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.

Is Crisis the New Normal?

Recent clashes over balancing the federal budget bear an eerie resemblance to the cries of crisis that  defined debates over health care reform debates for more than four decades. Over the past month, President Obama warned that sequestration–across the board budget cuts–would “put hundreds of thousands of jobs and our entire economy at risk.” Crisis rhetoric has a seductive appeal to political leaders, for it promises to spur action to deal with an acute problem. The Obama administration regarded warnings of a impending catastrophe as a way to break partisan gridlock in Washington, but such crisis talk suffers from a major credibility gap. Cutting federal spending (excluding entitlement programs such as Medicare and Medicaid, along with military salaries) by 2% is not likely to bring the federal government to a grinding halt. Difficult choices will have to be made, but the president’s warning that these reductions will cripple the American economy simply don’t hold up.

Constructing crises is now the new normal in Washington. To date, neither the “fiscal cliff” nor the threat of sequestration has yielded a meaningful compromise to address the nation’s long term fiscal problems. Instead, balancing the budget, like treating the chronic problems facing the American health care system, is a chronic problem which requires careful management, not brinkmanship. In the case of sequestration, crisis talk is counterproductive and lacks credibility. A new rhetoric of reform is desperately needed to lay the groundwork for a meaningful bipartisan agreement to tackle the nation’s chronic deficit problem.