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U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop (2023)

Chapter: 4 Framing and Shifting the Health Narrative in the United States

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Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
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4

Framing and Shifting the Health Narrative in the United States

Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
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The third session of the workshop explored health care perspectives and policy priorities held by policy makers and the general public. Panelists described various factors influencing commonly held views on health care, including political affiliation, individualism, loss aversion, geography, and American exceptionalism. The panel also considered how the COVID-19 pandemic and the movement for racial equity have influenced perspectives on health. Techniques and terminology for framing the issue of health spending were discussed. The panelists were Venice Haynes, the director of research and community engagement at United States of Care (USofCare); Eric Schneider, the senior vice president for policy and research at The Commonwealth Fund (TCF); Julie Sweetland, a senior advisor at FrameWorks Institute; and David K. Jones, an associate professor in the Department of Health Law, Policy, and Management at Boston University. Sarah Gollust, an associate professor in the Division of Health Policy and Management at the University of Minnesota School of Public Health, moderated the discussion.

PERSPECTIVES ON HEALTH CARE CHALLENGES

Gollust opened the discussion by listing some priority concerns submitted by workshop webcast participants: underinvestment in the social determinants of health and social services, high health care expenditures, underfunding of the public health system, disparities related to the COVID-19 response, and racial health inequities. She asked the panelists to identify major themes from their research on the perceptions of health care challenges held by the public and by policy makers and to relate these themes to the priority concerns posted by workshop participants.

Haynes explained that USofCare is a non-partisan, nonprofit organization that works with policy makers, advocate leaders, and the public with the goal of ensuring accessible, affordable health care for all in the United States. Using a people-centered approach, USofCare gathers perspectives from people across the country to better understand both common and diverse experiences and ideas on the health care system and health care reform. The organization’s policy innovation hub uses the collected data to identify existing policies that exacerbate health care challenges as well as state- and federal-level opportunities to improve health care value and access. Qualitative research indicates that cost is the most prominent health care challenge for the public, Haynes said. High deductibles and medical bills can overwhelm personal budgets, resulting in some individuals being unable to afford prescription drugs. Although high-quality care may be available, it remains inaccessible to people who cannot afford it. Haynes said that lack of access and other consequences of high health care costs are most pronounced in communities of color, older age groups, and people of lower socioeconomic status.

Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
×

Schneider said that TCF is a private philanthropy organization that focuses on health policy in the United States and abroad with the goal of informing insurance and health care delivery system reforms that will bring about a high-performing equitable system in the United States. He said that understanding the range of public perceptions is important in framing the issue of reducing medical care spending and directing resources to cost-effective health-improvement strategies. Public opinion has some impact on politicians in shaping policy, so TCF seeks to understand how members of the public conceptualize the problem, how they experience health challenges, and how they view potential opportunities and solutions. Schneider added that constraints on possible solutions tend to be related to values. Across surveys in the United States, the cost of care is consistently among the most frequent concerns related to health care, with about half of respondents reporting that they have concerns about the cost of care.

Health policy work often emphasizes the numbers of uninsured Americans and the need for access to health insurance, but the public’s most pressing concern is cost of care, Schneider said. TCF survey data indicate that cost burdens have increased dramatically for individuals over the past decade as employers have shifted a greater proportion of cost onto employees; this is reflected in out-of-pocket costs for premiums, co-pays, and deductibles. In the survey data, concerns about cost far exceed public concerns about access or quality, which were identified as concerns by fewer than one in five Americans. Additionally, the public holds conflicting views about equality. While the vast majority of respondents indicate that the U.S. health care system should treat everyone fairly, a majority of respondents report they are comfortable with the notion that wealthier people should have access to more medical care than poorer people—provided they pay for it themselves. Schneider remarked that these conflicting views present a conundrum for problem solvers. In the context of the majority of Americans expressing satisfaction with the status quo on access and quality and being more concerned about personal health care costs than aggregate spending, it is difficult to advance meaningful legislative change.

Sweetland said that FrameWorks Institute social scientists systematically investigate the communication-related difficulties and opportunities in discussing or advancing specific social issues. These social scientists design and test alternative frames for directing dialogue toward solid evidence and policy. To date, the group has conducted surveys with approximately 400,000 Americans on a variety of social issues. The health-related topics have included community health, early childhood services, adverse childhood experiences, adolescent health, issues related to aging and later life, gun violence prevention, tobacco-related health disparities, patient safety, and the social determinants of health such as geography, housing, education, immigration, and racism. Common public perceptions regarding

Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
×

health have emerged from this research, Sweetland said. Notably, the public perceives health as the absence of illness. Typically, it is more difficult for people to define what it means to be healthy than what it means to be sick; this is especially the case regarding mental health and mental illness.

The most dominant model of health is individualism, which characterizes health as a personal concern shaped by personal lifestyle choices, Sweetland explained. Most Americans are able to list two or three determinants of health, with the most prevalent responses being diet, exercise, smoking, and alcohol and substance abuse. A recessive model—one that is not foremost in thought but is present—is that stress plays a role in health outcomes. Sweetland remarked this can be a useful model for discussing community conditions. However, the public primarily conceives of health as a result of one’s own decisions, thus construing health consequences as a personal concern. Sickness is viewed as an individual or family problem, rather than a societal problem in which health and broader outcomes in society are intertwined. Health care is often considered a consumer good; therefore, varying levels of quality and cost are normal, expected, and even desirable features of the system. Similarly, a commonly held public view is that not everyone will have access to health care. The view of health as a personal choice and of health care as a consumer good of varying quality according to price creates challenges in advancing dialogue about limiting health care costs.

Jones said that his research explores the perspectives of legislators and other policy makers. Partnering with Christina Pagel, a professor of operational research at University College London, he surveyed and conducted focus groups with state legislators about health policy priorities. In 2017 they sent questionnaires to all state legislators serving on health or budget committees. The response rate for this group of approximately 3,000 legislators was about 10 percent. Population health and health care access were the top priorities indicated by Democratic respondents, whereas Republican respondents focused on reducing the role of government. Jones remarked that there is a tension between those priorities, but legislators from both parties indicated that reducing health care costs was the next most pressing priority. This presented an opportunity and an opening for dialogue.

The next step involved conducting bipartisan focus groups comprising state house and senate members. Jones expected that these groups would develop a shared understanding and language around health care costs and ramifications. All participants agreed that costs are a problem, but consensus quickly broke down when they addressed the context of cost in terms of whether the priority should be reducing cost for (1) the government; (2) hospitals, doctors, or insurers; or (3) families and individuals. The subsequent round of research examined what health care costs signify to various people. Surveys and interviews conducted in 2019 and early 2020

Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
×

generated a wide variety of responses without clear patterns. In the course of additional interviews, pharmaceutical costs emerged as the top concern. Aside from that shared concern, respondents fell into three groups along political lines: predominantly Democrat, predominantly Republican, and a large group in the middle consisting of both Democrats and Republicans who indicated that their lowest priority of the three described above was reducing the role of government. Jones remarked that areas of consensus around health care costs are more prominent than might be expected.

SHIFTING AN INDIVIDUALISTIC MINDSET

Gollust said that the dominant, individualistic conceptualization of health, health care, and costs poses a challenge in addressing the broader, systemic costs of health care. A fragile consensus that health care costs are a problem is strained by various and divergent perspectives on the nature of these costs. She asked the panel members about the information, framing, or communication techniques needed to shift the individualistic mindset toward a systematic understanding of the collective impacts of high health care costs. Sweetland spoke about the importance of distinguishing between a social analysis of a problem and the communications analysis needed to inform public thinking about that problem. Regarding high health care expenditures, the social analysis of the problem is that this is a matter of high costs, but that language may not shift public thinking. For instance, when the FrameWorks Institute held discussions on the overall economic costs of health issues, such as tobacco use or poor oral health, participants placed blame on the people experiencing the problem for the associated increased costs. Consumer-focused terms such as cost and price can be replaced with language that invokes civic responsibility to future generations, Sweetland said.

Schneider added that discourse around health care has been shifting in the United States, with current polling indicating that the majority of Americans now believe that health care systems in other countries may offer lessons for improving the U.S. system. During the past 20 years, TCF has conducted surveys across 11 high-income countries. The TCF Mirror, Mirror 2017 report indicates that the U.S. health care system is not the best in the world (Schneider et al., 2017). Schneider said that legislators are increasingly interested in solutions for local and state jurisdictions. While there is some interest in lessons from abroad, solutions piloted in other parts of the United States may be more attractive to these legislators than policies and programs from other countries.

Jones said that in his research conducted with Pagel, he further explored the perspectives of the segment of interviewees—comprised of Democrats, Republicans, and independents—who ranked reducing the role

Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
×

of government as the lowest priority. Many of them reasoned that government is already involved in health care, so rather than working to reduce government’s role, the focus should be placed on value, responsible management, and creative solutions. This group did not prioritize equity, which presents challenges in determining how best to approach health disparities, Jones said. He suggested two conflicting approaches: downplaying the role of inequities in discussing health costs or working to shift perspectives on equity. Haynes added that USofCare is working to develop messaging about equity that resonates with conservatives.

THE POTENTIAL IMPACT OF COVID-19 AND THE RACIAL EQUITY MOVEMENT ON HEALTH POLICY

The COVID-19 pandemic brought attention to racial health inequities and the interconnected nature of human well-being, while widespread protests for racial equity have highlighted the importance of racial justice, Gollust said. She asked whether this context could potentially accelerate or facilitate a public shift toward a systemic understanding of health care cost issues. Schneider replied that the scale of the consequences of the COVID-19 pandemic is on par with World War II or the 1918 influenza pandemic. To examine the influence of this monumental event, TCF has conducted polling and surveys to compare public opinion pre- and post-pandemic. These data, which are yet to be published, indicate that concern about racism and equity has increased, with 60 percent of respondents citing racism as a big problem in the United States, compared with only 49 percent in 2015. Furthermore, 19 percent of people indicated that racism is the most important problem facing the country; this percentage is the highest it has been since 1968. The percentage of respondents who reported that Black people are treated less fairly than White people when seeking medical treatment increased from 33 percent in 2019 to 42 percent in 2020, suggesting a greater awareness of discrimination in the health care system. The percentage of Americans who express confidence in the health care system has seen a modest increase since the COVID-19 pandemic. Schneider said that, given the attention on health care workers’ extraordinary efforts in responding to COVID-19, it is unlikely that the public will want to reduce spending on health services.

Gollust referred to a commentary she co-authored that described the villainization technique often used in past social movements, in which a “villain” is identified to rouse public support for policy strategies to address a problem (Niederdeppe and Gollust, 2020). For example, the strategic framing of the tobacco industry as the villain may have enabled public health advocates to garner support for more aggressive tobacco control legislation at the local, state, and federal levels. Given that the public is

Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
×

generally satisfied with the health care spending status quo, holds positive views toward the contributions of health care workers and vaccine developers, and values the role of hospitals as employers in local communities, Gollust asked how a movement toward decreased health spending can be achieved. Sweetland replied that research indicates that injustice and inequity can be framed as the villains in the health care spending narrative. Framing the health system itself as the villain undercuts the argument that investment is needed for reform efforts; framing cost as the villain can result in blaming patients for their behaviors. She said that an individualistic view of health-related matters has persisted during the COVID-19 pandemic, with individuals held responsible for following guidance related to COVID-19 and for their diet and exercise. In contrast, data indicate that views regarding racial inequality are shifting, creating potential openings for highlighting the need for health care system reform.

Haynes responded that USofCare public opinion polling indicated that 68 percent of respondents identified the presence of inequities in the health system. Black and Hispanic respondents were 30 and 22 percent more likely, respectively, than the overall sample to say that inequities exist. Approximately 25 percent of those polled reported experiencing discrimination in the health care system. The current heightened awareness of racism provides an opportunity to approach shortcomings in a nuanced health care system that has demonstrated heroism during a global pandemic yet marginalizes some segments of the population, Haynes said. Gollust added that heightened awareness of racism will be insufficient on its own to address the long-term challenge of racism in the health care system and in society at large.

Jones said that while awareness of racial and ethnic inequities is increasing, the politicizing of public health makes it more difficult to address disparities. For example, some people view the public health measure of wearing a mask during the COVID-19 pandemic as a government infringement on personal liberty. He added that the concept of injustice as the villain may be too abstract. In looking to blame a more specific root of the problem, some may villainize politicians, which in turn could make restructuring systems more challenging. In recent years, Jones has been working on a case study of racial and health inequities in the Mississippi Delta. In interviews with residents and policy makers, health care cost emerged as a commonly identified problem, along with the lack of health care providers in rural areas, a shortage of jobs that provide health insurance, and transportation issues. He said that when the issue of injustice is raised, policy makers can become defensive if they perceive an implication that they are being labeled as racists. Jones noted that anti-racism activist Ibram X. Kendi recommends framing conversations on racial inequality in terms of the racial implications of policies, rather than labeling specific

Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
×

individuals as racist (Kendi, 2019). Sweetland added that in research conducted on ageism in language, the phrase found to be most effective with participants was “a just society ensures that we all can continue to participate and contribute as we age.” This involves the concepts of social justice and social responsibility without being overtly political. Connecting various forms of injustice and broadening the conversation beyond race has also been effective in reaching larger groups of people. Sweetland noted that in regard to systems change, research found the most effective language in mobilizing people is “the system is not working for everyone, and it is our responsibility to make sure it does.”

Schneider remarked that it is challenging to link the concept of reducing wasteful medical spending with the concept of investments to remedy inequities. He suggested that insights from behavioral economics—specifically, the human tendency to overvalue losses compared with gains—are relevant, because efforts to reduce medical spending emphasize a potential loss for many. Moreover, gains in the future are valued less than immediate gains, presenting a challenge if shifts in spending from medical to social services in the present are designed to produce future—rather than immediate—health gains. Schneider stated that two health care systems exist in the United States: one system for people who are insured through employment and another for those who do not have employer-provided insurance, are covered by public insurance programs, and frequently use the health care system. Issues of racism and associated mistrust further complicate health care delivery. A possible consequence of reducing medical spending is that people in both systems may experience immediate losses or perceive themselves at risk of an immediate loss. For example, people experience a loss when nearby hospitals or clinics close; the threat of such losses is less abstract than the promise of a future benefit from social spending. Schneider added that one of the largest social spending increases for reducing childhood poverty, which was recently passed into law, was offered in the context of COVID-19 pandemic relief rather than associated with reduced medical spending (American Rescue Plan Act of 2021, Public Law 117-2, 117th Cong. [March 11, 2021]). Gollust added that individuals may have difficulty conceptualizing the abstract idea of health spending waste. Instead, they may perceive reducing health care costs as eliminating tangible services that they receive, such as screenings, diagnostic evaluations, and prescriptions.

Jones noted a tension in the dialogue about health costs between framing it as a problem for individuals or as a systemic issue. In his focus groups with legislators, some people focused on the costs of deductibles, premiums, and other out-of-pocket costs to individuals, while others said that the way to decrease consumer costs is by addressing systemic issues. Jones added that according to his research, policy can be advanced regardless of whether consensus is reached on the framing of this issue as individual or systemic.

Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
×

ROLE OF COMMUNITY-LEVEL EFFORTS IN POLICY CHANGE

Gollust remarked that framing health care spending as a problem to be solved entirely by the government can lead to individuals fearing that they will lose valued services. An alternative would be community collaborations—such as the one between United Way of Greater Cleveland (UWGC) and the Center for Medicare & Medicaid Innovation (CMMI)—which can shift authority to community members to demonstrate leadership and communicate with the public. She asked panelists for their perspectives on the most credible messengers for advancing policy change. Haynes replied that communities need to be more heavily involved in identifying solutions to health system problems because community members are experts on the personal experiences of people living with these problems. She suggested that rather than attempt to roll out a model for the entire country to use, the government can provide resources to local efforts that can be scaled up. A bottom-up approach that develops solutions in partnership with community-based organizations is less likely to lead to resentment from community members and may lead to local job creation, Haynes said.

Jones recounted that in interviews he conducted in Mississippi, he learned of a doctor who saw the consequences of inequities and inefficiencies on his patients and used his position to challenge hospital policies, insurance company prior authorization practices, and local culture. He added that local doctors are trusted and respected community members who can challenge norms. Schneider commented on the emphasis on community health in the 1960s by activists such as physician Jack Geiger—who helped bring the community health center model to the United States—and the Black Panther movement, which created a series of health clinics in Oakland. Community-oriented primary care could result in spending reductions, Schneider said, but efforts to strengthen it in the United States have been inadequate in recent decades. However, he added, other countries, including Cuba and Costa Rica, have effectively strengthened the notion of community-oriented primary care by coalescing the strength of the community’s confidence in nurses, doctors, and community health workers with greater accessibility, justice, and efficacy of care.

Speaking to Haynes’s point about the resentment that top-down approaches can engender, Schneider said that in working with the Utah legislature he learned that conservatives supported a locally generated initiative to build housing for individuals experiencing homelessness. He suggested that local efforts can be more pragmatic and garner bipartisan support more easily than federal programs. Highlighting the difficulty of reaching consensus on health care reform at the federal level, he said that his polling research indicates that approximately three-quarters of Democrats prefer a government-run health insurance system while the same

Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
×

proportion of Republicans prefer private insurance. Jones reported that his research has found the concern about health costs to extend across party lines, with some conservative legislators having voiced support for reducing government spending through supporting social determinants of health. However, as soon as the conversation turns to national plans, participants tend to adopt party-line stances on health care reform. This points to the power of local-level dialogue.

Sweetland said that the FrameWorks Institute is systematically tracking American perspectives during the historic COVID-19 pandemic as well as the broader calls for racial justice that have taken place in 2020 and 2021. She continued that both trust in the health care system and positive models of government have increased for Republicans and Democrats, potentially creating an opening for change. Techniques that can be effective include framing the social determinants of health as cost-saving measures and providing the specifics of one determinant rather than listing a host of them. For instance, connecting the availability of sidewalks and safe public places to exercise with the public understanding of exercise as a lifestyle choice can broaden perspectives from narrow health individualism. Schneider added that local community reinvestment strategies from hospitals into housing and other community needs are a method of building consensus at the local level to address the needs of populations that have historically been economically disadvantaged.

PERSPECTIVES OF MEDICARE RECIPIENTS

Gollust asked whether research suggests that people in the Medicare program have different perspectives on health costs than the general population. Schneider replied that it is difficult to distinguish the age cohort effect from Medicare insurance status. As is the case in other age groups, the attitudes of Medicare beneficiaries tend to follow ideological and partisan lines. People with Medicare are generally satisfied with their insurance, with 80 percent of Medicare recipients polled indicating satisfaction. The numbers are similar for Medicaid recipients, Schneider said. Many people do not understand that Medicare is a public insurance program, especially given that the Medicare Advantage program appears very similar to private sector insurance. Schneider added that the perception of loss is pertinent to the discussion on health reform, as Medicare beneficiaries are often concerned about reductions in benefits.

Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
×

TECHNIQUES USED IN FRAMING HEALTH SPENDING REFORM

Framing Health Services by Value

A participant asked whether any communication techniques are particularly useful in helping the public understand the difference between low-value and high-value health services. Schneider replied that a decade ago, the American College of Physicians selected the term “low-value care” to frame this issue for clinicians, with the hope that the terminology would spread to patients (Gardner et al., 2010). He added that the Choosing Wisely program is predicated on the idea that doctors can help patients navigate medical services to avoid low-value options.1 The framing of health spending in terms of value has been helpful in the clinical community, Schneider said, although it is less clear whether this has spread to the public. Jones added that Gov. Jared Polis of Colorado created the Office of Saving People Money on Health Care, which works toward a goal of transparency in health costs. He noted that consumer market principles do not always apply to health care and that increased transparency will not automatically enable patients to select services that bring down health costs. However, more transparency about price variation and profit margins can shift conversations about the role of markets in health care.

Sweetland expressed concern regarding a consumer frame for health care that contains terminology such as “low value,” “high value,” and “saving people money.” While Frameworks Institute has not tested terminology regarding health care costs specifically, research in communication about child care costs may apply. The researchers found the most compelling approach in communicating with the public was to frame the issue in terms of benefits and effectiveness. This involved communicating the scientifically based effectiveness factors that shape the quality of the child care experience; in the absence of these factors, children may spend a great deal of time in a program without receiving much benefit. Cost was not discussed, but high-value services were implied. Schneider added that a marketing mentality of health care is reinforced by the aggressive marketing of high-cost services, even though these services may have low value. He cited an article, “The Thousand-Dollar Pap Smear,” which details how a new technology for Papanicolaou testing offered slightly better detection at a much higher cost (Bettigole, 2013). Once evidence suggested that the new test was marginally better as a diagnostic test, it was widely adopted even though its impact on cancer prevention had not been evaluated. The health system had to absorb its higher cost. Low-value services are not the only cause of high health costs; high-value services that are more expensive than

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1 https://www.choosingwisely.org (accessed June 7, 2021).

Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
×

other high-value alternatives also contribute to the problem. Gollust noted that public opinion is influenced by the broader messaging ecosystem—including industry marketing, politicians, and the news media.

Geographic Contexts and Comparisons

Gollust asked how geographical comparisons of health spending and outcomes can shape the dialogue about health care in the United States. Jones replied that policies vary greatly from state to state, with the local context influencing the opportunities for dialogue. In his last round of research, he intentionally selected states representing different combinations of Republican and Democrat control of the governorship and legislature. He found that the ideological differences reached beyond political party, with divisions observed among those living in rural, urban, and suburban areas. For instance, Republicans in rural Colorado were more likely to be open to government intervention to increase health services, whereas their suburban counterparts tended to focus on limiting the role of government. Jones said that leaders from various states share ideas by communicating with one another and with Medicaid directors and representatives of the National Association of Insurance Commissioners. He added that insufficient research has been conducted on the impact of context when a program from one state is implemented elsewhere.

Schneider mentioned “state scorecards” published by TCF to compare state health systems. He commented that state leaders can be resistant to learning about progress in states that they do not identify as peers because of conflicting ideology or other factors. International comparisons may be more compelling, as people often have fewer preconceived notions about other countries than they might have about other states, but other countries may not be viewed as peers either. Peer comparisons seem most helpful as a motivator for people to investigate a problem or to identify a locally applicable solution. Demonstrations can be used to generate evidence that programs in other states or countries will translate to additional settings. Sweetland remarked that American exceptionalism should be considered when determining messaging strategies. Many Americans will assume that the United States is by definition the best in the world at everything, she said, and they will dismiss international comparison data that do not support this belief by rationalizing differences with cultural stereotypes rather than focusing on policy. Americans may not have many associations with other countries, but stereotypes persist. Sweetland said that a technique in navigating this exceptionalism is to generalize findings by omitting the names of specific countries where the data originated, instead saying that a certain policy or practice is working “elsewhere.” Schneider replied that one approach to American exceptionalism is to invoke several countries

Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
×

that have accomplished something that the United States has not, highlight differences between those countries to indicate that the policy can work in a wide variety of settings, and then suggest that a uniquely American solution be crafted based on the lessons from these other countries. Haynes added that the specific interests of policy makers can be considered in pulling tools and methods that align with those interests from other programs.

Disassociating Social Service and Health Care Spending

Given that the American Rescue Plan (ARP) included an extensive package of upstream investments, Gollust asked whether advocating directly for investment in social services and a social safety net might be more effective than pushing for a reallocation of health care spending. Schneider answered that he sees this as the best approach, both because the health dividend concept is too abstract for many people to understand and because it avoids framing the issue in terms of loss. He added that in the wake of the COVID-19 pandemic and the inequity it revealed, this could be a particularly powerful time to advocate for social investments that will also have health and spending consequences in the future. Sweetland added that advocating for social investment makes an affirmative case for what is desired, rather than what needs to stop. In addition, this can be paired with communicating the collective consequences of not taking action; this taps into loss aversion by highlighting lost opportunities while avoiding associating social programs with health care that people do not want to lose. When health spending is framed as being in competition with education or other priorities, the issue can become quickly politicized, Sweetland said. Jones added that safe, equitable housing and equitable education may be avenues to achieving population health, and these issues do not necessarily need to be tied to health in order to move forward.

Communications Campaign Targets

Gollust asked whether any benefit could come from a communications campaign that highlights adverse physical and economic outcomes associated with too much health care. Haynes suggested that a better approach might be to explore the problem that is driving health care usage, which she posited is likely related to social determinants of health. Schneider said that excess care is a difficult concept for many people to understand. Furthermore, international comparisons indicate that the United States has fewer doctor visits and hospital beds than several other high-income countries; it is price that drives up spending, rather than excessive use of services, he said. This is most clear when comparing U.S. prescription drug prices with those in Canada. Moreover, people who undergo unnecessary

Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
×

procedures experience inconvenience and waste their time and money. However, because the majority of unnecessary procedures tend to happen in low-risk situations, most people do not experience the most troubling avoidable adverse events, Schneider said. Gollust suggested that since physicians are the ones to prescribe services and make referrals, communications campaigns targeting doctors—such as the Choosing Wisely program—may be more effective than efforts to make the public understand the value of care and the overuse of services. Schneider added that in the early 2000s, chemotherapy was overused for people with advanced cancer. Payment incentives were changed, which led to an immediate decrease in the inappropriate use of chemotherapy. Therefore, he said, levers that do not directly involve the consumer are more likely to make an impact on unnecessary spending.

FINAL THOUGHTS

Gollust asked each of the panelists to share some closing insights. Jones commented that public opinion and policy change are not mutually exclusive and that they can influence one another. He explained that John Kingdon’s policy windows theory posits that windows of opportunity for political change are created when there is a convergence of consensus on the problems that need solving, available solutions, and political will (Kingdon, 2003). Jones said that his research indicates that a consensus on the problems that need solving has yet to be established in the United States. Sweetland remarked on communication efforts—specifically, the science involved in determining what to explain and emphasize versus what to leave unsaid. Narrative shift is a strategy that can be studied for use in building population health, she added. Schneider stated that in a time of heightened partisanship and political polarization, the window of opportunity seems to be opening for equity and social justice issues; this could potentially be taken advantage of to address health spending and the health dividend. Haynes added that a holistic approach can be used to frame health equity as a benefit for everyone.

Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
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Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
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Page 38
Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
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Page 39
Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
×
Page 40
Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
×
Page 41
Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
×
Page 42
Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
×
Page 43
Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
×
Page 44
Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
×
Page 45
Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
×
Page 46
Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
×
Page 47
Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
×
Page 48
Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
×
Page 49
Suggested Citation:"4 Framing and Shifting the Health Narrative in the United States." National Academies of Sciences, Engineering, and Medicine. 2023. U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26425.
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 U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop
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The Roundtable on Population Health Improvement, a convening activity of the National Academies of Sciences, Engineering, and Medicine, held a workshop on March 15-16, 2021, to explore issues related to increasing health care spending in the United States. The workshop, U.S. Health Care Expenditures: Costs, Lessons, and Opportunities, was organized to highlight the persisting challenge of health care expenditures that are not commensurate with the health outcomes they produce. This publication summarizes the presentation and discussion of the workshop.

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