Redefining the costs – and benefits – of health care reform

The cost of the Affordable Care Act continues to stir controversy. David Walker’s recent column in USA today highlighted a provision of the ACA that has received little attention to date. Walker, the former comptroller general of the U.S., noted that under ObamaCare, many cash-strapped state and local governments could shift the cost of health insurance for current and future retirees to federally subsidized health insurance exchanges. For states struggling to balance their budgets, and for municipalities teetering on the edge of bankruptcy (as several communities in RI have been in recent years), this provision of the ACA may be too good to pass up. If a significant number of states and local governments take advantage of this provision, however, the cost of the ACA will quickly outstrip even the most conservative projections. Cries of an emerging fiscal crisis will inevitably follow, leading to calls to scale back federal support, reduce coverage, or trim benefits.

Walker’s analysis is offers reformers with a chance to reframe the impact, and importance of the ACA. Health insurance exchanges, in short, could be defined as a lifesaving prescription for precarious state and local government finances. Reframing the debate over reform to focus on the benefits of the law for state and local governments could mobilize support for the law from the grassroots, as fiscally strapped communities across the nation seize upon a new method of intergovernmental cost sharing. The cost of the ACA would undoubtedly rise, but reformers could tell a new policy story that highlighted the benefits of  additional spending as a creative form of tax relief for hard hit local taxpayers or as a means of averting painful cuts in state and local services. Either notion could bolster support for reform, which continues to lag in the polls.

If supporters of health care reform do not address this issue, opponents certainly will. Rising costs will be defined as further proof that the ACA is unaffordable, and calls for repeal will intensify. As Walker notes, as we approach the implementation of health care reform, “we should recognize both the risks and the opportunities – including what could unfold at every level of government – and be prepared for the results.” Since policy debates revolve around storytelling, supporters of reform must not forget that the meaning of rising costs is not fixed. Costs can be defined as a crisis, or as an investment. How they are defined will depend on the persuasiveness of the policy stories told in the public square.

Health care costs in the public square

Health care costs in the public square

In April 2013, Salve Regina University hosted a wonderful conference on Storytelling in the Public Square that explored the role of narratives in framing public debates over important policy issues. This week, my essay on health care costs appeared on the conference web site; I examine Steven Brill’s widely discussed article in Time magazine – A Bitter Pill – in the context of previous journalistic exposes about the cost of health care.

Trust in government and health care reform

Public support for the Affordable Care Act (“ObamaCare”) is at an all time low, even as federal and state officials scramble to prepare the law’s new health insurance exchanges to enroll millions of new consumers this fall. The Kaiser Family Foundation’s April 2013 Health Tracking Poll revealed that only 35% of Americans hold “favorable” views of the ACA, compared to 42% who continue to oppose the law.

The ACA has a growing PR problem. Most Americans neither like nor understand the law’s goals or requirements. The Obama administration continues to pitch the benefits of the ACA in public events around the nation, but Americans aren’t buying the notion. Indeed, support for the ACA has steadily eroded since November 2012 (43% favorable) to 35% today. Supporters of the law hold Republicans responsible for its continued unpopularity, but there’s more here than meets the eye.

Officials are now preoccupied with the nitty gritty details of policy implementation – signing up insurers, designing web sites, and educating the public about the new coverage requirements, penalties, and options for purchasing subsidized insurance. This is a major undertaking, but the Obama administration and supporters of the ACA face a much larger challenge than simply ensuring that the exchanges work as intended. The future of the ACA, and of efforts to expand health insurance coverage to millions of uninsured Americans, ultimately rests on the ability of the president to restore faith in public authority. Recent scandals with the IRS and NSA monitoring of phone calls and emails did little to help matters on this front, but the issue is not new. The most recent Wall Street Journal/NBC News poll in early June found that Americans were evenly divided (48% yes, 48% no) on the question of whether “Government is doing too many things better left to businesses and individuals.”  Seen in this context, weakening public support for the ACA is a symptom of declining trust in government and diminished confidence that government should take on new or expanded roles in the economy. Since less than a third of the public was “generally optimistic” about “our system of government and how well it works” in the most recent NBC News/WSJ poll, the burden of proof rests with the Obama administration to make the case to the public that health care reform is not only in the public’s interest, but that government – not the private sector – is best suited to handle the task. As I argued in the conclusion to Cries of Crisis, ”the success of health care reform depends upon the ability of policy makers to convince a skeptical public that progress is not only possible, but also consistent with American ideals. Reformers must persuade Americans to suspend their doubts, if not outright hostility, towards government.” Until then, the future of the ACA rests on shaky ground.

How ideas shape policy debates

“The case for austerity was and is one that many powerful people want to believe, leading them to seize on anything that looks like a justification.”

Paul Krugman, “How the Case for Austerity Has Crumbled,” New York Review of Books (June 6, 2013)

Reading Paul Krugman’s discussion of how austerity policies became the new conventional wisdom in economic policy brought me back to my original interest in writing a book about the way Americans think about the need for health care reform. Krugman asks why a particular definition of the problem “was ever taken seriously, let alone canonized, in the first place.” I continue to raise similar questions about the health care “crisis” in America.Our health care system suffers from many significant, chronic problems, but they are not now, nor were they, crises. Unlike Krugman’s claims about the intellectual foundations of austerity policies, the cries of crisis that defined health care debates since the early 1970s did not stem from flawed data or conscious distortions of the facts. Instead, crisis rhetoric stems from a fundamental misunderstanding, or misdiagnosis, of the underlying conditions driving contemporary health policy problems. Our principal policy challenges – rising costs, a growing number of Americans without heath insurance, unaffordable malpractice premiums, the shortage of providers in rural and underserved communities, or the need for affordable long term care – are all examples of chronic conditions that require coordinated planning and treatment. Each of these issues worsens slowly over time, but no clear “tipping point” is visible that will compel public officials to act.

Crisis rhetoric appeals to elected officials and affected interests because of its ability to “pull rank” on other issues; as recent debates over sequestration demonstrated, reformers continue to believe that labeling an issue as a crises will force public officials to make hard choices, thereby “curing” the problem. In the end, doctors, hospitals, insurers, and other stakeholders who treat, or pay for the care of persons with chronic diseases should apply lessons from their own professional practice to contemporary debates over health care reform.

Ideas matter, for talk of a continuing health care crisis shapes public expectations and the beliefs of public officials. Nearly 25 years ago, Paul Quirk and Martha Derthick noted that ”the direction of policy change depends on the state of opinion about the public interest.” Since policymakers both shape and reflect public concerns,changing the way we talk about our health care system is central, not incidental, to the future of health care reform.

A looming health care crisis for seniors?

Crisis talk continues to dominate public debates about health care in America. This week, a front page story in USA Today warned readers that “a health care crisis looms for seniors” as 8 in 10 Americans over the age of 65 reported at least one chronic condition. The result, argues reporter Michelle Healy, is “an emerging health care crisis.” Alas, this notion misdiagnoses the underlying condition facing our health care system. While seniors now live longer, and as a result, cope with more chronic health problems as they age, this is hardly a crisis. As the story notes, the demographic shift of an aging America, coupled with recent rises in obesity, diabetes, arthritis, and other conditions are chronic conditions, not acute ones. This misdiagnosis is not simply a question of word choice. The concept of a “senior health crisis” is a misnomer that suggests that things have taken a dramatic turn for the worse. Implicit in such cries of crisis is the notion that swift action can reverse, or “cure” the crisis.

Ironically, Healy’s diagnosis of a crisis is based on the existence of several interconnected, chronic conditions (i.e., obesity, diabetes, etc) that are often preventable, evolve slowly–if not imperceptibly–over time, and quite common. To ensure that millions of older Americans don’t experience what David Cutler describes in Your Money or Your Life as “the failure of success” (in which we live longer, but feel worse), policymakers need to provide incentives for seniors to embrace healthier lifestyles. Access to well-coordinated primary care is also essential to manage these ongoing health concerns. Both are long-term challenges, particularly as we approach the rollout of the Affordable Care Act in 2014. The ACA emphasizes the importance of changing health behaviors, and also brings millions of previously uninsured, or under-insured Americans into the health insurance marketplace. A key challenge in the coming years is to ensure that all Americans–young and old–have access to regular primary care; in the short run, the ACA is likely to exacerbate the existing shortage of primary care providers who play a key role in counseling and supporting patients to modify their health behaviors.

Like all chronic conditions, changing health behaviors and persuading more doctors, nurse practitioners, and physician assistants to embrace primary care, despite powerful incentives to specialize, requires the implementation of “disease management” techniques to adjusts incentives for doctors and patients.

New cries of crisis – Insurance premiums set to rise

This week, news stories featured dire warnings for consumers about the cost of health insurance coverage. After the release of a new report by the Society of Actuaries, ominous predictions of spiraling insurance premiums appeared in the Wall Street Journal, the Associated Press, and other news outlets. I recently sat down with our Public Affairs coordinator at PC, Chrissy Centazzo, to place these new reports in context.

My odyssey to Ithaca

This week, I had the chance to share my arguments in Cries of Crisis with some wonderful students and faculty at Ithaca College. What was supposed to be an uneventful journey turned into my own personal odyssey, as I found myself caught between the Scylla and Charybdis of US Airways and United Airlines during my travels. After having my connecting flight from Newark canceled by United for “mechanical issues” on Monday morning, I flew to Philadelphia to catch a US Airlines flight; this flight was delayed for “maintenance issues” for more than 3 hours. The upshot of my travel troubles was that I missed the opportunity to visit two classes on leadership in health care taught by Dr. Karen Edwards, as I finally made it to Ithaca 8 hours after my scheduled arrival time. Although I was able to meet a number of students over coffee on Tuesday morning, I missed the chance to chat with many others. This posting is for them—rest assured, I would rather have spent time with you than waiting endlessly in airports trying to reach Ithaca! If I’d been able to join you, this is what I would have shared…

After reading Mike Figliuolo’s One Piece of Paper, I was struck by how his discussion of “buzzwords” that have no real meaning, but are nevertheless widely used, connects to my own arguments on the language of health care reform. Cries of Crisis explores the stories we tell about our health care system. For more than four decades, I argue that we’ve used what George Orwell describes as a “meaningless word” (crisis) to frame arguments over health care reform. No real consensus exists on what it meant to describe the health care system this way—the term raises more questions than answers. What, in other words, does it mean describe the health care system as “in crisis”? What should we do as a result? Can we solve it?

One of the most important things leaders do is to lead a conversation about how to define and ultimately manage difficult problems. Leaders, in other words, must tell stories to help those they work with make sense of the world and understand how to change it. Storytelling can occur in your work with patients where you’re trying to help others change their own health behaviors, advocating for patients with third-party payers, or fellow providers, or even as a member of a professional society advocating for its members in the political and policy making process. As a leader, you’ve got to choose your stories well, and make sure that they have narrative fidelity (truthfulness) and narrative coherence (in other words, they make sense).

My book tries to bring a fresh perspective to health policy debates by challenging the narrative fidelity and narrative coherence of crisis stories as a way to describe what’s wrong with the American health care system. Many people take the existence of a health care crisis as a given, but I try to dig deeper…to see if the conventional wisdom is credible, and makes sense. As a class studying how to “lead thought it’s important to understand the importance of presenting a fresh perspective on difficult issues. My book offers a different way of looking at the health care system, and ultimately a different way to talk about health care reform.

The ongoing popularity of crisis narratives to frame debates over health care reform is anchored in a belief that stories of impending collapse will force policymakers and the public to take action. Leaders often like the notion that they will be able to take decisive action that solves a problem. Political leaders used fear-based appeals such as repeated warnings of an impending “breakdown,” “collapse,” or “meltdown” to frame each call for health care reform from the 1970s to the present day. A forty-year crisis, however, just doesn’t make sense. For me, leadership in health policy revolves around shifting our conversation.  The stories we tell present the public with different ways of understanding the world, leaving citizens to decide for themselves which ones are most credible and persuasive.

For me, decades of discussion of health care reform describing the health care system as a crisis resembles Mike Figliuolo’s critique of organizations that make decisions a particular way because “the way they’ve always done it.” I found the discussion of asking “why” questions particularly useful in One Piece of Paper and thought that this provided a useful context for the appeal of crisis rhetoric over time. Thus, a series of “why” questions about the health care crisis might look like this…

Why do we use crisis rhetoric? Because Americans are unhappy with the state of the health care system.

Why aren’t we happy? Because costs are rising faster than incomes, gobbling up a larger slice of our economy, millions of people don’t have insurance, and we’re afraid that care won’t be there when we most need it.

Why are costs rising? Lots of reasons. On the one hand, many argue the system is wasteful, and that providers overcharge patients and encourage the unnecessary use of services. On the other hand, spending more on health care can also be viewed as an investment in promising new treatments and cures.

Why are we afraid? Because we worry that we won’t be able to afford care, or might lose our insurance, or that doctors or nurses won’t be there when we need them to be….

Why is crisis the wrong diagnosis for what ails the US health care system? Because we can’t agree on what it means, and because it’s been used for 40 years to describe problems that, upon closer inspection, are really chronic, not acute conditions. I argue that the health care system suffers from a collection of chronic conditions we need to manage, rather than a problem we can “cure.”

Why does crisis talk have “side effects” that undermine the prospects for meaningful reform? Crisis talk suggests a tipping point…if nothing is done, then things will deteriorate, quickly! In the absence of a “meltdown,” however, repeated warnings of impending collapse are unpersuasive, and erode the credibility of arguments for reform. By understanding the shortcomings of existing narratives of crisis, reformers will be able to tell better and more persuasive stories. As Walter Fisher argued, “the most persuasive, compelling stories are mythic in form, stories of ‘public dreams’ that give meaning and significance to life.” To date, the narratives of crisis that defined our public discourse about health care reform failed to do this.

Four decades of crisis talk is enough. Rather than turning to cries of crisis, I argue that we need to craft a new story of progress that can capture the public imagination and mobilize citizens and legislators to undertake the hard work needed to improve the health care system. The problems plaguing our health care system don’t lend themselves to a quick solution—that’s where leadership comes in. As future health providers, you’ll often find yourselves in situations where you need to help your co-workers wrap their heads around a problem, plan a strategy to address it, and then implement it. Storytelling is vital at each and every stage of solving problems, because it tells us why we need to do something and where we’re going. As leaders, that task will fall to you.