It doesn’t take a policy expert to know what patients want. They want knowledgeable, caring physicians who know them. They want quality care that prevents, treats and cures illnesses, and they want to be able to afford it.

It has been shown time after time that patients trust their doctors more than anybody; more than government, and more than the insurance companies. And when it comes to improving quality, physicians want and need the tools and resources to track and sysemmatically improve quality.

Although there are legitimate arguments going on between the President and Congress about issues such as a public option insurance plan and how to pay for universal coverage, there are proven and necessary steps to reforming the system that the public can get behind and all parties should be able to implement now.

Health information technology has proven to cut down on costs and save lives by reducing redundant imaging procedures as well as cutting down on the number of negative drug reactions.

Incentives for patient responsibility will encourage patients to take ownership of their own health and prove that prevention is the best – and most cost effective – treatment.

Reward care givers not on the number of tests they give, but on the quality of the care given---and with incentives big enough to change the way doctors practice. It’s not a stretch to say that most people understand and agree with the concept of merit based pay. That’s how most people in this country are paid so why not pay physicians the same way?

The American College of Cardiology, like many professional societies, has worked with its member physicians to address patients’ needs. The Door-to-Balloon initiative set practice standards to increase survivability of heart attacks; the Hospital-to-Home campaign is helping to reduce the number of cardiac-related readmissions; and the National Cardiovascular Data Registry ensures the information necessary to offer the efficient and quality treatment is available to cardiologists across the country.

In order to get the middle class – or any class for that matter – to buy into the reform process we – the stakeholders in the health care industry and our government – need to focus on the reforms that will successfully improve upon our system to make it more sustainable, cost-effective, and high quality.

Patients want their physicians involved in the health reform discussions. Physicians also want to be involved and will look out for their patients’ best interests.

While 47 million people are uninsured, the reforms for the insured are every bit as significant as those for the uninsured. In fact, this bill does more for the insured than any legislation in history.

As Ron Pollack and Drew Altman point out, it is critical that more of the middle class see that health care reform will benefit them. Fortunately, the bulk of the legislation is about reforms that will do just that.

The Herndon Alliance and Third Way have described the keys benefits in ways that all Americans can understand and appreciate:

• You will always have options for coverage, even if you change or lose a job.
• If you can’t afford insurance, you’ll get help with your premiums. If you hit a rough patch, you’ll get help to maintain coverage.
• If you run a small business, you’ll get tax breaks to buy coverage for yourself and your workers, and you’ll have a choice of affordable options.
• You’ll never be denied coverage because you fall sick.
• If you fall ill, your premiums won’t go up just because you’ve been sick.
• You’ll never leave the hospital with a bill too big to pay because your benefits have run out.
• Your doctors will be paid to make you well, not to order up procedure after procedure.

The President and Congressional leaders in the House and Senate are similarly explaining what’s in it you.

Health insurance reform will offer one of the most significant improvements in the lives of middle-class Americans since the creation of Medicare. Other health care reforms such as COBRA, HIPAA, and ERISA are just a confusing alphabet soup by comparison. It is time to stop letting the day-to-day battles obscure the potential for this larger achievement.

Passing the “What’s in it for Me?” Test

One answer to the “What’s in it for Me?” test for health care reform must be solutions that help slow or even reduce the growth of healthcare costs – something that hits every American in their pocketbook.

One solution is to help Americans do a better job of adhering to their doctor’s recommendations of therapies and medicines – especially older Americans.

For example, research shows that too many elderly Americans on Medicare who hit the coverage-gap reduce their monthly medication use by 14% relative to their use prior to entering the gap. While the Medicare Part D drug benefit has been a very popular program and has overall improved access to medicines for millions of seniors, the coverage gap has been a continuing source of frustration for some seniors.

Unfortunately, once they hit the coverage gap, the cost of their medicines drives too many seniors to reduce their use of critical medicines needed to prevent disease, treat chronic conditions and to live longer, healthier lives. Needless to say, healthier seniors, able to stay healthy because they are using the medicines they need can help to slow or even reduce health care costs for more expensive services such as hospitalizations or nursing home services.

The simple fact is that non-adherence to prescribed medicines is very costly. For example, if more patients took their medicines as prescribed, 23% of nursing home admissions could be averted. Indeed, estimates of the total cost of avoidable hospitalizations and unnecessary medical care and lost productivity from the lack of use of prescribed medicines range from $100 to $300 billion per year.

Efforts by the government to fill the coverage gap would likely be quite expensive. Last December, the Congressional Budget Office estimated that it could cost the U.S. Treasury as much as $134 billion and increase premiums by over 50%.

This is why solutions that help to close the coverage gap and promote better adherence are so important to our overall goal of controlling healthcare costs. To help, America’s pharmaceutical research and biotechnology companies have committed $80 billion dollars over the next ten years to help pay for overall healthcare reform. A very important component is our agreement to provide a 50% discount off the price of medicines for seniors who hit the Medicare coverage gap. We fully recognize the burden that the coverage gap has had on some beneficiaries, so we are willing to do our part to help close the gap as part of our commitment to help pass a comprehensive healthcare reform package.

The proposal is designed to assist those beneficiaries who do not receive low-income assistance, but still face difficulty affording necessary medicines in the coverage gap; whereas, mandating price controls for dual eligibles, who face virtually no premium charges or cost-sharing, has little financial impact on these beneficiaries. As soon as July 2010, theproposal would offer beneficiaries direct assistance at the pharmacy counter by providing a 50 percent discount on brand name medicines in the gap. Unlike the House Tri-Committee proposal, which contains additional policies that could raise Part D premiums significantly, this proposal would help beneficiaries hitting the coverage gap with a far more modest potential effect on Part D premiums.

What is most important is that this will help seniors affected by the coverage gap and who have stopped taking or limited their use of medicines by cutting out-of-pocket expenses for most seniors who hit the coverage gap in half.

Executive View: A Commentary on President Obama’s Eight Fundamental Principles for Progress in Health Reform

Several months ago, President Barack Obama identified eight principles detailing his philosophical stance on healthcare reform. As we continue to see new and more vigorous Congressional action aimed at accomplishing some type of reform, I would like to take this opportunity to demonstrate how closely the business practices of physician owned and operated hospitals align with those eight principles.

Guarantee choice: The plan should provide Americans a choice of health plans and physicians. People will be allowed to keep their own doctor and their employer-based health plan.

This guarantee is key to developing a uniquely American health system as choice is a core value of our society. Physician owned hospitals offer patients and their physicians another alternative model for hospital care. Data collected by the Centers for Medicare and Medicaid Services (CMS) confirm the high level of patient satisfaction with their care at physician owned hospitals. Survey data substantiate that the public believes physicians should be in charge of hospitals and endorses physician ownership of hospitals. The number of physicians who admit patients to physician owned hospitals dwarfs the number of physicians who actually have an investment interest in these facilities. For these factors and others, physician hospitals are an important element of the choice that the White House has advocated as a fundamental goal for health reform.

Make health coverage affordable: The plan must reduce waste and fraud, high administrative costs, unnecessary tests and services, and other inefficiencies that drive up costs with no added health benefits.

Physician owned hospitals are among the most cost effective, efficient providers of care in America. Physician ownership means that doctors are paying close attention to the bottom line for hospitals and especially for patients. There is no room in this model for wasteful spending, excess administrative costs, unnecessary tests and services or any other inefficiency that would negate the core values embraced by physician owners. This is why our members can provide complex medical care at rates far below those charged by large general hospitals. This is why Medicare spends less for every patient who enters a physician owned hospital than it does for the same care at large hospitals where interests are less aligned between doctors and administration. Physician ownership is the purest form of true physician/hospital alignment and is far more effective than the fabricated programs being considered such as gain sharing and pay-for-performance.

Protect families' financial health: The plan must reduce the growing premiums and other costs American citizens and businesses pay for health care. People must be protected from bankruptcy due to catastrophic illness.

Our hospitals demonstrate every day that high quality care can be affordable. The high quality of medical outcomes and financial efficiencies of physician owned hospitals reduce pressure on the health insurance system and ease the burdens on patients and their families. In fact, because of the affordability of care at our hospitals, several physician hospitals around the country currently contract to provide care to patients from countries such as Canada where healthcare access is limited. Because we are efficient, our hospitals can afford to provide such care on a feasible “out-of-pocket” budget. In addition, we pay taxes and provide charity care. As the Center for Medicare/Medicaid Services (CMS) found in its 2005 study, physician hospitals provide a net community benefit almost 8 times higher than hospitals not owned and operated by physicians. Bottom line, physicians are in a position to know what is best for their patients and to make care-based decisions, not system policy-based decisions.

Invest in prevention and wellness: The plan must invest in public health measures proven to reduce cost drivers in our system -- such as obesity, sedentary lifestyles and smoking -- as well as guarantee access to proven preventive treatments.

Every physician working at a physician owned hospital is acutely aware of the need to encourage every citizen to embrace healthier life styles, regardless of age. The payback in improved health and enhanced quality of life is enormous and has value far beyond simply reducing spending for medical services. At the same time we must be prepared to address the acute illnesses and injuries that befall everyone at some point in their lives. Physician owned hospitals are some of the most technologically advanced facilities in the country, bringing the best of modern medicine to their patients. In addition, physicians are working to guarantee continued access in rural and inner city areas… areas that are otherwise being disregarded by many of the large system providers not owned by physicians. In many states, physicians are purchasing and providing care at hospitals that are going bankrupt or otherwise being let go by previous non-physician owners.

Provide portability of coverage: People should not be locked into their jobs just to secure health coverage, and no American should be denied coverage because of preexisting conditions.

Ours is a restless, mobile society and the failings of our health insurance system should never be an impediment to the ability of any individual to fulfill his or her own vision of their personal “manifest destiny”. Nor should any institution be allowed to “corner” the insurance market in a community to prevent market entry by new providers. Physician owned hospitals have too often faced difficulty in negotiating insurance contracts because other hospitals have negotiated exclusive contracts, an anathema to our nation’s laws that guarantee free and open competition. Physician hospitals seek the right to provide care to everyone to whom appropriate care can be given, and to contract openly in an insurance market that provides portable, fair coverage.

Aim for universality: The plan must put the United States on a clear path to cover all Americans.

This is a critical element of the President’s plan. The wealthiest nation in the world can no longer tolerate the fact that so many individuals who want to have health insurance are denied that opportunity. Physician Hospitals of America (PHA) members try to do their part by providing charity care equal to 4.7 percent of their net revenue. We agree that insurance coverage for all would eliminate financial barriers to medical services, wherever they are provided; however, we also believe that such universality can be accomplished without encouraging, directly or indirectly, a single payer system.

Improve patient safety and quality care: The plan must ensure the implementation of proven patient safety measures and provide incentives for changes in the delivery system to reduce unnecessary variability in patient care. It must support the widespread use of health information technology with rigorous privacy protections and the development of data on the effectiveness of medical interventions to improve the quality of care delivered.

Numerous public and private studies demonstrate the high quality of medical services provided by physician owned hospitals. Physician owners strive to give their patients the best care possible and this is borne out by these statistics. PHA believes that the care models used by our member hospitals, such as low nurse to patient ratios that allow nurses to actually take care of their patients, should be emulated across all sites of service. We are happy to provide transparent information on the quality of care at physician hospitals and would be pleased to take part in any demonstration project aimed at improving quality and transparency for every hospital.

Maintain long-term fiscal sustainability: The plan must pay for itself by reducing the level of cost growth, improving productivity and dedicating additional sources of revenue.

The productivity gains inherent in the physician hospital model are impressive. If they could be replicated in other hospitals, the sustainability of our healthcare financing mechanisms would be greatly improved. Physician owned hospitals have already shown that they can deliver the same care for less money than other hospitals. Administration and Congress should demand that every hospital become as productive and efficient.

In conclusion, we realize that the challenges present in our health care system are not easily solved. However, physician hospitals have developed a model of care delivery that already achieves much of what the Obama Administration has asked. We should not be impulsively or carelessly legislated out of business. In a letter addressed to Congress earlier this month, President Obama recommended that additional consideration be given to varied hospital models such as the Mayo Clinic and Cleveland Clinic, as others may have much to learn from these models. Just as President Obama pointed out, we simply ask that Congress and the Administration consider the real evidence and acknowledge a model that is clearly working, physician owned hospitals.

I agree with James Gelfan'd statement:

"Talk about lowering costs. Talk about bending the curve. Talk about *how* this is going to be accomplished.

And don't just talk about it... do it. There is no way to talk about the House bill that is going to make it a good bill that lower costs. Congress needs to go back to the drawing board and bring forward bills that actually do something for most Americans, by lowering costs."

Question to James: Fair enough! But do you have any concrete proposals on controlling health spending?

And be careful how you answer, lest the Wall Street Journal accuse you of shifting costs from the public to the private sector or the hysterical right, egged on by Betsy McCaughey, accuses you of advocating Nazi-style euthanasia.

Uwe

What's in it for you?

Though the cost of doing nothing, as the conservatives like Mr. Gelfand and Goodman propose, is staggering, with the average family paying $10,000 more in premiums by 2019, people still need to understand what reform will do. The below is based on the House version of health care reform, HR 3200 - America's Affordable Health Choices Act, which is the strongest bill being discussed to date. In short, it will provide a guarantee of quality, affordable health care to everyone.

The big things will not change - you will keep your current health insurance, keep your current doctor, and keep your current benefits. All the health reform plans being proposed allow people to keep their health insurance if they want to, and that means keeping their current benefits and choice of doctor. So if you get your coverage through work, or if your spouse or parent covers you on their health insurance through work, these big pieces will not change unless you want them to.

Your health insurance will get better and more stable. Health reform gives your employer a strong incentive to retain your health insurance or make it better. They will have to offer you at least standard, comprehensive package of benefits and your employer will not be able to continue shifting additional costs of insurance to you - they will have to pay at least about 70% of the cost of your coverage.

Your health insurance will get cheaper. As the public health insurance option forces insurance companies to compete, prices of private health insurance will fall. Your costs, even if you keep your current health insurance plan, will go down.

If you lose your job, you will always be able to get affordable insurance. If for any reason you lose your job and your employer based coverage, you will be eligible for affordable health insurance that meets your needs, as described below, with the government helping you pick up the tab until you get back to work, and expenses will be capped to make sure you can't go bankrupt due to medical costs. You will always have a guaranteed, affordable backup to rely on if you need it.

Your employer will have to offer you good, affordable health insurance. Under the bill proposed by the House, employers will have to offer you health benefits. Those benefits need to meet a standard for coverage, so you can't be offered sub-par insurance that doesn't meet the needs of you and your family. And your employer will have to cover a large percentage of your health care costs (65% for families and 72% for individuals), ensuring insurance is affordable and your employer can't shift more costs to you. Small businesses are exempt from this regulation.

If you work for a small business that is exempt from regulations asking employers to provide health benefits you will always be able to get affordable insurance. You will be eligible for affordable health insurance that meets your needs, as described below.

You will be able to find coverage. You will have access to a new health insurance "exchange," where both public and private health insurance will be offered. You will be able to compare these plans side-by-side and choose what's right for you and your family. None of these plans will be able to reject your application for pre-existing conditions or for your gender. You will have guaranteed access to health insurance.

You will be able to afford coverage. Any health insurance plan in the exchange will be subsidized if you qualify. Subsidies will be available up to 400% of the federal poverty level, or $88,000 per year for a family of four. These subsidies will ensure that you will only pay a certain percentage of your income in health care costs (that percentage varies depending on how much you make). Bottom line: Health insurance through the exchange will be affordable to you.

You will save money. Even if you do not qualify for subsidies or choose the public health insurance option, competition from the public health insurance option will force prices for insurance to fall across the board.

Your coverage will be good coverage, stable and secure. All plans in the exchange will have to conform to federal regulations, making sure that the plan you purchase covers things that you and your family need - things like preventative medicine, regular checkups, and prescription drugs. And, under health reform, your health insurance company will no longer be able to deny you coverage or care for pre-existing conditions. Your insurance company will no longer be able to drop your coverage if you become sick, or charge you more if you're a woman. There will be no more annual or lifetime caps on coverage, so you won't be stuck with tens of thousands in uncovered medical bills. And if you pay your premiums, your insurance company won't be able to reject a renewal of your insurance plan.

Your expenses will be capped. Deductibles, co-pays, premiums, and other expenses will be capped at a percentage of your income (between 1.5% and 11%, depending on how much you make), so you no longer face exorbitant health insurance costs.

Your health programs will not be touched. There will be no eligibility or benefit cuts to Medicare and Medicaid. Health reform will be financed partly by finding savings in these programs. These savings will come from eliminating portions of Medicare and Medicaid that are no longer needed once we've passed health care reform for everyone. For example, right now, Medicaid pays hospitals a reimbursement for people who come to the hospital without health insurance, and thus stick that hospital with the bill. Under health reform, most people will have health insurance, making these reimbursements unnecessary.

The Medicare "Donut Hole" will be closed. The "donut hole" in Medicare's prescription drug program that leaves seniors with thousands of dollars in drug costs when their coverage runs out partway through the year will be gradually closed under health care reform.

Yes. Health reform will be fully paid for, and will not increase the deficit. It will not increase your taxes, either. The House has proposed increasing taxes on those that make more than a quarter of a million dollars per year to pay for health reform. The middle class will not be affected.

---------------------------

There is a short answer to the question of what health reform will do for you: Better coverage, lower costs, and the security of knowing you're not at the mercy of private insurance anymore. This is what health care reform will do for you.

The cost of doing nothing - the conservative plan for health care - is staggering: The average family will pay $10,000 more in premiums by 2019 if nothing is done. We can not afford the conservative health care plan. We must reform health care now, for you and me and our families.

Americans who ask how health reform will affect them or their family, friends, coworkers, or neighbors, will find that health reform will ensure that they--or the people close to them--will get the help they need when illness or injury, without having to worry about how that care will be paid for. In short, health reform touches all of us. It helps us know that those who help us every day in so many ways are also helped when they most need it.

A recent Commonwealth Fund report, Front and Center: Ensuring That Health Reform Puts People First, details the ways in which the current health system is failing and how a comprehensive set of insurance, finance, and delivery system reforms will benefit millions of Americans. Overall, the study shows that the inclusion of a national health insurance exchange giving patients the option of a public health insurance plan, along with private plans, would control premium costs, eliminate wasteful administrative spending, and provide insurance stability to consumers regardless of their income, employment status, or pre-existing health conditions.

Specifically, if coupled with efforts to improve quality and increase efficiency, these reforms would benefit:

• People who have no health insurance or have health insurance that leaves them vulnerable to high medical bills. This group of 71 million Americans would have affordable, reliable health insurance through health plans that meet standard benefit requirements and offer income-related premium assistance.

• People with insurance who have to change coverage frequently, and often not by choice, or one-third of insured Americans. This group would have the option to have stable insurance through the new national insurance exchange so that every time there is a transition—new job, divorce, graduation—there isn’t a potentially dangerous gap in health insurance coverage.

• People at risk of falling into medical debt. These people would be protected by a standard benefit floor and would no longer have to live with insurance that doesn’t cover the care they need.

• People who work for small businesses—a total of 49 million Americans. These employees would have access to more affordable premiums and better benefits because risk would be pooled across employers of all sizes.

• People buying their health insurance on the private market. This group of 14 million Americans would have better, more affordable health insurance available to them because all Americans would be required to have coverage, eliminating underwriting and achieving a 26 percent drop in administrative costs.

Families of all incomes want comprehensive reform. A recent Commonwealth Fund survey found that half of Americans think the health care system need fundamental changing and nearly one-third believe it needs to be completely rebuilt. Policymakers and our Congressional leaders must continue working together to extend affordable health insurance to all, improve the quality of care we receive, and lower national health spending to more sustainable levels. We all stand to gain when the country finally has a high performance health system that works for all Americans.

The answer to “What’s in it for me?” is really rather simple. There’s very little in it for you. Or at least for most of you.

Nothing in the bills before Congress will control cost.

All the bills would create perverse incentives to undermine quality through unhealthy competition in a Health Insurance Exchange.

And if Massachusetts is the guide, there may not be any increase in access to care.

And in return for higher cost, lower quality and no better access, you will have the privilege of paying more taxes. Make that, a lot more taxes. Make that, more taxes than anyone has even begun to realize.

The reason support for health reform is tanking right now is because Pelosi, Dodd, Obama, and the other leaders took too much of the advice posted here. Rather than take the public's concerns seriously and take the time to educate them on the issue, those in power instead take the view that the public are fools and are easily mislead (after all, they think Iraq supported al-Queda and they question the President's birth certificate). "Let's just pass it ASAP before people have a chance to figure out what it really does."

You have to think someone is stupid if you expect them to believe "we have to pump trillions more dollars into the system to make it cost less." While the President's aides at CEA and OMB continue to pump out phony reports that make assumptions laughed at by the CBO, the public is growing increasingly upset, because they are being treated like they are stupid.

Public: "How are you going to lower health care costs?"

Administration: "This is how good your life will be once we've bent the curve."

Princeton Profs and Union Front Groups: "If we don't bend it, this is how bad your life will be."

President: "I don't have time to explain this to you, because every day 14,000 people lose their insurance. Just trust me."

These responses do not at all make the case for the legislation currently being debated. The CBO clearly indicates "this legislation will increase health spending, bend the curve up" and yet Administration officials continue to show up at town halls and on the Sunday shows claiming "your health care will be less expensive!" People are smart enough to realize that nothing in the House or HELP bill is going to lower costs - otherwise, the President would not be bullying Congress' top number-cruncher.

Another serious mistake proponents make is trying to paint the "public option" as the remedy to all the health care system's problems. When pressed on how the bills lower costs, proponents say "insurance companies are the enemy, they're stealing from you! Whoever disagrees with us on public option wants the status quo for these corporate fatcats!" More subterfuge. Still no answers.

People want one thing out of health reform - lower costs. Deceptive talk about "increasing competition" and having the public sector "keep the private sector honest" (conjure images of Cold Cash Jefferson, PBGC Director, tax-fraud Secretary nominees) are not going to work.

I happen to believe that if (as part of a comprehensive overhaul that includes serious cost controls) we insure the uninsured, it will lower costs for everyone. But reformers have not seriously made that case to the American people. Instead, they are caught up on the idea of a government-run plan (and yes, deceptively messaging it as "public option" has failed), which will increase people's costs. Talking about insuring the uninsured means little to the more than 85% of Americans who have insurance. Talk about lowering costs. Talk about bending the curve. Talk about *how* this is going to be accomplished.

And don't just talk about it... do it. There is no way to talk about the House bill that is going to make it a good bill that lower costs. Congress needs to go back to the drawing board and bring forward bills that actually do something for most Americans, by lowering costs.

It is not unreasonable for Americans to wonder what health reform will do to their family, among other things. In assessing public policy, one always trades off the personal good against the larger public good.

And the tradeoff does not always go to “Me.” For example, many well-to-do Liberals favor taxing the rich more, full well knowing that their tax bills will go up, but hoping that these taxes will benefit others.

Surely everyone who joins the armed forces must conduct this calculus.

A question is whether in recent years the trade-off willingness curve (as economists call it) has been shifting so as to favor more and more the “Me” at the expense of the common good, i.e., whether Ron Barrett’s portrayal of the contemporary American psyche is accurate. Only the hairdresser (and, of course, Drew Altman) know for sure.

That question aside, an even more problematic issue is how the American public learns about what is in health reform for them. After all, we are dealing with a people of which a large fraction have been made to believe, sincerely, that President Obama is not an American citizen and of which some 40 percent (as I recall) believed as late as 2006 that the terrorist pilots flying the planes into the World Trade center were Iraqis.

What might those people actually have been made to think is in health reform for them, and how was that thinking forged? Is it, in fact, still possible to endow the general American public with an accurate perception of proposed public policies?

A message President Obama should hammer home crisply – and I mean crisply – to the American middle class is that the sun may be shining today on them, but that it is sailing into a perfect storm.

According to the Milliman Medical Index, total health spending (employer-paid premium, employee-paid premium and out-of-pocket spending) for a typical non-elderly American family of four is now $16,700. It has been growing at an average annual compound rate of about 8.5% since 2000. At a rate of only 8%, total health spending for that family will rise to over $36,000. Yet the gross wage base that should, ideally, support all of a family’s spending (even the part “paid” by employers but ultimately taken out of the employee’s take-home pay) has been growing only at 3% or so in the past decade and is not rising at only 1.8%.

Do the math! If health reform fails and the status quo continues unabated, health care will chew up the budgets of American middle class families like PacMan, and millions more middle class families will be tossed into the pool of uninsured. That’s what is in the status quo for the American middle class.

Instead of lengthy discourses fit for publication in Health Affairs, President Obama could get this message across with one simple flip chart. Perhaps then the American middle class would appreciate more what benefits their families may derive – perhaps not today, but over the next decade – from a program of systematic cost containment and federal subsidies for lower-income Americans.

Finally, President Obama needs to develop a crisp primer on the concept of “rationing.” He should teach the public what every freshman in economics is taught (or should be taught), namely, that prices and the individual’s ability to pay are the chief instruments through which free markets ration scarce resources among the unlimited wants of people. We know from research that millions of Americans forego the health care they think they need because of costs to them. That is rationing.

Thus, the issue before the American public is not whether there will be rationing of health care in America. There will be, and there is now. The issue is whether that rationing should be done on the basis of price and the individual’s ability to pay for health care, or through some other mechanism.

The decision to defer votes on health reform legislation in the House and the Senate until after the summer recess was hardly unexpected, but it creates a crucial window of opportunity to win (or lose) the fight for public opinion on health reform legislation. In past health reform debates dating back to the Truman era, public support has withered as debate intensified and critics scared the public that they have more to fear in health reform than to gain. This chart shows that pattern in the past:

Circumstances are very different in this debate and the past pattern of eroding support need not repeat itself this time. But as I forecast in my February web column “What Will Health Reform Do for Me?”, the critical factor will be whether or not most Americans see themselves gaining or losing from health reform. People are not being selfish. They are truly worried about paying for health care and health insurance and there are few if any legislative debates that will more directly impact people’s lives than health care reform. The barometer to watch is the percentage of the public who feel they and their family will be better off as a result of health reform and correspondingly the percentage who feel they could be worse off. Our July tracking poll found the percentage who say they will be better off remained unchanged since February, at 39%, but the percentage saying they would be worse off had almost doubled, from 11% to 21% (still a relatively low number). The percentage who thought it "wouldn't make much difference" to them or their family - a key group - stood at 32%.

Three factors will be especially crucial in the battle for public opinion over the next few months.

First it will be critical for the Administration and Congressional leaders who are advocating health reform legislation to focus on what the legislation does about the problems average people with insurance care about most - the struggles they are having paying for health care and health insurance and their worries that their coverage will become unaffordable for them or that they may lose it in the future. This is the issue - framed well in the presidential campaign, but given much less attention recently - that placed health care back on the agenda in the first place and gave it new political traction. The policy debate on Capitol Hill and much of the public rhetoric recently about health reform has focused on the intense interest policymakers have in the public plan option and on various ways to bend the health spending curve in the future through delivery and payment reforms. We hear a lot about bending the curve by modeling the Cleveland Clinic and the Mayo Clinic and by reducing regional variations in costs and utilization. (The latter have been rediscovered but are not a new phenomenon; startling small area variations were documented back in the seventies when I worked with the pioneer of variations research, Dartmouth's Jack Wennberg in a firm called The Codman Research Group.) These are all critical issues, but they are somewhat opaque to average people and not the public’s primary focus. The elements of the legislation most relevant to average people are the coverage expansions and subsidies that can directly help individuals and families pay for health insurance and the insurance market reforms that will give virtually everyone greater peace of mind that they will not be dropped or priced out of coverage if they get sick. To date, the experts' agenda has overshadowed the public's agenda and the list of the thorniest issues being negotiated on Capitol Hill has dominated media coverage. To win the war of public opinion and answer the average citizen's question "How will this help me", this will need to change. The President may have signaled this shift in his sharp focus on health insurance reforms in Raleigh, North Carolina last week. The danger zone here is that as Congress cuts back on the cost of the legislation, it will no longer meet the expectations of many people who will now be required to have health insurance and are expecting generous coverage and substantial help with their health care bills. But the combination of subsidies and insurance reforms can do a lot, and this is where the focus needs to be from the people’s perspective.

Second, the President is without question health reform's communicator-in-chief and the most important counterweight to the opposition on health reform, but he cannot be the only prominent voice explaining health reform to the American people, if only because Presidential power and media exposure needs to be expended carefully and at the right times. Congressional leaders advocating for this legislation are understandably preoccupied negotiating the details of health reform. However, Congressional leaders are national leaders too, and especially during the recess they also have a critical role to play not just in their home districts but on the national stage dispelling confusion and explaining what the legislation will and will not do for average people. There is no question that opponents will be out in force. Without an all hands on deck approach to public communication at the national level the Truman-Clinton pattern is more likely to repeat itself.

Finally, the news media will need to grapple with familiar, but difficult philosophical questions. What is the right balance between the day-to-day scorecard of the legislative process and political debate and informing the public about the impact on individuals and their families? Is it the media's job to cover charges and countercharges or also to the best of its ability ferret out the facts about what is really in the legislation versus the spin and hype designed for political advantage (on both sides) or commercial interests? There are legitimate reasons to be for or against the current legislation. But, for example, does the health reform legislation as drafted really threaten rationing in any form at any time in the foreseeable future? If you were to speculate, wouldn't you assume that relatively faceless private insurance companies would have an easier time denying care than a public entity, which people would hold their Congressional representative accountable for or could even march on? And is there anything in the legislation that really would constitute a government takeover of health care (with a public option that according to the CBO might attract a relatively small percentage of the perhaps thirty million people who may enroll in exchanges by 2019), if in fact there is a public option included in the final legislation at all. The public option is a real issue, but it is also a symbolic issue for both sides; the water fluoridation of health reform. Couldn't more be done to distinguish rhetoric from facts?

News coverage matters because the public gets not only its information but its sense of comfort or unease about health reform from news coverage. In terms of its impact on the public it is far more important than paid for TV ads run by interest and advocacy groups. Make no mistake health reform is complex and confusing. But more than anything else, the public's answer to the question "How will this help or hurt me?" will depend a lot on how the media handles the coverage challenge.

So if you are asking the “What’s in it for me” question, then here are three big things to think about:

1) The public is waiting to hear much more about how health reform will affect them. Will they hear it or just the hot button debates and political spin?

2) Who will the national spokespersons be?

3) What is the role of the press? How will they take on this challenge?

While it is critical that we make every effort to cover all Americans, it is also important to highlight how health care reform will help middle-class families who are insured. Middle-class insured Americans are already bearing a huge burden of out-of-pocket costs that are growing much faster than their incomes – leading to higher rates of medical debt and personal bankruptcies.

Meaningful health care reform means more than covering the uninsured: It means making existing coverage more stable, more affordable, more secure, and less at the whim of an inadequately regulated insurance industry.

For the insured middle class, health reform will:

• offer stability of health coverage, ensuring that good, affordable coverage remains available when people change or lose jobs or start their own businesses;

• keep health coverage and care affordable, both by decelerating health care costs and by providing sliding-scale subsidies;

• ensure accountability from insurance companies, preventing them from denying coverage or charging discriminatory and unaffordable premiums to people who get sick;

• increase health coverage options for people who want more choices of health plans;

• provide prescription drug help for seniors who need multiple medicines by closing the infamous “doughnut hole” that makes needed medicines unaffordable;

• reduce the “hidden health tax” – the surcharge that is added to insurance premiums to pay for the uncompensated health care provided to the uninsured – which the actuarial firm Milliman, Inc. estimated to be $1,017 on average for family coverage in 2008; and

• protect small businesses by providing subsidies, reducing the “hidden health tax,” enabling pooling of coverage through “exchanges” that should secure economies of scale, and stabilizing premium costs if a worker gets sick.

As more and more families experienced increases in premiums, deductibles, and co-payments in the past years, and as working families experienced stagnant wages due to employers’ burgeoning health care costs, there has been a growing appreciation that the status quo is unsustainable. Indeed, the status quo, in this respect, is a misnomer: Inaction on health care reform will take away families’ peace of mind as affordable, quality health coverage and care can no longer be taken for granted.