Part of the reason the 1993 effort to reform our health care system failed was because the debate focused almost exclusively on expanding coverage to those without insurance. Covering every American is a critical objective, but Americans who had health insurance in ’93 were concerned that the changes being suggested would change their insurance in a way they did not like or want.

This time around President Obama has wisely focused on reducing heath care costs. Cost of health care affects everyone – those with insurance and those without – and even if we attempt to provide coverage to every American, without also taking action to reduce costs our health care system will still be too expensive and not deliver quality care across the board. So we must reduce cost, or as the phrase goes, bend the growth curve.

This message not only makes sense, it’s also the right message and one that consensus can be built upon.

Our work for Herndon Alliance and HCAN has shown strong support for health care reform.

• Health care is a top priority. The current economic crisis increases the urgency for health care reform. Health care reform remains a high priority and is seen as part of fixing the economy. People see rising health care costs as their #1 personal economic concern.
• Rising costs continue to be a top concern for voters, the vast majority of whom are insured. Voters are concerned it will cost more to insure the uninsured.

• Advocates come to the table to get health care access for all, but voters are looking for help with rapidly rising health care costs. (81% dissatisfied with cost, 57% strongly)

• Health care reform communications should highlight quality, affordability and guaranteed coverage for all.

· Having choices in health care gives voters a sense of control. Choice means choice of a public health insurance plan or private insurance, choice of doctor and keeping your doctor in charge of decision-making. Choice defined this way is important to control because it limits the power of insurance companies by introducing competition and not allowing them to come between the patient and their doctor.

· Security, peace of mind and control are very important, especially with women.

• Voters, especially women, want affordable health care they can count on and that mirrors life’s transitions: job changes, part-time and full-time work, having a major disease, retiring before Medicare kicks in, etc. This has gotten more important recently in this economy.

· Voters are angry at “greedy” insurance companies and CEOs. There is no debate among them about this.

• Voters are strongly in favor of regulatory reform, such as requiring coverage for pre-existing conditions and coverage of more illnesses. In focus groups, many bring up these types of reforms unprompted
• Advocates need to channel the public’s anger, not fear.
• When voters are fearful, they become self-protective and change-averse, worrying that reform will make things worse.

· The opposition to health care reform is insurance and drug companies who want to keep profiting from families who are struggling. Focusing on CEO’s adds even more intensity to the arguments.

• Voters respond to keeping their doctors, having more control over their health care, and that affordable coverage is guaranteed.
• Instead of scaring people into change, direct their anger at greedy insurance companies and their lobbyists who are blocking reform. Voters also respond strongly to a choice of a public health insurance plan or private health insurance plan including keeping what they have. This also creates competition to hold costs and profits down and provides a basic standard package of benefits.

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As readers of this blog know, we do a lot of polling on health reform and health policy. We push our polling on policy options to the limit of what it is reasonable to ask the general public about, and in our regular tracking poll we also test out arguments likely to be made in a health reform debate by both sides, pro and con. There is no question that there are better and worse messages to use in talking about health reform and also that there are arguments that can be made to scare the public about health reform legislation. These are not too different from the arguments that worked in the last debate about the Clinton health reform plan in 1993-94. Some of these messages are discussed in the Luntz and Begala memos and I won't go through them here. But the real conclusion I reach from our polling is that messaging is not the main challenge this time around. Indeed, if health reform comes down to messaging it is probably not a good omen.

The central challenges are these: First, to try to forge at least some bipartisan support, in part to diffuse the prospect of a hot national debate on health reform that could confuse the American people and potentially sap support. Second, to focus like a laser on the challenge of paying for reform, and specifically on expanding and subsidizing coverage. This is the highest hill to climb in putting together health reform legislation and also the surest way - spin and messaging aside - to deliver to the American people what they are looking for in health reform legislation; help paying their health care and health insurance bills. Finally, once there is legislation on the table with details specified about how health reform will work and will be financed, speed will be of the essence. A protracted debate about health reform filled with the usual spin and half truths can only unravel support (and can only really be countered by effective public leadership by a popular President).

In short, messaging is always important but it should not be decisive this time, and if it is, it is probably a sign of trouble.

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As the political debate over health reform increasingly focuses on the impact on providers and the insurance industry, it is important to remember the core purpose of reform: ensuring that all people are able to afford health coverage and access needed care. Putting patients and families at the front and center of our system is a goal that needs to guide future deliberations. This strategy enjoys widespread support across income groups, geographic regions, and political affiliation. Nine of 10 adults believe that health reform should improve the quality of care, ensure that everyone has access to affordable care and coverage, and reduce the number of uninsured.

Millions of Americans stand to gain under a successfully reformed system. This includes:

• The uninsured and the underinsured
• People with unstable coverage
• People who lose their coverage when their life circumstances change
• People entering the labor market who cannot find a job with coverage
• People who must wait to qualify for coverage until they have worked long enough or been disabled long enough
• People who cannot afford their out-of-pocket costs or health insurance premiums
• People who are discriminated against because they are sick, older, or female
• People who spend hours with hassles over medical bills
• People who cannot find a doctor who helps coordinate their care.

Most Americans fall into one of these categories and have personally experienced the shortcomings of our current system. Even before the recession, an estimated 116 million working-age adults—two-thirds of all adults—reported being uninsured or underinsured, having medical bill or debt problems, or experiencing difficulties obtaining needed care. Too many of us rightfully worry that we will not be able to afford to get sick, will see our children lose the protection of family coverage, or will exhaust a lifetime of savings to pay for medical bills.

It is imperative that we realign the financing and delivery of health care so that people are front and center. The political challenges to doing so are formidable, but the expectations for our political leaders are also high. Too often, the voices heard in the halls of Congress speak for those who have a strong financial stake in the $2.5 trillion currently spent on health care. An economic crisis is a time to listen to the concerns of individuals and families. Designing health reforms that put people's interests first should go a long way toward forging consensus and enacting legislation during this historic window of opportunity.

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At a recent Washington summit on health care costs hosted by the Peter G. Peterson Foundation, an array of experts grappled with the disconnect between what health care actually costs and what people think it costs. As a follow-up, I recently wrote a short piece about the psychology of health reform in which I suggested that reform is both driven and constrained by our mutual need—as voters or politicians—to feel good about health reform. We want to feel that we are doing something for others. Yet when the growth rate in the government’s health budget is unsustainable, somebody, somewhere is eventually going to be paid less than is currently promised.

Now, a simple poll will tell us what we already know: that politicians can often appeal to us most easily by discussing spending increases and tax cuts rather than with the other side of the balance sheet. But unlike a recent Medicare expansion, neither political party can get by with that type of message today if it really wants to reform health care. Each knows that somebody must be identified to pay for expanding coverage and access, and for eventually bringing the system back into balance. When both sides of the balance sheet become transparent, the required messaging becomes more complex and nuanced. It will sell only if the public is convinced that there are net gains for both health care and the well-being of society as a whole.

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May I, for once, be a little bit provocative and propose that the plebs – otherwise known as “the American public” – is not (and should not be) even in the game of health reform and therefore need not be consulted on it? So who cares how health reform is pitched to the plebs?

The American public had its say last fall, when two quite different visions for health reform were clearly put before them, and they made their choice. Now it is the turn of the chosen emperor (the President), the courtiers (the Congress) and the gentry (the leaders of sundry interest groups) to hash out a deal that, first, pleases them and, second, might please the majority of the plebs.

This arrangement is called “democracy” -- certainly in our latitudes, where the gentry can openly purchase retail the affection of the courtiers. (It would not be allowed in parliamentary systems).

If ultimately the plebs does not like what came down in health reform, they have the freedom to put in place a new emperor and courtiers who promise to change things. It is then that the elite must communicate with the plebs on health reform, not now.

Now, pitching messages to the plebs in between national elections appears to be part of the game – I emphasize “game” -- of policy making, wherein the courtiers flatter the plebs as the ultimate fount of wisdom in our country. De Tocqueville had remarked on it. Luckily for all, as I had argued in a paper entitled “Turning our Gaze from Bread and Circus Games,” (Health Affairs, Spring 1995), and copying none other than the Roman pet Juvenal, the plebs is far more interested in panem and circenses [bread and circus games] than the serious intricacies of health policy – or of foreign- or energy- or monetary policy, for that matter. These serious matters therefore have to be left to the emperor and his experts, to the courtiers and their experts, and to the super-smart emissaries of the gentry who hold important purse springs for the former. As I had put it at the end of that paper:

“Given the general public’s age-old preoccupation with panem and circenses, it will generally go along passively with its leadership, unless that leadership makes evidently egregious mistakes or is evidently divided. Thus we start wars, thus we bomb whomever our leadership has decided to bomb, thus we end wars, thus we allow the leadership (along with leaders of sundry special interest groups) to regulate and sometimes deregulate the conduct of the plebs, and thus, perhaps one day, we shall undertake a major reform of our health insurance system. Perhaps.”

Now, given our proclivity for panem et circenses, it is natural that our media turn any serious policy into just one more American sport that can be pitched in terms of winners and losers, not among the people, but among the policy making elite. In other words, like everything else, including plastic surgery, the media tend to turn politics into just another form of circenses. The fact that all this has to be conducted in sound bites tells much about the nature of that sport. There are winners and losers in this game, not, as economists would look at it, enhancements or deterioration in human welfare. Pollsters play an important role in this game. They allow Keith Olbermann and Sean Hannity to do their respective shticks on TV.

In the meantime, let us pray that the emperor, the courtiers and the gentry do something in American health care genuinely to enhance human welfare in our country. They just might this time.

As to the plebs, they are among the hardest working people in the industrialized world. Let them have their panem and circenses, and do something good for them.

Of course, to say all this openly is, as my students would put it, ”like, totally politically incorrect.” But is it unfair?

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So far President Obama has been masterful at messaging. Both the health care media and the Congressional Republicans have let him get away with completely contradictory claims.

While claiming that America spends too much on health care and promising to do something about it, Obama at the same time proposes to spend an additional $1.5 trillion over the next ten years. While claiming that we must do something to control health care costs, Obama proposes to inject an additional $150 billion in spending every year -- a move that will inevitably lead to more health care inflation. While claiming he wants to improve access to health care, Obama has already enthusiastically signed a bill that will move 2 million children from private insurance to SCHIP, which in most places pays Medicaid rates. His health pan calls for putting millions more into Medicaid, which studies show is only marginally better than being uninsured.

As long as the media and the Republicans continue to let him get away with these claims, there is no reason for him to change the message. Not one whit.

In 1994, a middle class, a middle aged couple from the suburbs named Harry and Louise defeated health care reform. They turned their back on reform because congressional Democrats and the WH couldn’t answer the one question they asked: What’s in it for us? 15 years later, they’ve been sitting and watching from the sidelines. It’s time to bring them back into the debate.

The conventional wisdom is the way to reach middle class is a message of cost control. But what’s really behind concerns about high costs is that the erosion of benefits and the threat of losing coverage altogether because an employer can no longer afford it. The cost message also ignores how reform will stabilize coverage for the times when job-based coverage isn’t stable.

For the middle class, stability is paramount. Only 64 percent of working age citizens have stable private coverage, according to a recent Third Way analysis of coverage data from 2003 to 2007. 29% had gaps in coverage, no coverage, or had to switch back and forth between public and private coverage.

The lack of stability afflicts everyone: 9% of four-year college graduates, 14% of people in households with a full-time worker for all four years and 5% of people in households with incomes above $105,000 experienced a loss of coverage over the four year period.

A message of stability emanates from the heart of reform proposals that too often are presented as perplexing terms such as guaranteed issue and community rating. Here is an example of a stability message:

Reform will mean peace of mind when it comes to health care. You will never lose coverage because of illness or an accident. You won’t be locked into a job just to keep the benefits. Your costs will become predictable and affordable. Doctors and hospitals will be rewarded for providing the best treatment for you, not the most treatments for them. Your coverage will stay with you through life’s ups and downs.

With nearly a trillion dollars of new federal spending at stake over the next ten years, the middle class will be engaged in the debate. The question is: under whose terms? Opponents want to scare voters about a government takeover, rationing and declining quality. Supporters need to persuade the middle class that the benefits are worth the costs and the risks.

Some advocates for reform are focused on cost; others on access. But for the middle class, the glue that holds the two issues together is stability.

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