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This chapter is from the book

Occupy Health Care

Paul Keckly suggests that “a massive, predictable pushback directed at the US healthcare system may result in an Occupy Health-care movement” similar to the Occupy Wall Street movement.29

Americans are questioning the value of long-standing institutions and, increasingly, are responding by either avoiding them or trying to upend them. And so it is, he says, with health care.

Rebuilding the System

Are Americans satisfied with their health care system? The answer is “not very” when compared with other countries. In a survey by the Commonwealth Fund in 2013 of the general populations in 11 countries—Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States—responders were asked whether their country’s health system (a) “works well, needs minor changes,” (b) “needs fundamental changes,” or (c) “needs to be completely rebuilt.”30 Responders in the United States were much more likely than their counterparts in other countries to endorse major reforms. Only a quarter of Americans said the U.S. system worked well enough to need only minor changes, while almost half said it required “fundamental changes,” and another 27% said it should be completely rebuilt. Compared with other countries on the percentage of responders who said it should be completely rebuilt, the United States is more than three times that of the average of all the ten countries, almost seven times that of the United Kingdom, and more than twice that of the country closest to it (Norway). The survey indicated frustrations with the American way of health care that contribute to the preference to rebuild the system, which mostly had to do with cost and complexity. Americans were significantly more likely than their counterparts in other countries to forgo care because of cost, to have difficulty paying for care even when insured, and to encounter time-consuming insurance complexity.

Generation Unmoored

The Millennial Generation, the 18–34 year segment of the U.S. population, is about 80 million strong and is at the leading edge of this avoid-and-replace attitude. The Pew Research Center surveys the different generations of the U.S. population on their attitudes, beliefs, values, and actions. Its 2014 report focuses on how the Millennials compare with other generations, including Generation X, Baby Boomers, and Silent and the implications on how they may change the status quo of established institutions and facilitate the emergence of new ones.31 For comparison, the ages of the other generations are Generation X, 34–49; Baby Boomers, 50–68; and Silent, 69–86.

One of the major observations of the report is that Millennials are “unmoored” from important institutions. For example, 50% have no political affiliation (compared with 37% of Boomers), 29% are religiously unaffiliated (compared with 16% of Boomers), and 26% are unmarried between the ages of 18 and 32 (compared with 48% of Boomers). Another major finding is that Millennials are relatively untrusting of people and institutions. Only 19% say that most people can be trusted, half the percentage of Boomers. Millennials are not faring well economically, due in no small part to the Great Recession. They are the first generation to have higher levels of student loan debt, poverty and unemployment, and lower levels of wealth and personal income than their two immediate predecessor generations had at the same stage of their life cycles. Finally, they are connected to “friends” on social media and are avid users of digital devices. Eighty-one percent of Millennials are on Facebook, where their generation’s median friend count is 250, far higher than that of older age groups.

Their rejection of mainstay institutions, lower levels of trust, poorer economic status, and their preference for digital communications among peers may have profound implications for the institutions of health care. According to Keckley, they expect service 24/7, delivered through multiple devices, anywhere they prefer to be, and responsive to their expectation for convenience and efficiency. They, like responders to the Commonwealth Fund survey, are undoubtedly frustrated by the lack of coordination of services, by “paper” rather than digital, and by paternalistic approaches to their health care and insurance. They want health care data on prices and quality to be readily available and transparent just like it is in other industries, including retail and banking. They have little regard for bureaucratic inefficiencies and have a negative view of the difficulties in getting insurance and getting their own data from medical records. They question the necessity and value of the services proposed by doctors given their financial situation and the steep out-of-pocket expenses they face with high-deductible insurance plans. They want to know the evidence about what works and what does not. They do not accept the adage that “doctor knows best” and are likely to flip the paradigm from “My health is up to my doctor” to “my health is my responsibility and I need to have the tools to manage it.” They may have a jaundiced view of excessive profits, unless it is clearly earned through dedication to purpose and the delivery of good results. And they want the arguing in health care to stop between insurers and providers, members of Congress, and other warring factions.

A new insurance plan, founded by two Millennials who think they know what their peers want (as well as the rest of us), is called Oscar. It is taking on the staid business of health insurance by providing an easier customer experience, a well-designed website, unlimited phone calls with physicians, and price transparency. One of the founders, Joshua Kushner, 28, thought there has to be a better way when he opened up a bill from his insurer and could not understand a thing.32

The infamous Explanation of Benefits (EOB) letters are anything but explanatory and seemingly intended to obfuscate the important information on prices and payments that consumers need. The phone calls with physicians can include a quick diagnosis and prescription for common ailments and a discussion about whether to go to the ER after a fall. Oscar also provides an estimate on what the out-of-pocket prices would be for procedures and specialists. This addresses one of the last bastions of secrecy. It is well known that common procedures, such as an MRI, x-ray, and colonoscopy, can have prices that vary threefold or more depending on the provider and payer agreements.33 And neither the provider nor payer seems to “get it” that people deserve this information and do not like that it is hidden. Mr. Kushner says, “What we’re doing here—showing prices—should have been done 20 years ago.”34

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