Does the Affordable Care Act give the American people what they want?

Now here’s a novel idea. What if someone asked the American people, or a demographically representative group of it, what it wants from healthcare. That would be called “market research.”

Ask the public what it wants, listen carefully, and then give it to them.

Turns out that the New York-based Commonwealth Fund has done just that.

In brief they found:

  • 72% of American adults believe that our healthcare system needs to be fundamentally changed or completely rebuilt.
  • 71% have experienced difficulty in accessing a doctor without having to go to an emergency room, especially any time other than Monday through Friday, 8 to 5; 55% report wasteful poorly coordinated care; and 21% reported having experienced a medical error in the past two years.
  • 96% want accessible, coordinated, well-informed care; 94% want a medical home; 86% want doctors and nurses to work as teams; 92% want information technology applied to healthcare; and 57% want Internet access to their records and email communication with their physicians.
  • 75% expressed worry about their own future healthcare.
  • And, 86% believe that prices for all aspects of medical care including products and services should be negotiated by public and private payers to control costs and improve quality.

These results are remarkably uniformly spread across income and education levels, geographic regions, and political affiliations.

The problems cited are real and damning.

The wish list is what any sensible person would expect, especially for the kind of money that we spend.

The systematic incompetence of healthcare as experienced by “the market,” would not be tolerated by the public from the airline industry, automobile manufacturers, computer companies, restaurant chains, clothing manufacturers and sales, not even from cable TV or cell phone companies.

We in healthcare should be ashamed of ourselves.

The Affordable Care Act (ACA) does address many, but not all of these issues, either directly or in pilot programs.

The problem is that even if the ACA is not found unconstitutional by the highest court, or unfunded by a hostile Congress, its full rollout is still at least three years away.

I believe that this prolonged delay to full implementation will be found by historians to have been the fatal flaw in its construct.

George Lundberg is a MedPage Today Editor-at-Large and former editor of the Journal of the American Medical Association.

Originally published in MedPage Today. Visit for more health policy news.

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  • IVF-MD

    Very interesting results. However, of the five-item wishlist above, who wants to bet that all five would get worse in the long run if government health care finally gets fully implemented? Well #5 is a given to get worse, just by definition.

    It’s great that the people are asked what they want, but in the real world, people speak most effectively with their spending dollars and if allowed to do so, then naturally, the things that people want will thrive and grow and the things that they don’t want will fade away and stop sapping resources. In my humble opinion, less bureaucracy and waste is the answer, not more of it. But other people are entitled to disagree. It would be enlightening to hear their logic, though. Thank you.

  • pcp

    “96% want accessible, coordinated, well-informed care; 94% want a medical home; 86% want doctors and nurses to work as teams; 92% want information technology applied to healthcare; and 57% want Internet access to their records and email communication with their physicians.”

    97% are in favor of rainbows and cute puppies. And 99% want the right to drag their doctor through an expensive process of litigation for any perceived error of commission or omission.

    Not a lot of useful information here, and, no, I’m not ashamed of myself.

    • Melissa

      Thank you for the laugh. It has been a long day at the clinic and your comments gave me the first spontaneous smile of the day.

  • Joe

    The surveys are all but useless. “Do you want to have your cake?” Check a box, “Yes” or “No” … “Do you want to eat it, too?” Check a box, “Yes” or “No”.

    A useful survey would take scarcity into account – perhaps by ranking services, aspects, or ideas in terms of importance.

  • Margalit Gur-Arie

    “94% want a medical home; 86% want doctors and nurses to work as teams”
    and from the article…
    “Most adults believe that doctors and nurses should work in teams and practice in larger groups, rather than on their own, to improve patient care (Exhibit 10).
    • Nearly nine of 10 adults (86%) believe it is important for doctors and nurses to work together as teams, with an expanded role for nurses.
    • About seven of 10 adults (65%) feel that group practices would benefit patient care.
    The public’s support for doctors practicing in larger groups is consistent with earlier surveys and with a growing body of evidence that finds larger, multispecialty group practices and integrated delivery systems can deliver higher-quality care, and potentially more efficient care

    Is there a copy of the survey posted anywhere? Were people asked if they want to see nurses instead of doctors, or just something about cooperation?
    As to large multi-specialty groups, I would like to know how that question was posed as well.
    It is not difficult to pose just the right questions so you get the “right” answers.

    • IVF-MD

      MG-A, with all due respect, I don’t quite agree with your interpretation or what patients mean by wanting “team medicine”. When patients say they want their care rendered by a team, that does NOT necessarily mean large multi-doctor groups, as you imply. For example, my patients who came to my practice after having been seen previously in a large-group setting tell me outright that they greatly appreciate that I am the sole provider who talks to them every visit, I do all their ultrasounds, I do all their inseminations and when the time comes, I’ll be the one doing their surgery. I have yet to have one say, “Don’t you have a teammate or some other random doctor whom I’ve never met to see me this today?”

      I agree with you that the survey results depend a lot on the wording. If the question was “Do you want your doctor and nurse to work as a team or would you rather they operate independently in the dark, not knowing what each other is doing?”, then I bet you’d get 90%+ choosing the former. Working as a team does not imply tag-teaming the patient with multiple doctors seeing them over the course of their visits. It could well mean having each member of the practice working in unison with each other. It does NOT have to multiple different doctors. At least that’s the way I interpret it.

      • Margalit Gur-Arie

        I’m pretty sure you are right. The above is a quote from the article describing the survey, and I was questioning its validity.
        This is one of those rare occurrences where the liberal me completely agrees with the libertarian (?) you…. :-)

        • IVF-MD

          M G-A, I’m confident we both want the same thing. Good medical care. Good accountability. Good quality of life for everybody and incentives to sway people to contribute to the world and do the right thing. We both also want the powers of corporations to be kept in check.

          I appreciate learning from you.

          • Margalit Gur-Arie

            Strange how everything seems just minor quibbles when you put it this way….
            I am the one doing the learning here, and it’s been a pleasure.

      • Dave

        Yes, I’m pretty sure by team, they just mean they want a real PCP and then all of their specialist care actually coordinated. IE test results are shared, and the left hand knows what the right is doing. There was a previous article where it was stated that one patient had like 5 B12 levels ran in a month! Not that these are super expensive, but such was totally unnecessary and occurred due to poor communication. Stuff like that happens more than it should.

        However, it won’t be fixed as specialists (and PCP’s to a lesser degree) don’t get paid to talk to one another. So such communication/teamwork will be kept to a minimum.

  • doc99

    Be careful what you wish for. You may get it.

  • Stalwart Hospitalist

    As others have commented above, I believe such a survey would be more useful if it framed questions in such a way that patients would realize that having more of one thing may result in less of another.

    There is no free lunch.

  • DocB

    repeatedly, people “say” they want competent coordinated care and attention from their doctor (presumably a PCP.) however…
    the current system doesnt pay for that and no one really wants to even talk about correcting the problem that “steals” time away from the patient doctor relationship.

    until we give PCPs back “TIME” with patients…. NOTHING will improve. ultmately… someone has to pay for that. as long as we ignore that… nothing will improve….

  • Alice

    Ask the public what it wants, listen carefully, and then give it to them. [end quote]

    You mean ask the public what they want that is within reason?  If you asked me what I want…hmmm….heated gowns…foot massage while getting a test…oh teasing….but money is the issue starting with doctors wages (and you do not want to give the public what they want in that area…they would have doctors making far less money, and working more hours.  The image of the four day work week, golfing, overly vacationed doctor still persists).   I better share I think doctors are paid fairly.  I was just at a cancer symposium in Chicago yesterday. Those doctors did a magnificent job…their sacrifice should be repaid.  The doctors were very clear they were there to serve and help and offered  an open line via email if we had more questions. 

    Basically, this free symposium (that did have a survey with each doctor’s name listed with a rating system next to it) gave patient’s the voice they are trying to find.  Sure it seems inflected right now.  Most patients are just starting to understand the consequences of inaction upon their own health, and few understand the dire straights all these wants represent.  Many just want….many fear the cost of that group think.

  • Alice

    I was thinking about how this poll can be compared to education.  What parents want, or students, or educators need and want….is often quite different….just as the roads there will have intertwining paths.  Methodologies will differ greatly, and premature decisions can be made on supposed evidence that isn’t truly as comprehensive as the hypothesis derived from that can show when tested. We are in a time of uncertainty…we try to avoid resentment from patients and doctors…but money clouds it all (and it is part the reason we have such staunch regulation on insurers and doctors…bad behavior by a few brought regulation that helps and hurts).  

    I believe expectations will vary greatly amidst age groups…the older group being the most entitlement minded and needy.  And like the school system the young can gain more just by simple accountability…not more money…not more government.

    I guess I think this sums up medicine, although the quote is about schools…”What is learned is that the only thing that spreads well in schools are kids’ viruses”.

  • Doc D

    The Commonwealth Fund is a well-known liberal advocacy organization. They have promoted false comparisons about US longevity (when you remove data on violence and auto accidents the US ranks near the top…as admitted by and infant mortality (other countries don’t count certain births as “live” so their data looks better).

    It’s hard to find balanced polling and surveys. If you want the other side of the story go to the Heartland Institute. Again you’ll get a viewpoint, but a different one.

    For raw data, see the Kaiser Family Foundation, who promote government reform in their hearts, but at least let you see the real data. For instance, when everybody was talking about 42 million uninsured, their data showed that 20% were people whoi were already eligible for Medicaid but hadn’t signed up, and that 10 million were the “temporarily” uninsured for the 3 months between jobs until the new job’s plan picked up. Kaiser just didn’t make much effort to point all this out.

    Organizations like the Commonwealth Fund design their studies with a result in mind, as do many others. It’s our job to see beyond what they “want” us to see.

  • Christy Thomas

    There are lots of comments here deriding the survey instrument itself, and those comments are probably valid. But what you are not dealing with is the original premise: that we as consumers of health care would not put up with this delivery system if it were any other industry, be it education, financial services, or consumer goods. In an economic system like ours, shoddy delivery, hidden prices, undecipherable billing practices, and an inability to get the services needed when needed means the demise of such businesses, organizations and services.

    I am not a medical professional. I am a pastor, and I see the horrors of what happens with medical care all the time. I see children growing fatter and sicker because health care is really sick care and no one is teaching these children (or their parents) health practices because it just doesn’t pay. The almighty dollar wins. So children get expensive operations and medications when what they need is radical dietary change. I see my overly-medicated elderly fall and break their hips leading so often to a death sentence because no one will actually coordinate those medications and get them off most of them since no one can possibly figure out all the interactions of multiple medications.

    I can’t even begin to talk about what happens to the dying–it is our national tragedy, the way we treat those near death. Ridiculous procedures done with prolonged hospitalizations keeping them separate from their families and leading to depression and hope-destroying fear as the are confined to hospital rooms when most people really would prefer honest conversation and loving, Hospice-type care at home. But it doesn’t pay either–so the almight dollar continues to win–and at the expense of the entire nation.

    Throw out the whole health insurance industry–they are the only ones making money in is awful system. Start insisting that patients remember that doctors are human, medicine is an imperfect art, not a perfect science, and death is a part of life. Then toss out mal-practice premiums so physicians can run an office at reasonable costs. Start with an honest, visible pricing system, so people actually know in advance what tests will cost and can be given the option of trying to first rebuild their health by better nutrition and body habits first.

    I know this is radical. But I do not think that small fixes will do anything here.

    • IVF-MD

      Pastor Thomas, you hit the nail right on the head when you say that people would not put up with “shoddy delivery, hidden prices, undecipherable billing practices, and an inability to get the services needed when needed” in any other industry. Now here’s the critical thinking question. Why is that? In other words, why do people put up with dissatisfaction in medicine, but they don’t put up with it with restaurants, consumer goods, etc? By the way, I will correct you in that for the most part people DO put up with it in education.

      The answer is CHOICE. When people have a choice, it forces providers and businesses to compete to put out a better product. That’s a GOOD thing. Everybody benefits. Doctors and businesses have to work harder and put forth more effort, but in the long run, that actually leads to MORE happiness. This is because I’d be a lot happier if my job success hinged on my doing good work as opposed to my having bureaucratized job security where I get paid even if I do mediocre work (ie government work mentality). When a field has a near-monopoly, then they can get away with being mediocre (or worse). I’ve probably written 100 comments on Kevin’s site saying this in one way or another, and you don’t look forward to my repetitive consistency of principle, but a return to free market principles will improve medical care, patient satisfaction and overall quality of life.

      • Alice

        I agree about choice, and accountability. I would surmise the overweight problem Christy pointed out starts at home. Dr. Oz did a show on potluck dinners and tried to help a church that was drowning in obesity and diabetes. He took their blood samples after a church dinner and guests were educated much better after he left. Doctor visits are often about treatment…patients need to educate themselves beyond the quick stop exam room. Doctors give literature that is rarely read…we want the quick fix, not the long drawn out, hard work to fix it, or prevent it road.

        Christy..I loved your passion…but as a Christisn I am big on volunteering and thinking if we can help one person we make headway. Maybe the churches could help their flock and speak about gluttony and diet? Charity begins at home, and surely it is charitable to feed our children well? A life lesson?

    • DrB


      nicely put, but can rational thought actually win the day in this country driven by emotion?

      • stitch

        Read any discussion about immunizations and I think you will have the answer to your question.

        • Alice

          I agree….doctors who actually believe Big Pharma financed studies. Truly dismaying to those seeking real research.

          • stitch

            thank you for proving my point.

        • Alice

          Stitch…if you want some really good research write to me at:

          It is enlightening to enquiring minds who want nothing but the unadultered truth…with no agendas.

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