Do you trust the American health care system? Can policymakers help you trust it more?

Despite high marks for nurses, a 2023 Gallup poll found that only a third of Americans trusted the U.S. health system, down ten points from 2021 at the height of the COVID-19 crisis and only three ticks above the all-time low, clocked in 2007. The lowest level of confidence was awarded to Congress, with just 8%.

So how can the least-trusted group of people in America—and their fellow policy experts in all levels of government and organizations—help its citizens trust their health care systems more? The first step is understanding what’s driving the distrust.

This was at the heart of a recent panel focused on how to build trust in health care. Hosted at the Johns Hopkins University Bloomberg Center in Washington, D.C., by the Hopkins Business of Health Initiative and moderated by Bloomberg Distinguished Professor of Health Policy and Economics Melinda Buntin, the panel dug into research, rhetoric, and the nuances that contribute to an overall struggling environment for trust. 

What can transparency do?

Richard Burr, who served in the U.S. House of Representatives for 20 years and then shifted to the Senate for two, is now a principal policy advisor and chair of the Health Policy Strategic Consulting practice at DLA Piper. He believes transparency can go a long way.

“The American public has no idea what the cost of a visit is going to be,” he said. “It’s hard to assess value if in fact you don’t know what the visit costs. It’s amazing, the discrepancies between what insurance pays and is charged and what you would pay out-of-pocket if in fact you negotiated the visit. So there’s every reason for people to be concerned about a system that really is bifurcated in the way it operates.”

But other experts, like NYU Stern School of Medicine Assistant Professor Lauren Taylor, say transparency isn’t as effective at generating trust as we might like to believe. 

“We’ve done research that if we could just show what it would cost, people would be forward-thinking, would drive down cost. It just hasn’t worked,” Taylor said. “People aren’t as rational of consumers as we would want them to be.”

Instead, she said, there are at least two issues at play. One is the distinction between trust and trustworthiness; just because a person, organization, or system is deserving of trust doesn’t mean people will trust it. For example, Americans believe about two-thirds of American hospitals are for-profit vs. not-for-profit or nonprofit because they see what they believe to be outsized cost for delivery and assume it means the provider is getting a good-sized cut for their bottom line. In reality, it’s more like one-third. 

Patient-provider relationships: It’s complicated

The other issue, says Taylor, is that health care is too complicated for most people to trust, and it always will be.

“They can’t predict cost because they don’t know what they’ll find [during the course of care],” she said. “It’s just an open-ended affair and it requires some degree of true vulnerability, both with my body and with my pocketbook.”

Plus, Taylor said, proximal relationships drive trust, and health care doesn’t have as many of those relationships anymore. 

Johns Hopkins University Carey Business School Associate Professor Michael Darden agreed.

“In the 1960s, most physician-patient interactions were a patient visiting a sole provider,” he said. “They had repeated interactions with that person, and despite the fact that medical technology was relatively limited compared to today, those repeated interactions were opportunities to build trust.”

Now, Darden said, physicians are grouped, owned by umbrella organizations with potentially different incentives. If you walk out of their office with a prescription, you’re charged with trusting the Centers for Disease Control and the Food and Drug Administration, too—large, complex, governmental agencies. And you’ve been part of an incentive-driven process, where a fee-for-service model drives high volume and short visits.

“I don’t necessarily think doctors or hospital administrators have become more greedy,” Darden said. “I think it’s that the rules of the game have changed so dramatically.”

The price we pay

And then there’s the question of debt. When medical bills are high, trust matters more. 

“This is completely different from any other sector because when people seek care, they really need it,” Darden said. “This is not like buying a house.”

But, he pointed out, new research from Stanford economist Neale Mahoney released as a National Bureau of Economic Research working paper found no evidence that medical debt relief improved, on average, beneficiaries’ finances, access to credit, or physical or mental health. Ultimately, Mahoney said the findings indicated that trying to reduce peoples’ medical debt may be happening too late to make a difference. That means, by extension, it doesn’t help with trust. 

The high cost of medical intervention in certain diseases, while it may not be applicable to large populations, is one area where Burr sees potential for accountability on the part of the provider or the medical technology innovator, which could lead to more trust. For example, he said, a curative treatment for sickle cell anemia saves millions of dollars over time, but to build trust, the drugmaker might have to, in a sense, insure outcomes. 

“I think what we’re going to see as we get more technical and more expensive [is that] innovators are going to be pulled into this in a way that there may even be guarantees, “If you have this procedure, if you take this therapy, and 20 years from now [the condition is] reversed, the innovator is liable to cover it.”

The past is prologue

Sickle cell anemia may be a particularly interesting example, if only because it overwhelmingly impacts Black individuals. Historic inequities of access to care is another factor in limitations on trust. Buntin asked directly about how health systems should think about this history as they try to build trust. 

Burr outlined the broad understanding of breaches, including geographical limits to care and equitable distribution networks for vaccines. Darden highlighted concierge medicine—the ability to pay for access to care that otherwise wouldn’t be attainable. Taylor mentioned the Institute for Health Care Improvement’s roadmap.

“If the health care administrator or leader is serious about rebuilding trust, it starts by acknowledging past breaches of trust,” Taylor offered. “That’s really uncomfortable for leaders and managers to do.”