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September 21, 2009

Health Reform: The Impossible Dream?

Over the weekend after Obama's health reform speech to a joint session of Congress, only about one-third of Americans surveyed said they understood the President's plan.  Of those who actually heard his speech, more than half said they understood it, but they got tripped up on questions about the details, according to a poll conducted by Siegel+Gale via Wego Health The poll results show in great detail how little most people understand about this issue, despite the fact that the President -- along with everyone else in Washington, and most people I deal with on a daily basis -- has been spending an awful lot of time talking about it.  (Hat tip to Jane Sarasohn-Kahn at Health Populi).  The detailed survey results may help Obama's team fine-tune the message to the public at large.  My guess is that many, many folks are equally ill-informed about most other things in life -- the survey only asked about health reform ....

Even if people understood the message clearly, the bigger question is whether they would support the proposals being bandied about. 

(As an aside, It's worth noting that as of this writing there is no piece of legislation that is "the president's plan" and the Senate Finance Committeee's "Chairman's Mark" (until last week considered by many to be the last best hope for a vehicle for health care reform) was released in form apparently designed to appeal to Republican members of the committee, who nonetheless spurned it; over 500 amendments have been offered (see September 19, 2009), and they will be considered in the very near term.  The process has bogged down -- not irretrievably, one would hope, but certainly at the expense of clarity, swift action and Congressional and Presidential attention to other pressing matters.)

The short answer is:  Well, it depends.  The longer answer: fine-tuning the message would really help.

A couple of points to expand on these cryptic answers:  Since most people in the U.S. have some form of health coverage and are largely satisfied with it, we face what is known as "the endowment effect."  In brief, if you own something, you tend to overvalue it.

To quote James Surowiecki, writing in the August 31 New Yorker:

What this suggests about health care is that, if people have insurance, most will value it highly, no matter how flawed the current system. And, in fact, more than seventy per cent of Americans say they’re satisfied with their current coverage. More strikingly, talk of changing the system may actually accentuate the endowment effect. Last year, a Rasmussen poll found that only twenty-nine percent of likely voters rated the U.S. health-care system good or excellent. Yet when Americans were asked the very same question last month, forty-eight per cent rated it that highly. The American health-care system didn’t suddenly improve over the past eleven months. People just feel it’s working better because they’re being asked to contemplate changing it.

Second, there is the "status quo bias;" most people are inclined to leave well enough alone.  People believe we're talking about a budget-neutral, zero-sum health reform game, and since the President has promised to extend coverage to the uninsured, most insured folks believe that will be at some cost to them.  Again, Surowiecki:

Still, just because you can’t change human nature doesn’t mean you can’t change health care. The key may be to work with, rather than against, people’s desire for security. That’s surely one reason that Obama has consistently promised people that if they like the health insurance they currently have they can keep it. This promise will make whatever reform we get more inefficient and less comprehensive, but it also assuages people’s anxieties. It might even be possible to use the endowment effect and the status-quo bias in the argument for change. After all, although people tend to feel that they own their health insurance, their entitlement is distinctly tenuous. Because it’s hard for individuals to get affordable health insurance, and most people are insured through work, keeping your insurance means keeping your job. But in today’s economy there’s obviously no guarantee that you can do that. On top of that, even if you have insurance there’s a small but meaningful chance that when you actually get sick you’ll find out that your insurance doesn’t cover what you thought it did (in the case of what’s called “rescission”). In other words, the endowment that insured people want to hold on to is much shakier than it appears. Changing the system so that individuals can get affordable health care, while banning bad behavior on the part of insurance companies, will actually make it more likely, not less, that people will get to preserve their current level of coverage. The message, in other words, should be: if we want to protect the status quo, we need to reform it.

Fine theoretical underpinnings for the notion that health reform can be seen as both anathema to, and a sine qua non of, the status quo ... but that brings us no closer to the goal of delivering a clear message to the general public.

As I've said before, the President's initial approach to this whole thing ("I've told you what's important to me.  Send me a bill that I can sign.") made much more sense to me.  Despite being 100% right on the money in most of his commentary on the GOP's non-reality-based critiques of reform plans in play, he's now mired chest-deep in the details and in the political tug-of-war.  That's a mistake, in my opinion.  I'd like to see him pull back to the half-dozen or so basic health reform principles that he articulated early on.  Yes, I know it's more complicated than that, but in this highly-charged atmosphere, trying to explain all of the details apparently leads inexorably to inanities about death panels and the like, so we're far better off focusing on the broad outlines in public messaging. 

What do you think?

David Harlow
The Harlow Group LLC
Health Care Law and Consulting


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