The New Health Dialogue

I have the high privilege of being invited to speak about health reform all across the country. This gives me a tremendous opportunity to learn from “real” people, not just the policy wonks and political professionals I spend my time with in DC. 

Since Tuesday night in Massachusetts, I think I’ve learned the following, and somehow, reading the papers and listening to the talk buzzing around, these points seem highly relevant..

1. Even many people who celebrated Republican Scott Brown’s victory in Massachusetts agree that we desperately need health reform -- fixing the insurance markets and fixing how we deliver health care. If we don’t find a way to make health care more affordable, the middle class won’t be able to maintain its access to care, and the uninsured will be even worse off than they are now. Middle class people understand this, and they worry about it, more than some might think. People understand, at least once they’re told, that our fiscal future is at risk if we don’t reign in health care cost growth. They understand what it means to the overall economy, and they get what it means for small businesses who are already struggling.

2. The main concrete message from the Massachusetts election and the town halls last August and lots in between is that a surprisingly large number of people from various political persuasions feel like no one in DC is listening, on any issue, especially the economy and the Wall Street bailouts. Health care has become a proxy in this struggle to be heard.

3. Because of partisan vitriol and confusion in DC, most Americans have tuned out the specifics of the health care debate. Indeed, this debate would be complex and confusing even in the best of worlds. They are frustrated with how hard it has been to learn what is really in the bills, and have lost what little trust and faith they may have had in elected leaders or anyone else who tries to explain this complicated  legislation. They also have a hard time believing any reform that requires the kind of deals Ben Nelson got for Nebraska is worthwhile for the country as a whole. They don’t connect the dots from Republican intransigence to empowerment of the 60^th senator in a filibuster prone world. They are outraged by the trading and dysfunction, and they blame the party in power, because it is the one making the deals. They can’t believe there is not a better way. 

Since so many of my colleagues have already reminded us all that incremental reforms -- things like prohibiting insurers to reject people with pre-existing conditions without also having mandates and subsidies -- won’t work, I won’t repeat those arguments here. The way I see it, the pro-reform camp, of which I remain a determined member, only has one feasible option at this point: the House must pass the Senate bill. Then Congress can amend and improve key provisions through reconciliation or whatever other way makes sense legislatively and politically. And then everyone who supports health reform will need to explain it, clearly, patiently, honestly and repeatedly, to a critical  mass of the American people over the coming months and years. Here are three reasons this is critical now.

1. One big difference in this debate and the 1993-94 version is that many health care system stakeholders support the goals and outcomes of reform. They range from physician leaders, hospital system administrators, drug companies, even some insurers. By and large they support reform because they understand, better than most, that our system is not sustainable, that it will take a decade or more to get it on the right path, and that therefore we should start this afternoon. They have been preparing their organizations and communities for a post-reform world, new information, new incentives. To stop now, would be to say to them, “never mind.” They would be forced to develop more self-protective strategies to survive. None of those strategies are good for transforming our system from volume to value.

2. We need to signal to the American people that coverage expansion and new insurance markets are coming, so that people know that relatively soon they will no longer be denied coverage and care when sick, and so that insurers will know the days of aggressive underwriting are numbered. We desperately need to change insurers’ business models, so it really is insurance not just risk selection. The longer we wait, the harder it will be. And it's plenty hard now.

3. To stop now, even to adopt some really watered down reform package, is to implicitly agree the tea baggers (and other foes of reform spreading anger and fear) are correct about health reform being a bad idea. They could not be more wrong. That anger is scary to sitting politicians who would like to be re-elected. But when some people are wrong, leaders have to tell them so. You don’t have to yell back, and you’re not going to convince everybody. But letting health reforn be framed as a "bad" idea is a recipe for disaster. To avoid that, to overcome the fear, to clarify the confusion, we need real leadership. In my view, health system leaders have stepped up, reform advocates have stepped up, and some members of Congress have held firm, too. Now is the time for the President to do what only he can do, lead us all to a better and healthier future. 

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