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.


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