what if I get hit by a bus?” The other three concerns address cost, availability of drugs and access to doctors. He argued that “much of the tinkering ... seeks to enroll people in a healthcare system that they cannot afford.”

Smith said that little change for the uninsured is on tap unless policy makers address the question of “how can we make the underlying asset more affordable,” recommending that insurers “unpack” basic healthcare services from other services in order to create a system that is workable for low-income Americans. He said that he sees “great promise in the retail clinic model” that provides after-hours care without incurring emergency-room charges, as well as increased use of telemedicine and non-physician providers.

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