The National Issues Forums Institute, Public Agenda, USA TODAY, and other partners are collaborating on Hidden Common Ground (HCG), which focuses on areas of agreement among the public on solutions to tough public problems during the election year. The HCG work on health care included traditional focus groups, deliberative focus groups, and a national survey conducted by Public Agenda in late 2019 as well as a series of in-person and online forums convened in the NIF network.  All HCG reports so far are at http://hiddencommonground.org/

This comparison of the results of NIF forums using the issue guide "Health Care: How Can We Bring Costs Down While Getting the Care We Need?” and of the results of focus groups and national surveys was prepared by Will Friedman, John Immerwahr and David Schleifer of Public Agenda and released May 1.

The Public Agenda survey of Americans’ attitudes toward improving the health care system raises a perplexing question.  Americans are distressed about the current state of health care and there is a nearly universal consensus that the system should be changed. There is also a broad consensus about the goals for change. But Public Agenda found a stalemate on the policies to achieve those goals.  None of the most widely discussed approaches commands majority support and one in four Americans say that they don’t know enough to express an opinion. The desire for change is red hot but interest in the solutions is lukewarm at best.  

Comparing the focus groups, forums and survey suggests a hypothesis that might explain this dilemma.  Many people in the groups and forums struggled with a deep conflict: their fears for themselves and their compassion for others made broad changes seem very attractive. But their negative experiences with the health care system and their sense of practicality made them worry that changing something so large and complex could leave people worse off than they are now.

 
Main areas of consistency across the four methodologies:

•    Dissatisfaction with the current system, even among those with ostensibly decent health insurance.
•    Broad endorsement of a number of major goals for improving the health care system.  
•    A frank recognition that health care is an incredibly complex subject that most people only vaguely understand. 

Areas where the forums and focus groups added nuance to the survey findings:

1. Medicare for All starts out controversial and becomes less appealing through deliberation:  The Public Agenda survey found that 45 percent of Americans support a Medicare for All-type plan, but it is highly divisive, supported by 65 percent of Democrats but only 22 percent of Republicans. This division was evident in the groups and forums. Some focus group and forum participants valued the idea of national health care that would provide universal coverage and be less complicated than the current patchwork.  Others were opposed because of its reliance on a massive government program. In deliberations, however, even those who supported universal coverage expressed worries about the impacts of such a massive change on the enormously complex health care system, leading them to call for slower and more incremental changes.

Hypothesis: Support for Medicare-for-all might diminish with more deliberation and discussion because even supporters worry about the practicality of such a massive shift. 

2.  A market-based approach emphasizing personal choice and deregulation evokes 
conflicting reactions. The Public Agenda survey found a lukewarm reaction to a more market-based approach to health care: 46 percent of Americans supported this and 28 percent opposed it. In the deliberative groups, people were enthusiastic about greater transparency in health care but vigorously rejected letting people purchase stripped-down health insurance policies. They feared that people would buy inadequate coverage, leaving society on the hook for their care.  

Hypothesis:  Support for a market-based solution may also diminish as supporters think through its consequences for people who make poor choices. 

3.  In comparison to the other alternatives, build-on-what-we-have looks better and better. But that is not a full-throated endorsement of the Affordable Care Act:  The Public Agenda survey presented a limited version of an incremental strategy consisting of a public option-type plan. It garnered lukewarm support with 47 percent of Americans supporting and 37 percent opposed. Republicans were evenly divided but Democrats supported it by three to one. The deliberative forums presented a robust version of a build-on-what-we-have strategy. Some elements were enthusiastically endorsed in the deliberative groups and forums – specifically an incremental approach, a public option, prevention and a sensible approach to end of life decisions. But the ACA personal mandate was largely opposed.  

Hypothesis:  The public’s desire for incrementalism may be attractive because it balances the desire for and the fear of change. But given the deep dissatisfaction with the current system this may be an uneasy, unstable stance rather than a settled and comfortable position.