Distrust In The U.S. Health System: Are We Paying Attention?

Like 20 million others, I watched the 9-hour Senate Judiciary Committee hearing last Thursday. The testimonies and subsequent questioning of Dr. Christine Blasey Ford and Judge Brett Kavanaugh were intense. It is certain to be headline news this week as the FBI investigation into the veracity of Dr. Ford’s allegations is concluded. 

In my meetings in New York City, Salt Lake City and Seattle this weekend, the Kavanaugh hearing was on everyone’s mind. Reactions to the testimonies of the principals and the decorum of the Committee varied, but there was consensus on one topic: our political system is dysfunctional and needs fixing. The people I talked with think partisanship trumps policymaking and statesmanship is beyond reach in our current political environment.

Gallup’s surveys about the public’s trust in our institutions since 1973 confirm their view: 11% of U.S. adults say they have “a great deal or quite a lot” of trust in Congress, down from 45% four decades ago.

Gallup: The Institutions Americans Trust Most (% A Great Deal/Quite A Lot)

Institutions 2018 2008 1998 1988 1977
The Military 74 71 64 58 57
Small Business 67 60 57 na na
The Police 54 58 58 52* na
The Church/Organized Religion 38 48 59 49 64
The Presidency 37 26 53 50 43
The Supreme Court 37 32 50 56 45
The Medical System 36 35 40 34 74
Banks 30 32 40 39 60
Public Schools 29 43 37 39 53
Organized Labor 26 20 26 26 39
Big Business 25 20 30 25 32
Newspapers 23 24 33 35 38
Criminal Justice System 22 20 23 17* na
TV News 20 24 34 46* na
Congress 11 12 28 35 45

* Gallup did not survey opinions on 6 of the 15 dating back to 1973. For most of these, surveys began in 1993.

In Gallup’s June 2018 survey, trust in the military and small business scored highest consistent with prior surveys. But of the 15 institutions, only one has seen its level of trust fall as precipitously as Congress: the medical system. Over the 40-year period, trust in Congress has fallen 34% and trust in our medical system has dropped 38%.

These findings parallel polling done by Pew Research, Harris and others: trust in the U.S. healthcare system is low. Edelman called it an “extreme trust loss.”  (Edelman’s Trust Barometer, June 12, 2018) 

Trust is the most valuable asset individuals, organizations and institutions possess. In healthcare, trust is foundational. We trust our physicians to recommend treatments based solely on their effectiveness and appropriateness to our diagnosis. We trust that our drugs and technologies are recommended solely on the basis of their efficacy and effectiveness. We trust our hospitals are safe and their clinicians practice evidence-based care. We trust our health insurance plans protect us from financial ruin due to unforeseen medical costs. We trust the advisors used by healthcare organizations—the consultants, lawyers, accountants—offer independent counsel void of concern for their own personal enrichment. We trust our health system puts purpose before its profits. But when our personal experiences suggest otherwise or egregious missteps garner media attention, distrust displaces trust.

Stories about fraud, price gauging, coverage denial, excessive profit, avoidable error, ethical breeches and unhealthy work environments cast doubt and compromising trust in our healthcare system. The frequency of news coverage and social media attention to our misdeeds is intensifying, lending to the growing distrust in healthcare. Surveys by Harris, Pew and Gallup show the public’s trust in our system’s major institutions—hospitals, health insurers and drug manufacturers—at near all-time lows. And high-profile disputes between insurers, hospitals and physicians lend to the public’s suspicions that our talk does not replicate our walk.

Can growing distrust in our health system be remedied? Or does it matter? After all, the profits for our system’s biggest operators are robust. The supply of new drugs and technologies is flush and expanding. The ranks of those lacking insurance coverage are less than 10% and the public believes the quality of care in U.S. healthcare is still the world’s best. Not to worry? Hardly.

Public trust is necessary to our system’s long-term viability. The erosion of public trust invites displacement by alternatives. “Medicare for All” is appealing to those that distrust the status quo. “Amazon Health” is appealing to those who are less concerned about trust and more concerned about its lack-luster performance in meeting their needs. Disruptors see opportunities in every domain of our system in large measure because many no longer believe its claims to care about quality, accessibility and affordability.

Public policies that require expanded access to price transparency and quality ratings for drugs, hospitals, physicians, nursing homes and other players are a start. But probably not enough to restore trust. Net Promoter Scores and patient/consumer experience monitoring are useful but fail to gauge the depth of an organization’s institutional trust.  

This week, we’ll hear a lot about the potential confirmation of Judge Kavanaugh and the veracity of serious claims brought by Dr. Ford and other accusers. But looming in the background is perhaps a bigger issue—the level of public trust in our institutions—Congress, the Supreme Court and the news media. Trust in our institutions is vital to our free society. That includes healthcare.

Growing distrust in our healthcare institutions is an issue that must be taken seriously.

Paul