Untangling the Politics of Health Care Reform

August 25, 2009 — In recent months, the public debate about reforming the U.S. health care system has often generated more heat than light, with exaggerations, sound bites and canards – like the debunked notion of "death panels" – overshadowing the substantive arguments inherent to an immensely complex undertaking. But health care is also an immensely personal and emotional issue, setting the stage for raucous confrontations.

In an attempt to untangle some of this, UVA Today turned to Eric Patashnik, an expert on the politics of health care and a University of Virginia professor of politics and public policy. Recently, Patashnik was appointed associate dean of the Batten School of Leadership and Public Policy and was awarded two national grants to research the politics of efforts to improve the use of evidence in medical decisions.

Q. What are the most important aspects of health care reform?

A. There are two main health care problems: About 15 percent of Americans lack health insurance, and health care costs are rising rapidly.

These problems compound one another. As medical care becomes more expensive, obtaining health insurance becomes less affordable for American families. The dilemma is that covering everybody will increase costs for taxpayers and people who already have coverage. Many people are unwilling to support health care reform if it means they will have to pay higher taxes or insurance premiums.

Q. Debunk one or two of the worst health care reform myths.

A. Both conservatives and liberals fall prey to their own myths and misunderstandings. Conservatives say we have a private health care system. In fact, we have a mixed private/ public system. Health care delivery is largely private, but government pays for a huge share of medical care through Medicare and Medicaid and through tax preferences for employer-based insurance plans.

Liberals think that Americans overwhelmingly despise the current health care system. Actually, most Americans are satisfied with the quality of their personal medical care. While about three-quarters of Americans will agree, when asked, that the health care system is a mess and needs major reform, more than eight in 10 say they are satisfied with their current medical arrangements. This tension between collective unhappiness and individual satisfaction is at the core of the health reform debate.

Q. How are both sides of the reform debate using scare tactics to shape the debate?

A. Fear is a powerful motivator in politics, and both reform advocates and opponents are trying to use it to their advantage.

Reformers want people to focus on the insecurity of their current health insurance plans. If you lose your coverage, and you or one of your loved ones develops an expensive illness, your family – unless affluent – could go bankrupt. The problem for reformers is that Americans are more concerned about the economy than they are about losing their health insurance next year.

Opponents are stoking fears that reform will degrade health care quality, reduce the freedom to choose doctors or coverage, or even lead to government rationing of medical services.

There is considerable social science evidence that voters exhibit a negativity bias, meaning they focus more on losses than on gains of equal size. It should not be a surprise that senior citizens (who fear cuts to their Medicare benefits) have been more vocal than have the people who would benefit from expanded insurance coverage.

Q. Public opinion surveys indicate that roughly 80 percent of Americans support universal health care coverage, but about 50 percent say President Obama is on the wrong track regarding health care reform. How do you explain this disparity?

A. Americans support the idea of universal health care in the abstract, but support plummets when people think it means they could face higher taxes or health care costs. And citizens worry that universal health care coverage will lower the quality of their own care by expanding the demand for medical services faster than the supply of doctors.

The most important constituency for reform is not the 15 percent of Americans who lack health insurance, but the 85 percent who have it. The challenge for reformers is to convince the majority of Americans who have coverage that they will not be hurt in the transition. Public reactions to the Obama plan are an indication that reformers have so far failed to provide the necessary reassurance.

While the health care bills under consideration in Congress do not impose direct cuts in Medicare benefits, they would slice provider reimbursement rates, and many seniors worry that doctors will choose to opt out of the Medicare program (just as many specialists today refuse to treat Medicaid patients).

Q. Proponents of health care reform frequently cite basic statistics, not in dispute, that U.S. per capita health care spending is vastly higher compared to spending in other industrialized countries, yet the U.S. ranks poorly on most standard measures of health status, like infant mortality and life expectancy. Why does reference to these undisputed facts and the experience of other nations (apparently) seem to have relatively little impact on American public opinion?

A. While policy analysts and social scientists (myself included!) like to focus on statistics and cross-national comparisons, most Americans think about health care in personal terms. What does this reform mean for me? For my loved ones? For my ability to keep my relationship with my physician?

The political scientist James Q. Wilson persuasively argues that Americans are heavily influenced by expert opinion on matters on which they are personally uninformed, but that expert opinion is much less influential when it comes to issues where American have firsthand knowledge. It is hard to think of an issue where Americans have stronger personal beliefs than health care.

Q. Is it politically feasible to take any measures that will "bend down the cost curve" significantly? How?

A. One idea that has been discussed is to establish an independent government body that would evaluate the relative clinical effectiveness of different treatment options. What's the best way to treat localized prostate cancer? Surgery to remove the prostate gland? Radiotherapy? Or, given the risks of complications and side effects of those treatments, would many patients be better off following a protocol of "active surveillance"? What's the best way to treat heart disease, knee arthritis or back pain? Doctors and patients today often lack the objective scientific data they need to answer such questions. A comparative effectiveness board could help doctors and patients make more informed treatment decisions.

The United States spends a lot of money on treatments of unproven or dubious efficacy. But we haven't had enough experience with comparative effectiveness research to know whether better information can reduce waste and tame the growth of medical spending. And the politics of evidence-based medicine is just explosive. Past governmental efforts to improve the medical evidence base have generated opposition from providers and patient advocacy groups.

This is a topic I'm currently researching with my Yale colleague Alan Gerber, with support from the Robert Wood Johnson and Smith Richardson foundations.

Q. What are the best features of the current U.S. health care system? Are there legitimate reasons to fear that a "reform" will diminish or destroy any of those features?

A. The best features of the American health care system are that it generates a lot of innovation (some of which dramatically improves health care outcomes), most people are satisfied with their own doctors and medical plans, and most senior citizens have reasonable coverage.

While there are many things in the system worth preserving, the status quo isn't working. Millions of working Americans cannot obtain or afford health insurance. We invest far too little in objective research to determine the most effective treatments for common conditions.

And health care costs are out of control because of the perverse incentives from the fee-for-service system. In most fields, technological innovation lowers consumer costs, but that's not been the case in health care. Workers' wages have been stagnating in part because a growing percentage of employee compensation is going for medical care. The federal budget is on an unsustainable path because of Medicare costs. At the state level, rising Medicaid spending is straining state budgets, leaving less money available for other priorities (including higher education).

All this said, I appreciate why many people, especially seniors, are worried about the unintended consequences of reform. Americans may have voted for President Obama, and wanted a change from the Bush years, but public trust in government remains low. People are reeling from the economic crash and the financial bailouts, and they are anxious about the direction in which the country is headed.

The struggle of health care reform is fascinating, and the outcome will reveal a great deal about who and where we are as a nation.

— By Brevy Cannon