A blog covering the health/care ecosystem and people.

In the U.S., peoples’ expectations of their health care experience is melding with their best retail experience — and that’s taken a turn toward their digital and ecommerce life-flows. The American Customer Satisfaction Index Insurance and Health Care Study 2020-2021 published today, recognizing consumers’ value for the quality of health insurance companies’ mobile apps and reliability of those apps. Those digital health expectations surpass peoples’ benchmarks for accessing primary care doctors and specialty care doctors and hospitals, based on ACSI’s survey conducted among 12,274 customers via email. The study was fielded between October 2020 and September 2021. Year on year,

Most U.S. adults across political parties favor allowing the Federal government authority to negotiate for drug prices — even after hearing the arguments against the health policy. Drug price negotiation, say by the Medicare program, is a unifying public policy in the current era of political schisms in America, based on the findings in a special Kaiser Family Foundation (KFF) Health Tracking Poll conducted in late September-early October 2021. Overall, 4 in 5 Americans favor allowing the Federal government negotiating power for prescription drug prices, shown in the first chart from the KFF report. By party, nearly all Democrats agree

A new look into Americans’ views on health privacy from Morning Consult provides a current snapshot on citizens’ concerned embrace of technology — worried pragmatism, let’s call it. This ambivalence will flavor how health citizens will adopt and adapt to the growing digitization of health care, and challenge the healthcare ecosystem’s assumption that patients and caregivers will universally, uniformly engage with medical tools and apps and technologies. More Boomers are concerned with health data app privacy than Gen Z consumers, as the chart illustrates. 46% of U.S. adults said that health monitoring apps were not an invasion of privacy; 32%

Years before we knew how to spell “coronavirus,” I gained Italian citizenship while retaining my U.S. citizenship. My family’s plan was to, soon thereafter, split time for work and life between the U.S. and the E.U. Then, COVID-19 emerged as a pandemic the world over, and the move to Brussels in January 2020 was quite short-lived. Now, the plan is in play and I’m writing this post from our home in Brussels, Belgium. Why Brussels? Among many smart reasons, the city is welcoming, our farm-to-table food style is doable, the walkability is brilliant, and the transportation options are accessible to

Rising costs, generational shifts, digital transformation, and fast-growing investments in new health care models and technologies are forcing change in the legacy health care, noted in the State of Consumerism in Healthcare 2021: Regaining Momentum, from Kaufman, Hall & Associates. As the title of Kaufman Hall’s sixth annual report suggests, health care consumers are evolving — even if the traditional healthcare system hasn’t uniformly responded in lock step with more demanding patients. Kaufman Hall analyzed 100 health care organizations in this year’s consumerism survey to assess their readiness to embrace consumer-centric strategies, understand how the industry prioritizes these approaches, evaluate

“Racial and ethnic inequities in the US health care system have been unremitting since the beginning of the country. In the 19th and 20th centuries, segregated black hospitals were emblematic of separate but unequal health care,” begins the editorial introducing an entire issue of JAMA dedicated to racial and ethnic disparities and inequities in medicine and health care, published August 17, 2021. This is not your typical edition of the Journal of the American Medical Association. The coronavirus pandemic has changed so many aspects of American health care for so many people, including doctors. Since the second quarter of 2020,

“We don’t un-learn,” Dr. Amy Abernethy asserted as she shared her pandemic perspectives on a panel with 2 other former U.S. health policy and regulatory leaders. The three spoke about navigating compliance (think: regulations and reimbursement) in an uncertain world. An uncertain world is our workplace in the health/care ecosystem, globally, in this moment. So to give us some comfort in our collective foxhole, my last post for this week of immersion in #HIMSS21 is based on the keynote speech of Michael Dowling, CEO of Northwell Health. Dowling keynoted on the theme of “Leading for the Future,” sharing his lessons

“Most Americans clearly recognize the potential benefits that improved health IT can offer, and they want this transformation of the health care system to continue,” the Pew Charitable Trusts research concludes in Most Americans Want to Share and Access More Digital Health Data. The Pew team surveyed 1,213 adults ages 18 and over in June and July 2020, interviewing in English and Spanish. As digital health industry stakeholders will be convening at the 2021 annual HIMSS conference in Las Vegas and digitally, this report is well-timed to give us a level-set on just “where” U.S. health citizens are with respect to

There is no doubt that the COVID-19 pandemic motivated health care providers, payers, and patients to adopt digital tools and contact-less services, allowing people to deliver and receive medical care. Still, 18 months into the pandemic, now endemic and in its fourth wave of cases spiking around the world and in many parts of the U.S., some aspects of “digital transformation” seem not to have fully transformed American healthcare, we learn in HIMSS’s annual 2021 State of Healthcare Report. HIMSS collaborated with the organizations Trust  Accenture, The Chartix Group, and ZS on this year’s research. Nine in ten clinicians have recommended

“What if…healthcare happened where we live, work, play, pray and shop, delivering the highest levels of retail experience?” I asked and answered in my book HealthConsuming: From Health Consumer to Health Citizen. The chapter called “The new retail health” began with that “what if,” and much of the book responded with the explanation of patients evolving toward health consumers and, ultimately, health citizens empowered and owning their health and care. This week, Dollar General announced the hiring of its first Chief Medical Officer, Dr. Albert Wu. With that announcement, America’s largest dollar-store chain makes clear its ambitions to join a

The FDA’s approval of the first therapy to treat Alzheimer’s Disease in over twenty years brought attention to a not-yet-convened debate of U.S. health care costs and spending, innovation, and return-on-the-investment (as well as “for whom” do the returns accrue). In my latest post for Medecision, I explore different angles on the Aduhelm and Alzheimer’s discussion, covering: The macro- and micro-economics of Alzheimer’s and the $56,000 list price for the drug The FDA regulatory process and aftermath U.S. consumers’ bipartisan support for drug price regulation through Medicare negotiation and private/commercial sector adoption Congressional legislation addressing the price of medicines in

Post-pandemic, the consumer’s priority purchases are grocery, nesting, and health, according to David Shah, a leading thinker about social and design trends. David presented the latest Pantone forecast on color and society in NewTopia – A Balance of Color Opposites – Color for a Post-COVID World this week. I had the opportunity to attend the session, and want to share the health and wellness-related insights David shared in his fast-paced view on the role of color in bolstering wellbeing and community looking out to 2022/23. For context, Pantone plays a role in your life you might not realize. In health

Wherever you live in the world touched by the coronavirus pandemic, you felt (and were) stress-tested. Both you were, and your home was as well. In this year’s 2021 annual report by Deloitte into Connectivity & Mobile Trends, their report details How the pandemic has stress-tested the crowded digital home. This analysis was done, as it is every year, by the Deloitte Center for Technology, Media & Telecommunications. Deloitte’s Center commissioned an online survey among 2,009 U.S. consumers to gauge five generations of peoples’ perspectives on connected life in the context of COVID. The report covers the various life-flows of

The COVID-19 pandemic accelerated a whole lot of digital transformation for people staying home. For digital natives, that wasn’t such an exogenous shock. For older people who are digital immigrants, they will remember their initial Zoom get-together’s with much-missed family, ordering groceries online in the first ecommerce purchase, and using telemedicine for the first time as a digital health front-door. Laurie Orlov,  tech industry veteran, writer, speaker and elder care advocate, is the founder of the encyclopedic Aging and Health Technology Watch website. She takes this propitious moment to assess The Future of Wearables and Older Adult in a new report.

We want to go outside, drive our cars, shop for groceries, stay and get healthy. These are the key themes coming out of the 2021 Axios Harris Poll 100 on the most visible brands with high (and low) reputations among U.S. consumers. In the top-ranked “excellent” and “very good” brands numbered 1 through 50, we find five core health care brands that were most visible to U.S. consumers: Moderna ranked #3, Pfizer #7, CVS Health #24, Walgreens #46, and Kaiser Permanente #47. The only pure healthcare brand in the bottom 50 was Johnson & Johnson at #72, between Dollar General

The COVID-19 pandemic has re-shaped consumers for work, school, fitness, cooking, and certainly for health care. PwC’s Health Research Institute has combed through their consumer survey data and developed insights on health consumers, shared in a summary titled Consumer health behavior and the COVID-19 pandemic: What we’ve learned. Most U.S. consumers would be likely to have a clinician visit their homes for several kinds of medical care, including: “DIY care,” as PwC exemplifies as a home strep or flu test, or remote monitoring, likely among 85% of people A chronic care visit, likely for 78% of consumers A visit for

Investments in the digital health sector have fast-grown in the past decade, reaching $14bn in 2020 based on Rock Health’s latest read on the market. The COVID-19 pandemic accelerated the field across many industry segments. With such turbocharged growth on the supply side, Beazley, experts in specialty insurance, explores the risks of digital health and wellness in a new report, Digital health, telehealth and wellness: Attitudes to risk and insurance. With great potential for both innovation and reward comes great risks: Beazley points to the facts that, over two-thirds of digital health companies lack insurance coverage for medical malpractice for

The Wall Street Journal featured the grocery chain Kroger in an article yesterday titled, COVID-19 Vaccinations, Tests Give Boost to Kroger’s Health Ambitions. “With 2,250 pharmacies and 220 clinics largely in the Midwest and the southern U.S., Kroger is the fourth-largest pharmacy operator by script count,” the Journal noted, adding details about Walmart, CVS Health, and Walgreens all fast-expanding their respective health care footprints. As more consumers view their homes as personal and safe health havens, there is no shortage of suppliers in the food, retail, and mobility sectors working fast to meet that demand for convenient and accessible services.

With a vaccine supply proliferating in the U.S. and more health citizens getting their first jabs, there’s growing optimism in America looking to the next-normal by, perhaps, July 4th holiday weekend as President Biden reads the pandemic tea leaves. But that won’t mean Americans will be ready to return to pre-pandemic health care visits to hospital and doctor’s offices. Now that hygiene protocols are well-established in health care providers’ settings, at least two other major consumer barriers to seeking care must be addressed: cost and access. The latest (March 2021) Kaiser Family Foundation Tracking Poll learned that at least one

Five years ago, in 2016, the W2O Group said that, “Relevance is reputation.” That year the firm began to study the relevance of, well, relevance for organizations especially operating in the health/care ecosystem. 2020 changed everything, the W2O team asserts, now issuing its latest look into the issue through the Relevance Quotient. Relevance is built on recognizing, meeting and exceeding stakeholder expectations of organizations. In the Relevance Quotient methodology, W2O Group defines key stakeholders as employees, patients (including the sick and the well, caregivers, consumers, et al), health care providers, advocacy groups, analysts and investors, policy makers, journalists and media outlets.

Consumers favorite brands in 2021 are baked with health, from medical care through to the social determinants that make our wellness and mental health better, based on the 2021 Prophet Brand Relevance Index. The top ten brands in 2021 are Apple (the top brand for the sixth year in a row), Peloton, KitchenAid, Mayo Clinic, LEGO, Costco, Honda, Johns Hopkins Medicine, PlayStation, and Amazon. In this year’s study, Prophet remarked that, “Almost overnight, they’ve [consumers] reconsidered beloved names like Disney, making room for brands that serve them better…As they weather some bleak moments, consumers want brands that will commit to

The growing use of APIs in health information technology innovation for patient care has been a boon to speeding development placed in the hands of providers and patients. Using APIs can help drive interoperability and make data “liquid” and useable. APIs can enable “Data liberación,” a concept proposed by Todd Park when he worked in the Obama administration. Without securing patients’ personal health data leveraging APIs, those intimate details are highly hackable explained in All That we Let In, a report from Knight Ink and Appr0ov. It is likely that behind growing health data hacks is the marginally greater financial

At the start of CES 2021, I had the opportunity to catch up with Karsten Russell-Wood, Portfolio Marketing Leader, Post Acute & Home, Connected Care at Philips. We brainstormed just as CES 2021 was going to “open,” virtually, for the consumer electronics conference’s first all-virtual meeting. Philips, a longtime major exhibitor at CES, created an entirely new online experience for the CES attendees – a sort of virtual gallery of different exhibits that are accessed from a single point in a “room” with various entry points. One of the company’s key messages for CES 2021 was health care delivered outside

The coronavirus pandemic disrupted and re-shaped the annual CES across so many respects — the meeting of thousands making up the global consumer tech community “met” virtually, both keynote and education sessions were pre-recorded, and the lovely serendipity of learning and meeting new concepts and contacts wasn’t so straightforward. But for those of us working with and innovating solutions for health and health care, #CES2021 was baked with health goodness, in and beyond “digital health” categories. In my consumer-facing health care work, I’ve adopted the mantra that our homes are our health hubs. Reflecting on my many conversations during CES

Spending on connected health monitoring devices in the U.S. will reach $845 million based on the forecast of the Consumer Technology Association, convening the annual 2021 CES this week in a virtual format. CTA unveiled the 2021 key trends we’ll see presented this week through the online exhibition hall and in educational sessions on the CES.Tech platform. Six major themes emerge at #CES2021: digital health, robotics and drones, 5G connectivity, vehicle technology, smart cities, and over all — digital transformation. All of these have applications in health and health care, especially accelerated in need by the COVID-19 pandemic which has

explained in a new report from EY co-sponsored by the American Hospital Association (AHA) and the AHA Center for Health Innovation. Digital Transformation – Anywhere Care envisions “health care with no address, or bringing care to the consumer or patient rather than expecting the patient to go to the hospital” as a “vital sign” of health care’s changes going into the new year of 2021. COVID-19 accelerated a movement in which I’ve been involved for over a decade, known as “participatory health.” In its early phase in the U.S., Dr. Tom Ferguson identified the emerging role of the internet in

From appointment scheduling to checking in, payment and clinical encounter follow-up, patients now expect digital experiences across the health care continuum….and really great ones, like they get from Amazon and other platforms that earn high net promoter scores. That is the big message from the 2020 Healthcare Consumer Experience Study published by Cedar, based on the input of 1,502 U.S. adults who paid a medical bill between October 2019 and October 2020. The timing of this study coincided with the start of the COVID-19 pandemic in the U.S. through at least seven months of American patients’ experiences in 2020. Two-thirds

Before the coronavirus pandemic, patients had been transforming into health care payors, bearing high deductibles, greater out of pocket costs, and financial risk shifting to them for medical spending. In the wake of COVID-19, we see health consumers-as-payors impacted by the pandemic, as well as for existing diagnoses and chronic care management. There is weakening in U.S. consumers’ overall household finances, the latest report from the U.S. Bureau of Economic Analysis (BEA) asserted (published 25 November 2020). In John Leer’s look into the BEA report in Morning Consult, he wrote, “Decreases in income, the expiration of unemployment benefits and increased

By April 2020, over one million Medicare members were receiving health care via telemedicine. The graph here shows you the hockey-stick growth for virtual care use by older Americans into the second month of the coronavirus pandemic. The COVID-19 public health crisis up-ended all aspects of daily living in America for people of all ages. For older Americans, avoiding the risk of contracting the tricky virus in public, and especially, in health care settings, became Job 1. The pandemic thus nudged older people toward adopting digital lifestyles for daily life, for shopping, for praying, and indeed, for health care. Laurie

While 85% of people are open to receiving a COVID-19 vaccine, over one-half of them would want to wait some time to observe if after-effects developed in people who took the jab, according to a new study from Acxiom, the data analytics-marketing company. Not all people are as enthused about getting a coronavirus vaccine at all, Acxiom discovered: in fact, those hardest hit by the virus — Black people — would be the least-likely to want to get a COVID-19 vaccine, discussed in in Vaccine Hesitancy in the U.S., a survey the company conducted among 10,000 people in the U.S.

“If you build it, he will come,” the voice of James Earl Jones echoes in our minds when we recall the plotline of the film, Field of Dreams. A quick summary if you don’t know the movie: the “it” was a baseball field to be built in a rural cornfield. The “he” was a baseball player, ultimately joined by a dream-team of ball players who would convene on that dreamy field to play an amazing game. Today, the day after Pfizer announced a 90% benefit for its coronavirus vaccine, bolstering Wall Street returns on 9th November 2020, two new consumer

Until 2016, physicians’ voting rates in U.S. elections had not changed since the late 1970s. Then in 2018, two years into President Donald Trump’s four-year term, the mid-term elections drove U.S. voters to the election polls…including health care providers. Based on the volume and intensity of medical professional societies’ editorials on the 2020 Presidential Election, we may be in an inflection-curve moment for greater clinician engagement in politics as doctors and nurses take claim of their health citizenship. A good current example of this is an essay published in the AMA’s website asserting, “Why it’s okay for doctors to ask

The coronavirus pandemic has revealed the importance of connectivity, WiFi, broadband, as a social determinant of health and living. Connecting from our homes — now our health hubs, workplaces, schools, entertainment centers, and gyms — is necessary like air and water for survival across daily life flows. Digital connectivity can ameliorate social isolation and anxiety, bolster mental health, and access needed medical care via telehealth channels. As a result of the pandemic, staying connected is more important than ever for older people, Best Buy Health learned in a survey of U.S. adults. Insights from this study have informed the launch

One universal experience health systems around the globe have witnessed in the first months of the coronavirus pandemic has been the dramatic pivot to telehealth and virtual care platforms. The latest report from Philips Future Health Index series attests to that, and to clinicians’ general recognition that telehealth has been crucial in the early phase of the crisis. However, younger doctors’ experience with telehealth has led to them being more bullish on the value of the modality than older physicians, Philips learned. Philips conducted 500 interviews with doctors in China, France, Germany, Singapore, and the United States to assess their

In the Fear of Going Out Era spawned by the COVID-19 pandemic, many patients were loath to go to the doctor’s office for medical care, and even less keen on entering a hospital clinic’s doors. This drove health consumers to virtual care platforms in the first months of the public health crisis — including lots of older people who had never used telemedicine or even a mobile health app. In the August 2020 National Poll on Heathy Aging, the University of Michigan research team found a 26% increase in telehealth visits from 2019 to 2020, March to June 2020 year-over-year.

The pandemic has become a sort of forcing function on all aspects of daily living, include health care. Deloitte’s latest wave of health care consumer market research updates the COVID-19 impacts on the U.S. health care landscape and asks the question in the study report’s title: “Are consumers already living the future of health?” For the general survey of U.S. Health Consumers, Deloitte polled 4,522 U.S. adults 18 and older online in February and March 2020. Deloitte conducted an additional 1,510 interviews with consumers in April to gauge peoples’ perspectives on the pandemic, health and well-being. In the Great Lockdown

While I’m on holiday this week, restoring and re-setting, I’ve been sharing pages from my ABCovid-19 Journal with readers of Health Populi. I created this journal during the early phase of the pandemic in the U.S., as a form of art therapy, creative outlet, and learning. Today is Day 4 of sharing: we consider the letters “P” through “T,” and what I saw in the early coronavirus era. P is for pandemic This “P” was self-evidence in our collective early COVID-19 lexicon. The “P” word was uttered by the Secretary General of the World Health Organization on March 11, confirming

The use of health and wellness services delivered in retail pharmacies is growing, and health consumers’ satisfaction increases with use. That’s the headline for J.D. Power’s 2020 U.S. Pharmacy Study. This is the 12th year of J.D. Power’s U.S. Pharmacy Study, this year based on a survey of 13,378 pharmacy customers who filled a prescription between June 2019 and February 2020. The study assessed four retail prescription drug channels for consumers: brick and mortar chain drug stores, brick and mortar mass merchandisers, supermarket pharmacies, and mail order. The top ranked brands were: For brick and mortar chains, Good Neighbor Pharmacy

This week, announcements from the Consumer Technology Association (CTA) and Withings further bolster the case for the private sector bolstering public health in this pandemic…and future ones to come beyond the Age of the Coronavirus. Since the pandemic emerged, CTA has been reaching out to members and stakeholders to be a useful resource for the consumer electronics industry and its customers. Digital health resources have been an especially useful touch point for CTA’s constituents (including me, as a member who is active with the Association). On 27th July, CTA announced the Association’s launch of the Public Health Tech Initiative. In

The phrase, “burden of health care,” has two usual meanings: one, to do with the massive chronic care burden, and the other, involving costs. There’s a third area of burden in U.S. health care — the onerous patient experience in finding and accessing care, assessed in the 2020 Change Healthcare – Harris Poll Consumer Experience Index. Two in three U.S. consumers feel like “every step of the healthcare process is a chore.” That burdensome patient experience leads to one in two people in America avoiding seeking care, the poll found. That’s not just self-rationing health care due to costs, but due

Patients embraced virtual care and communications at very high rates in the first months of the pandemic, and want to continue to use telehealth platforms after the pandemic ends. The new era of virtual care has begun and is here to stay, Accenture expects in its latest look at How COVID-19 will permanently alter patient behavior, a patient survey conducted in May 2020. Accenture polled 2,700 patients around the world, 450 participants each from China, France, Germany, Japan, the U.K., and the U.S. Patients represented one of three conditions, with one-third each managing cardiovascular, immunology/rheumatology, and oncology. Topline, consumers “faced

Advertising Age announced their list of the top 20 brands in 2020 this week. Ad Age’s lens on these was heavily tinted by consumers’ lives coping with the coronavirus pandemic: “The coronavirus has brought new attention to typically boring, decades-old consumer staples, while hastening the rise of digital newcomers that were only just beginning to gain traction pre-pandemic,” Ad Age explains in the introduction to the list of the selected brands. As the editors of the MadMen-and-Women’s most influential industry publication, they explain, “Ad Age chronicles 20 brands that are having a moment.” This moment to them as well as

The core business of hospitals is patient care, often baked with teaching and research. But wait — there’s more, asserts the Lown Institute in their approach to ranking America’s Best Hospitals in 2020. The Institute’s methodology for assessing what’s “best” addresses ten pillars. Several of these are the “stick-to-the-knitting” components of the Webster Dictionary definition of hospital work: patient outcomes, clinical outcomes, avoiding overuse, patient safety, and a recent focus, patient satisfaction. Community benefit has been part of a hospital’s life, especially in the not-for-profit world where hospitals must demonstrate goodwill generated for and provided in the neighborhoods in which

Today kicks off the first all-virtual conference of the ATA, the American Telemedicine Association. ATA’s CEO Ann Mond Johnson and team turned on a dime over the past few months, migrating the already-planned live conference scheduled in early May to this week, all online. I’ll be midwifing a panel this afternoon at 440 pm Eastern time, initially focused on how health care can garner patient loyalty. That theme was given to us in the fourth quarter of 2019, when initial planning for ATA 2020 had begun. What a difference a few months make. Not only has ATA pivoted to an

The 21st Century Cures Act emphasizes patients’ control of personal health information. ONC rules issues in March 2020 called for more patient-facing health tools and apps to bolster health consumer engagement and empowerment. But the emergence of the coronavirus in the U.S. revealed many weakness in the American health care system, one of which has been health inequities faced by millions of people — especially black Americans, who have sustained higher rates morbidity and mortality for COVID-19. There have also been digital health divides found in the COVID-19 pandemic, discussed in a timely essay in JAMA, Digital Health Equity as

Doctors maintain their top status as U.S. patients’ most-trusted source of coronavirus information. However, as patients continue to be concerned about exposure to COVID-19, 3 in 5 are concerned about being at-risk to the virus in their doctor’s office, according to research from the Alliance of Community Health Plans (ACHP) and AMCP, the Academy of Managed Care Pharmacy. Patients’ concerns of COVID-19 risks have led them to self-ration care in the following ways: 41% have delayed health care services 42% felt uncomfortable going to a hospital for any medical treatment 45% felt uncomfortable using an urgent care or walk-in clinic,

“We’re not getting back to business as usual any time soon,” Sage Growth Partners and Blackbook Research introduce their latest report on the COVID-19 pandemic, As the Country Reopens Safety Concerns Rise. One of the areas that won’t be getting “back to business” soon will be patients’ visits to doctors’ offices, hospitals, and urgent care centers, the report notes, based on a survey conducted among 591 U.S. consumers on April 28 and 29, 2020. Millions of U.S. health consumers’ feel unsafe, an increase among those who feel that way compared with SGP/Blackbook’s study from last month, a concern that ratcheted

On Monday, 6th April 2020, the Prime Minister of New Zealand, Jacinda Ardern, has determined that the Easter Bunny and the Tooth Fairy are essential workers in our age of the coronavirus pandemic. The PM has posted an Easter egg coloring project on her Facebook page to support children (and people like me who like to color) in the #StayHome era. In the U.S., the day before on Sunday 7th April, Dr. Deborah Birx advised Americans that, “The next two weeks are extraordinarily important. This is the moment to not be going to the grocery store, not going to the

Health care pocketbook issues rank first and second place for Americans in these months leading up to the 2020 Presidential election, according to research from POLITICO and the Harvard Chan School of Public Health published on 19th February 2020. This poll underscores that whether Democrat or Republican, these are the top two domestic priorities among Americans above all other issues polled including immigration, trade agreements, infrastructure and regulations. The point that Robert Blendon, Harvard’s long-time health care pollster, notes is that, “Even among Democrats, the top issues…(are) not the big system reform debates…They’re worried about their own lives, their own