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The Keckley Report

Public Enemy #1 in Healthcare: Ignorance

By February 29, 2016March 1st, 2023No Comments


In our healthcare system, public health enemy #1 is ignorance. More than obesity, heart disease and mental health, our collective lack of informed understanding of how the U.S. health system works is costly and threatens our future.

In a testy exchange in Tuesday night’s GOP Presidential debate, CNN’s Dana Bash repeatedly asked Donald Trump for specifics about his health policies. He, along with his fellow contestants, espouses repeal of the Affordable Care Act, but thus far, its replacement or what his administration would do is lacking in detail. Trump offered no answers. But before sophisticates and critics pile on, bemoaning the lack of civility in our political discourse and shallowness of policy solutions on both sides, let’s be honest. Soundbites work, especially in healthcare policy. As a populace, only 1 in 8 adults is proficient in understanding the basics of how the health system operates and only half in our population have a basic level of health literacy to understand the terms we throw around.

Unlike any other sector in our society, healthcare occupies a unique position in the electorate: every individual is an expert. Each of us uses the health system frequently, and many daily. We frequent doctor’s offices, hospitals, clinics and pharmacies, and based on these, develop strong beliefs about our system based on our unique experiences and those shared by others in our social circle. How, then, is ignorance a threat?

In 2006, while at Vanderbilt, I conducted a study for the Agency for Healthcare Research and Quality (AHRQ* to dig deeply into the core beliefs that anchor how consumers view the system. Based on sixteen two‐hour focus groups in San Diego, Chicago, Teaneck NJ and Columbia TN stratified by age, socioeconomics, insurance and health status, seven core beliefs emerged:

  1. “I believe medicine is too complex for me to understand and prefer my physician to tell me what to do
  2. “I believe good medical care is about getting access to my doctor when I need him/her
  3. “I believe healthcare is better for some than for others
  4. “I believe healthcare should be available for all but not under government control”
  5. “I believe health costs are high but there’s not much I can do”
  6. “I believe the profit incentive in the health system is strong and care is compromised”
  7. “There’s not much I can do”

My report concluded: “Consumer attitudes reflect personal experiences with the system, primarily interactions with doctors, hospitals, and insurance companies. Therefore, the context for understanding healthcare consumerism is deep seeded beliefs about the health system, not attitudes about specific problems, concepts, ideas, organizations or policies. Beliefs do not change easily: when they do, the change is transformative. The belief system of healthcare consumers is highly personalized, built from personal experiences and powerful emotions. For the vast majority, these experiences are negative, and particularly for those in minority and uninsured groups.”

I remember those facilitating those groups and reviewing the videotapes as I prepared the report. It’s easy for folks to talk about healthcare. Their personal experiences guide frame their strongly held beliefs, and the sense of helplessness to address its complexity and accessibility is profound. I suspect not much has changed in the decade since.

As I watched the exchange Tuesday night, and daily media coverage of the Presidential contest in both parties, I find myself frustrated by the reluctance of candidates to offer specifics about their health policies but I understand why. Politically, it exposes candidates to potential attacks from opponents, and practically, it would fall on deaf ears.

There’s scant evidence the majority of consumers are inclined to be informed. Transparency about the performance and profitability in each of the industry’s key sectors is at an all‐time high. Employers are forcing employees to assume greater financial risk in their plans and using tools to equip them to shop appropriately. Private insurers and technology giants are making big bets on direct‐to‐consumer digital tools to equip consumers to manage their own care. And even Medicare is opening the vault to its treasure trove of data to expose the system to heightened public scrutiny. But an informed view of how the system behaves remains largely elusive.

British philosopher and mathematician Alfred North Whitehead wrote “it’s not ignorance, but ignorance of ignorance that is the death of knowledge.” Ignorance is lack of knowledge. While the knowledge held by U.S. consumers is experiential, it is incomplete. As a result, it’s harmful to our health and costly to our system.

Little wonder the candidates are long on promises and short on specifics. The voters aren’t listening.


P.S. Tomorrow, the Super Tuesday primary contest in 11 states will be settled and, in all likelihood, the field narrowed in the Campaign 2016 contest. In the next 8 weeks, The Keckley Report will focus on the key healthcare issues in the campaign in a non‐partisan, fact‐based approach: The Issue, The Facts, The Options (with upside and downside for each).

*AHRQ Contract No. 290‐04‐0016


“In our workplaces and classrooms, we teach the virtue of civility and espouse contempt for bullies. But in our politics, it’s rewarded.” (Keckley Tweet 2‐1‐16)


Facts you can use

Literacy: 14% of adults have Basic or Below Basic Health Literacy, 53% have intermediate health literacy skills. 21% have basic and 12% have proficient health literacy skills National Assessment of Health Literacy, U.S. Department of Education, 2003 Institute of Education Sciences, 2003

Overall literacy trend: the average score for adults age 16 to 65 in the United States on the Program for the International Assessment of Adult Competencies (PIAAC) (2012) was not significantly different from the score on ALL (2003-08) but was lower than the score on IALS (1994-98). (National Center for Education Statistics)