Speaker 1 (00:05):

Welcome to Hospitals in Focus from the Federation of American Hospitals. Here’s your host, Chip Khan.

Chip Kahn (00:15):

Welcome to Hospitals in Focus. We appreciate you taking time out from your busy schedule to listen in. At a time when skepticism runs rampant, divisive American politics seem to reflect a fraying of the very fabric of our nation. And when trust for our critical societal institutions is clearly waning, there remains significant trust in our country’s doctors, nurses, and hospitals. This appears to buck the trends. What does polling tell us about this apparent sustained support and trust in our caregivers?

(00:51):

And what are its implications as we face stressful public policy challenges in the critical election year? How will healthcare perspectives shape choices in the elections? To help us unravel these questions, we’re joined by Philip Morris, a strategic maestro in the world of polling and a partner at LSG. In our podcast today, he will help us navigate the complex interplay of healthcare, public opinion, policy, and politics in turbulent times. Welcome, Phil.

Phillip Morris (01:27):

Great to be here, Chip. Thanks for having me.

Chip Kahn (01:29):

Phil, let’s sort of start at the macro level. According to your polling, what are the top issues that the public is focusing on right now as we enter this election year?

Phillip Morris (01:42):

So at LSG, we regularly conduct national polling of confirmed likely voters, and our polling shows that the top issues that are most important to likely voters in this year’s election are inflation, the economy and immigration, in that order. Anything that can help bring down the rising cost of living is viewed as a meaningful step forward for voters. Voters feel economic uncertainty despite the fundamentals of the economy being relatively strong and voters would like to see action on immigration to secure the border.

(02:15):

When we look at what is most important now compared to the 2022 midterm elections, abortion then was the third most important issue while immigration ranked six. So as we’ve gotten closer to this presidential cycle, immigration has grown in importance to voters and abortion has declined as we move closer to November.

Chip Kahn (02:35):

Although I guess abortion is an aspect of healthcare, but I didn’t hear healthcare per se in your top issues. I assume it’s still an underlying factor. How does it fit into the mosaic that you’re going to be looking at this year of those issues and matters of concern that will affect voters?

Phillip Morris (03:02):

While healthcare is not a top three issue now like it was in the last presidential cycle, it ranks forth right behind immigration. And when we ask voters what their most important healthcare priorities are that they would like to see lawmakers address. Lowering healthcare costs consistently ranks at the top of their list. Addressing healthcare costs is so important because it directly ties to inflation and their rising cost of living, the single most important issue to voters this cycle.

(03:34):

That ranks higher than improving healthcare quality, expanding access to coverage or really anything else. So while I wouldn’t call this election a healthcare election, I would expect a cost conversation to continue this year as it relates to healthcare.

Chip Kahn (03:51):

Phil, along those lines, if costs are a factor for voters, there are a lot of players in healthcare, there are a lot of stakeholders. Who do they blame? Who do they focus on and what parts of cost are most important to them?

Phillip Morris (04:07):

So voters in our surveys and others are very clear on who they blame most for rising healthcare costs and the lack of transparency in healthcare prices. When we ask who they blame most for rising costs, a majority say pharmaceutical and health insurance companies are most responsible. Only 18% in comparison say they blame hospitals most. When we ask who they blame most for the lack of transparency in healthcare pricing, a plurality 49% say insurers are most to blame compared to only 20% who say hospitals are. Voters tell us that every health plan is different.

(04:46):

So their expectation is first and foremost that their insurance plan provide clear and transparent pricing information about what is and is not covered as well as at what cost.

Chip Kahn (04:59):

You talk about the issue of who they blame. Now let’s look at another aspect, and I talked about in my introduction, this issue of trust. In terms of the stakeholders that you’ve begun to list out, where do caregivers, doctors, nurses, and hospitals stand relative to others that you measured in your survey work?

Phillip Morris (05:21):

So voters’ attitudes toward a lot of the healthcare sector as it relates to costs very much translates to their overall favorability toward these different aspects of the healthcare industry. Hospital favorability ranks among the highest in the healthcare sector with 72% of voters saying that they have a favorable impression. In comparison, we see a significant drop-off with half, 50% saying they have a favorable impression of insurers and less than half, 42% having a favorable impression of pharmaceutical companies and less than a third, 32% saying they’re favorable toward PBMs.

Chip Kahn (06:01):

I hear that insurers, PBMs, those that deal with coverage aren’t testing that high. What kinds of things are affecting the public’s attitudes, particularly when Medicare Advantage is a form of managed care that’s becoming so important inside of the Medicare program? More than half of seniors today are on Medicare Advantage and obviously on the private sector side, all Americans that have coverage are covered by some kind of managed care. What are the concerns that you are hearing about or seeing in your work?

Phillip Morris (06:36):

So I think the concerns generally center around costs and access and anything that is perceived as a threat to those is going to be viewed negatively by voters. I think when we’ve looked at Medicare Advantage specifically, we conducted a recent survey which shows the overwhelming majority of voters have concerns about some of the practices of Medicare Advantage plans and particularly how they can impact access or costs. Over 80% of voters say they’re concerned about Medicare Advantage plans denying payments for medically necessary treatments or services, delaying patients’ access to care by requiring prior authorization and limiting patient’s choice of in-network doctors and hospitals.

(07:21):

And so all of those impacting access in some way. We also saw three fourths of voters say they’re concerned about using supplemental benefits to attract seniors to plans that may not meet their full needs, which can of course have a cost impact. So I think at the heart of what’s really driving favorability and unfavorability to a variety of parts of the healthcare sector, it’s really centered around how they’re performing on costs and access. And we see consistently hospitals are faring best on those metrics while some others have many more challenges.

Chip Kahn (07:58):

Well, it does seem like the voters are aware of what’s going on right now regarding denials and delays of payment. Clearly they’re concerned about a limited physician choice, and I also hear from you, potential deceptiveness of ads in terms of marketing of these Medicare Advantage plans to seniors. One other issue that I’m interested in whether or not the public is sort of aware of, is the issue of nurses at the bedside in hospitals and other settings and other healthcare workers who are in short supply right now.

(08:36):

Is there an awareness of this among the public? Does it sort of make the Geiger counter for them?

Phillip Morris (08:43):

So remarkably the vast majority of voters are aware that we have a national nursing shortage and believe it’s important that we work to address it. They see the nursing shortage as a threat to access and quality of care at their local hospitals. It’s another reason why voters are also very concerned when labor unions call for nursing strikes, which can exacerbate that workforce challenge hospitals face and negatively impact patients. And we also see that they view hospitals as playing such a critical role in educating and training the nation’s physicians.

(09:21):

And so any policies that can further incentivize growing that healthcare workforce are viewed very favorably among voters.

Chip Kahn (09:29):

One of the concerns that we have is that there’s much discussion among policymakers about cuts to hospitals that would affect hospital funding and other moves that might limit our ability to maintain access of hospital care for patients, particularly in rural areas, underserved areas. Going back to my Geiger counter question, does that hit the Geiger counter for voters and how do they feel about the questions of their representatives of being supportive of sustaining hospital funding for patient care?

Phillip Morris (10:10):

It sure does, and that’s not the case for every industry. Some industries in our polling, we see there’s not a whole lot of concern or sympathy for the level of funding that they receive. However, for hospitals, hospital funding is very much viewed as patient funding and directly either positively or negatively impacting patients. The overwhelming majority of voters we’ve surveyed, 82% say they believe it’s important that there is adequate government funding to ensure hospitals in rural and underserved communities stay open.

(10:43):

In fact, 70% of them would be less likely to vote for their member of Congress if they cut funding for hospitals and threaten their ability to stay open. Protecting access to care is so important that there is real political impact for lawmakers on this issue. Despite the media narrative around consolidation, a majority 60% say they support hospitals being able to consolidate into larger health systems and understand how this helps keep hospitals open serving patients and preserving access to care. Why do they support consolidation?

(11:22):

Most voters, 64% say they believe hospitals that operate as part of a larger or regional network generally deliver higher quality of care. So they are seeing value in consolidation despite we know what opponents out there and certainly some media reports have tried to portray. And it’s a huge benefit for voters and patients.

Chip Kahn (11:45):

These observations are so helpful and it sounds like there’s tremendous public awareness around the issues of the role of hospitals in communities and the need to sustain quality of care.

Phillip Morris (12:00):

There is, and I think voters very much see hospitals as at the center of ensuring community health. And that’s why even unpacking further why there’s high levels of support for consolidation, we’ve also heard voters tell us that healthcare is complicated. And the idea that they can move seamlessly through a health system and address their comprehensive healthcare needs is a really attractive proposition and helps ensure that a hospital or health system is really playing the quarterback for their individual health as well as the health of their community.

Chip Kahn (12:37):

Moving on to the election season, I’ve been listening to a lot of podcast pundits talking about how one candidate or another will win and one party or another will take over the chambers in the Congress. But clearly from my experience and my observation, it’s probably too early to tell, but that’s only part of the story. The other part of the story is what are the factors that are likely to be effective here in making that narrative for this election?

(13:12):

What are the factors that our listeners should be looking at and looking for that are going to define this election?

Phillip Morris (13:19):

I think this is a really important question because there are already countless polls out there and there will continue to be that attempt to project what we will see in November. I think we know from the last two cycles the overwhelming majority of those will be inaccurate. And we were very fortunate last cycle to be one of the most accurate. And so what I just want to share with your listeners is some of the things that they should look for to make sense of interpret results that they’re going to see as we get closer and closer to the election itself.

(13:48):

I’ll start by saying that from polls that exist out there as well as ones we’ve conducted. Ones that have this election at sort of a dead heat right now, I would argue are accurate as far as where we are currently in the race. There’s maybe a slight edge for Trump versus Biden head to head and a slight edge for Republican candidates versus Democrats on the generic ballot in some key swing states, but we’ve got a lot of time between now and November. As we get closer things that I would be looking for.

(14:20):

Number one, polls that are conducted of likely voters and conducted online, not polls of registered voters or self-reported likely voters. We only care about those we know vote in elections and that can be confirmed with their voter file, which we do and some other pollsters, unfortunately not all, because of the cost of doing so. When I mentioned polls conducted online, if you look at the most accurate polls last cycle, ours included, all of them were conducted exclusively online.

(14:53):

We operate in a world in which for the past few cycles now, you have a majority of voters who are voting more against a candidate than they are for a candidate. And as a result, they are infinitely less likely to be honest when they’re asked over the phone by a live person who they’re going to cast their vote for. Many are not proud of who they’re voting for and that’s why the anonymity of online polling has proven to be far more accurate these last few cycles.

(15:23):

Second, I’d also be looking at not just overall results nationwide, but how are these candidates performing with key demographics. Looking at results among swing voter is so critical as a proxy for the swing states that are going to decide the election. Looking at how they’re performing with seniors. We know seniors vote at the highest rate of any age group, that’s going to be critical. Women, minorities, critical audiences that we know, particularly a democratic candidate like Biden would need to overperform with or at least meet last cycle standards to be highly competitive.

(16:02):

Third, I’d also look at trends and who has the most momentum as we get closer. I would caution against putting too much stock in any one moment in time when we’re looking at an election. It’s very easy for folks right now to draw conclusions based on where these candidates are, but as we get closer and that level of scrutiny rises, who has the most momentum? As was the case last cycle, we actually saw Biden pick up momentum late, which helped carry him across the finish line.

(16:32):

And finally, in terms of some of the issues I’d be looking at the economy and inflation, first and foremost we know is very much going to be decisive and a litmus test. Has Biden done enough to bring down inflation as voters go to the voting booth? Biden’s age we know also is one of the biggest concerns they have, and so how he performs in those head-to-head sort of matchups as we get closer is going to be critical. And lastly, candidate messaging and rhetoric. In 2016, this worked really well for Trump. In 2020 it did not.

(17:07):

If you look at the messaging the Trump campaign put out in 2020, “Keep America Great.” A majority of voters did not think as we are struggling to recover from a pandemic that America was great then. If you look at Biden’s messaging then, “Build Back Better.” That tapped into the emotion that a majority of voters were feeling that we needed to build our country back from the economic and health impact that the pandemic had had. So as we get closer to this race, the messaging is also going to play a critical role in seeing who earns the support of those key swing voters.

Chip Kahn (17:44):

By definition, a black swan is something unexpected, something that people didn’t think was possible, but are there any kind of factors that you might see from your experience that we can’t say would affect but could emerge and change the dynamic? War internationally is something that we face right now. I don’t know if that’s much of a factor, but anything else that people might be looking for?

Phillip Morris (18:11):

One would think traditionally, and this is why I caution sometimes against looking at past [inaudible 00:18:18] indicative of kind of the future. You would think that war would have a significant role in. What’s remarkable is as we’ve been involved in some way in some of the geopolitical conflicts that exist around the world, foreign policy and national security has not risen to the top or even close to the top as an issue that’s going to be decisive to voters. Voters are very much looking inward here at home in terms of how they’re thinking about who they’re going to vote for.

(18:44):

So while I would normally say that the past would indicate that war in the Middle East or an escalating conflict between Russia and Ukraine may play a larger role, I’m not sure that I’m convinced that that would here. I think that some of these more charged domestic issues could potentially have an outsize impact if they were to surface at the right time. I think abortion I mentioned was an issue that was a top three issue for voters in the midterms and has certainly fallen.

(19:16):

All it would take is a challenging law or laws that do not align with where a majority of Americans are on that issue to potentially galvanize democratic voters in a big way that could be helpful to Biden. I think the role the Supreme Court now is going to have to play in deciding the validity of Trump appearing on the ballot in certain states as well as a host of other issues that could in some way impact this election. I think that’s another area that based on how the court approaches that could galvanize folks on the right or the left and help either of those candidates.

(19:52):

So I think it will be some of these more charged niche domestic issues that could end up having an outsized impact should they surface at a key moment in this race.

Chip Kahn (20:05):

That’s very helpful in terms of thinking about the future. Let’s sort of use ’24 to project this into ’25 and we close out with a question from your experience. What trends do you think are likely to be important as we move into 2025? Assuming that the November election does decide who the next president is, and maybe this time everybody will live with whatever the decision is, although that’s seems questionable in today’s society. But what are the trends that you see right now that are going to probably be impactful in ’25?

Phillip Morris (20:43):

I think there’s a couple that I would highlight. The first one is how any candidate in either party approaches breaking through division and gridlock. We know 2023 was one of the least productive years in Congress in history, which is consistent with a trend we’ve now seen for the last several years. Five of the six most unproductive years that Congress has ever had have happened since 2011, and we know that a majority of voters want and expect each party to work together to get things done as well as the public and private sector to work together.

(21:19):

So with an election year and spending battle ahead this year, we know ’24 will likely be another rather unproductive year. But as we look to 2025, voters are going to be demanding action on some of these key issues, and so it’s going to be really important to see how candidates and parties position themselves as being a part of progress or part of the solution as opposed to just a brake pedal. I’d also say I mentioned how costs and inflation are such an important issue for voters this cycle.

(21:52):

Cost, I expect to continue to be the litmus test for voters across a variety of issues. I think when we think of healthcare, costs being the litmus test is exactly why single payer and public option bills have largely not gained any traction at the federal or state levels. The vast majority of voters say they’re unwilling to pay any more in taxes or healthcare costs to fund or subsidize the creation of a new government run healthcare system.

(22:23):

So while bumper stickers like Medicare for All and public option poll well, when they’re defined or explained, a majority of voters simply do not support them. And I think that as we look ahead to 2025 and some real policymaking potentially starts happening, costs are going to be the litmus test for any of those proposals in the minds of voters.

Chip Kahn (22:45):

Phil, we so appreciate you spending some time with us today and I think you’ve given us a lot for our audience to think about. I just really appreciate all you do and thanks for being here.

Phillip Morris (22:56):

Thanks, Chip. Great to be with you.

Speaker 1 (23:03):

Thanks for listening to Hospitals in Focus from the Federation of American Hospitals. Learn more at fah.org. Follow the Federation on social media @fahhospitals and follow Chip @chipkahn. Please rate, review and subscribe to Hospitals in Focus. Join us next time for more in-depth conversations with healthcare leaders.

Phillip Morris