As the Obama administration and Congress go back to the drawing board on health care reform, experts are warning that they must not only focus on the process—how to get enough votes to pass any legislation this year—but also pay more attention to public opinion and do a better job of explaining the proposals to average Americans. By its very nature, effective reform is complex—with many moving parts inextricably interconnected. Altering one part can weaken or destroy others. Lawmakers have to proceed with caution.
And as they start again, they need to address a critical question: What happened to sour a majority of people on reform in the 14 months between November 2008, when Barack Obama won the White House with an apparent mandate to overhaul the dysfunctional health care system, and January 2010 when Scott Brown won a special election in Massachusetts widely perceived as a rejection of reform legislation then on the table?
Brown’s unexpected victory—placing a little-known Republican in the traditionally Democratic Senate seat that became vacant with the death of Edward Kennedy, a longtime champion of health care reform—was a turning point. Senate Democrats lost the crucial 60th vote needed to block a Republican filibuster and pass legislation.
“As ugly as the process was, as imperfect as the legislation was, it was all absolutely about to happen except for the special election in Massachusetts,” says Drew Altman, president of the Kaiser Family Foundation, a nonpartisan health policy research group.
The election stopped reform in its tracks. Obama, however, responded by vowing to find a way through the impasse: “I’m not going to walk away from this just because it’s hard,” he said shortly after Brown’s win. “We’re going to keep working to get this done—with Democrats, I hope Republicans, anyone who is willing to step up.”
But as the politicians go forward, they might also cast a glance backward, Altman says. “I think the Democratic leadership missed the boat in not realizing that the inside fight [in Congress] is very different from the outside fight.”
Just before the presidential election, 62 percent of Americans said it was “more important than ever to take on health care reform,” while 34 percent disagreed, according to a Kaiser tracking poll. But since September 2009, all the major polls have shown that more people strongly oppose the Democratic proposals than strongly favor them. After the Massachusetts result, a Gallup poll found that a majority of Americans (55 percent) wanted lawmakers to suspend work on the legislation and consider alternatives, while 39 percent wanted them to pass it.
A central problem, though, is what “it” means. To date, Americans have yet to be presented with a single health reform bill they can examine to see how it affects them. Obama’s strategy—announcing his principles for reform but leaving it to Congress to hash out the details—resulted in five different committees coming up with widely differing proposals last year. By late December, those were reduced to two bills, from the House and Senate, which have much common ground but also major differences that perpetuate public confusion.
“I think the president could have done a great job of selling one bill if we’d had one, but we didn’t,” says Robert Blendon, professor of health policy and political analysis at Harvard’s School of Public Health. Instead, the messiness of the political process, the way the debate dragged on, the complexity of both bills and their changing provisions, he adds, “got people very, very worried.”
Along the way, the proponents of reform lost the plot. “What Americans care about is how this is going to help me pay my medical bills, what’s going to happen if I lose my job, or if I get sick and have a preexisting condition and need insurance—and the answers to those questions were in the legislation,” Altman says. But the public debate, full of jargon about “bending the cost curve” and health delivery reform, “just didn’t connect with average people,” he adds.
That confusion allowed critics of reform—especially during angry August when lawmakers faced constituents in heated town hall meetings back home—to define the proposals, erroneously, as a “big-government takeover” that would lead to rationing of care and even “death panels” that would “kill off Granny.” The issue was no longer what was actually in the legislation. Instead it became “a big ugly debate that made people nervous and anxious,” Altman says.
Yet when average Americans who oppose the bills become aware of their specific reforms, they very often change their minds, according to a recent Kaiser survey.
For example, 73 percent of people surveyed said they would be “more likely to support” the legislation after learning that it contains tax credits to small businesses to provide health insurance for employees; 66 percent on hearing that it would leave most people’s current coverage unchanged; and 63 percent on hearing that it would require insurers to cover people with preexisting medical conditions.
Now, some lawmakers want to carve out the “most popular” pieces of the legislation to pass in separate bills. Trouble is, economists say, that can’t work.
Take the popular proposal to eliminate preexisting medical conditions—a step that would allow millions of today’s uninsured to get coverage, especially those ages 50 to 64 with health issues who at present can’t buy insurance at any price. It sounds simple. But to work, everyone must be required to have coverage (one of the most unpoplar proposals, polls show) so that the added insurance risk from the less healthy can be spread among a larger pool of people. Without that big national pool, insuring those with preexisting conditions would mean huge increases in everybody’s premiums. Of course, if there’s an individual mandate, there has to be a system of penalties for people who don’t buy insurance and subsidies for people who can’t afford it. And if there are subsidies, they have to be paid for . . . and on it goes.
As Princeton economics professor Uwe Reinhardt argues in his Economix blog, there’s no such thing as “simple” health reform: Just banning preexisting conditions “opens a veritable Pandora’s box of additional, required legislation which, once fully fleshed out, would pretty much constitute the core of the insurance-reform bill currently in the Senate.”
Or take another popular idea: filling in the infamous “doughnut hole” in the Medicare drug benefit. If reform legislation is passed, drug manufacturers will immediately pay 50 percent of the costs of people who now pay full price for drugs when they fall into the gap. But the drugmakers’ offer, too, is conditional on having everyone buy insurance, which would bring them a vast new supply of customers under age 65.
“It really does become a matter of the hipbone being connected to the leg bone,” says John Rother, AARP’s director of policy. “The legislation has to be large enough to solve all these problems at once. But the conundrum is that the larger it is, the less people are able to understand it.”
Americans also are angry, the polls show, at the hostile partisanship between Republicans and Democrats that they perceive to have brought about a virtual paralysis in Washington. “The public doesn’t like it when Mommy and Daddy fight,” says Rother.
Last month Obama seemed to signal that some kind of congressional marriage counseling is in order when he called on both parties to “transcend petty politics” and said he was open to Republican ideas on health reform, but warned that Democrats could not give up everything they believe in for the sake of bipartisanship. “That’s not how it works in any other realm of life,” he said. “That’s certainly not how it works in my marriage with Michelle. There’s got to be some give and take.”
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Patricia Barry is a senior editor at the AARP Bulletin who covers Medicare and health policy issues.