Friday, August 28, 2009

What should Obama do about the drop in public support for health reform?

There no longer is any question that public support for health care reform is faltering. But the battle for the public's hearts and minds can still be won, but only if reformers understand the reasons and adjust their plans accordingly.

Many health reform advocates blame the drop in public support on the "lies" being spread about health care reform by "special interests" and on the endless reporting of angry voters at town hall meetings. It is true, as I wrote on Tuesday, that the public seems to be buying into many of the untruths being spread by reform opponents, despite the efforts of the mainstream media, and organizations like ACP, to set the record straight. It would be a mistake, though, for health reformers to ascribe their problems to uninformed voters being misled; calling voters "stupid" is not exactly a recipe to win popular support.

A new public opinion tracking poll by the Kaiser Family Foundation provides a more nuanced view. It shows that "a slim majority of Americans continues to favor moving forward on health care reform now despite an intensifying ad war and a political climate of contentious town hall meetings that coincide with rising concerns about the reform effort." But voters increasingly doubt that health reform will be good for them: 51% of voters are more worried "that Congress and the president will pass a reform bill that won't be good for [them] and [their] family" compared to the 39% who are more worried "that Congress and the president won't be able to pass health care reform this year."

Almost half (48%) are more worried that "under a new health reform bill, government agencies would play too big a role in deciding what medical procedures people can or can't get" compared to 38% are more worried that "currently, insurance companies play too big a role in deciding what medical procedures people can or can't get." A solid plurality of voters are concerned that health reform will reduce their choices of doctors and hospitals and increase wait times for non-emergency treatments.

The critics of health reform, though, should think again before concluding that they have won the public opinion battle. 63% of the respondents described themselves as "hopeful" about the health reform plans being discussed in Washington; only 41% described themselves as "afraid" of the plans.

Moreover, voters generally favor many of the specific ideas in the pending bills, with majorities favoring or strongly favoring expanding state programs for the poor, offering tax credits to help people buy coverage, requiring that all persons have coverage; requiring employers to offer coverage or pay into a health insurance pool; and creating a government-administered option similar to Medicare to compete with private insurers.

These data suggest several things to me. One is that a "hopeful" public still wants health reform and are inclined to support most of the key elements of the pending bills, but they are anxious that the result will be to limit their choice of doctor and give the government too much authority over patient care decisions. To put it differently, it seems to me that the public's opposition really isn't to expanding coverage, but to effect of cost controls on their own access to care.

Writing in the Washington Post conservative columnist (and physician) Charles Krauthammer sees a way out for the Democrats: drop the cost controls, the public plan, end of life counseling, and the idea of the government funding research on "best practices" and instead "promise nothing but pleasure - for now. Make health insurance universal and permanently protected. Tear up the existing bills and write a clean one - Obamacare 2.0 - promulgating draconian health-insurance regulation that prohibits (a) denying coverage for preexisting conditions, (b) dropping coverage if the client gets sick and (c) capping insurance company reimbursement. What's not to like? If you have insurance, you'll never lose it. Nor will your children ever be denied coverage for preexisting conditions."

Krauthammer predicts cost control and rationing will come later on.

President Obama has been insistent that health care reform must deal directly with costs, and putting aside tough cost controls - instead focusing on guaranteeing insurance coverage that can't be taken away - would be a huge shift for him and likely make the nation's long-term fiscal outlook worse. But the polls suggest that this might be the best way for him to salvage support for health care reform from voters who want better health insurance coverage, but not if it limits their health care choices.

Today's question: Do you think Obama and the Democrats should shift the debate from controlling costs to expanding coverage?


Arvind said...

Very interesting indeed. My take on the survey - more people believe now that reform will hurt them but will probably help others. Seniors in particular, and others in general do not favor reducing doctors' payments in order to reduce costs in the long run.

Its interesting that the average public's impressions/expectations mirror those of practicing physicians. Somehow the Congress and organizations like the ACP seem to think exactly opposite. This should show that there is a vast disconnect between policy-makers and the actual folks in the trenches that receive and deliver health care.

This would be a great time to rethink the objectives of any reform proposal and how to achieve them. Please talk to the average community physicians and their patients, and you will have very simple, uncontroversial answers.

Robert J. Sobel, M.D. said...

Hasn't this always been the essence of the debate, how to do both? It's time to get blunt and recognize how the business is run. It's hard to get any meat in the comments section for Dr, Krauthammer's articles, as the labels come a flying, but he seems to impress a lot of folks and identifies problems quite astutely from my limited reading.

Watching C-SPAN this week and seeing a former HCFA director under Clinton and the recent CMS director Tom Scully reminds me of how easy it is to disagree on the ideological/theoretical terms when they fail reality testing. We are close. We need to constantly work to optimize Medicare, reduce those who need Medicaid (as states can't afford and doctor access limited), and give a regulated private sector the utility role.

None of this works without the primacy of respecting physician and patient autonomy and control of costs via more vigorous attention to the commodities within health care (drugs, DME).
Regulated Royalties added to the evolving consensus ideas would punish only those whose service we no longer need (the hassle administrators who have evolved well beyond any ethical bounds; for-profit, shareholder dependent corps that become bottom-line blind). The insurance companies will have to divest and reorganize. Congress should be able to figure this out.

You have already cited how primary care growth would control costs. New technologies and hospitals have their role, but we can't let them bankrupt us. Prorate the costs of the new and invovation will not be stymied and rationing will not be needed.

Steve Lucas said...

One of the few general statements made in the health care debate that I agree with, and touched on by Arvind, is there is a very different perspective between those inside and outside the beltway. Being outside the beltway I see the problem as access to insurance at a reasonable cost, and then accessing a doctor that is not practicing medicine driven by drug company, insurance company, or malpractice standards.

We have all seen those left in dire straits due to lack of insurance, or the inability to pay out of pocket for care. Most hospitals cannot even quote a price for any given procedure given all the discounts and various pay schedules. This is disturbing.

Like many I would like to see the process slowed down and concrete numbers given to cost and cost savings, not vague promises of paying for the program by reducing fraud. We also need to look at the impact on all of those involved in the medical process.

Doctors are not the bad guys in this discussion. Patients are not the bad guys in this discussion. The pressure being placed on these relationships, and proposals that will further interfere with the patient/doctor relationship, combined with cost, are what is driving the loud cries from people truly concerned about the wholesale changes being promoted in some circles.

It was recently pointed out in this blog that the most expensive part of the medical process is where the doctor's pen meets the prescription pad. I, like many, would like to see this returned to a joint decision between the doctor and patient, not one driven by outside interest.

Insurance needs to be accessible and cost effective. Simply mandating insurance with the current broken system will not fix anything. If we are going to restructure 16% of the US economy we need to look at this carefully and with due consideration.

Lets not rush into some grand experiment, but take the time to resolve as many issues as possible, understanding that no solution is perfect, and not everybody will receive the same care.

Steve Lucas

PCP said...

Well said Mr Lucas. I think you have captured in a nutshell the misgivings of most independent minded Doctors, and a freedom cherishing populace on this issue.
Until and unless this is at the center of the debate and the rest of the interests serve us rather than the reverse that is currently happening, we will never get a plan that passes.

In short Pres. Obama needs to enlist the help of Doctors, not the AMA, but of in the trenches doctors. He needs to learn that any reform should respect the desires of the public not the academic elites like Atul Gawande. The cold hard reality is that the interests of many special interests need to be gored if he wants reform. Big Pharma, the insurance industry, DME suppliers, Home Health, Medical device manufacturers, PBMs, Pharmacy Chains............geez there are so many 3rd parties that have now got their hands into the jar now that, it will not be easy.
However unless he can come up with legislation that makes those other parties servants of the Doctor-Patient relationship, instead of what is currently the case, he will not win over the public's nor in the trenches Doctors support.
The public trusts Doctors because we have earned that trust, the public distrusts Politicians because they have earned that too.

Mr Obama needs to learn to enlist the support of those who can convince the public. He cannot come to the AMA and dismiss our concerns on Tort reform for instance.
I have always said we have more leverage in this discussion than our leaders have understood. Only because of the trust we have earned with our patients over the years. We are very bad at leveraging that into policy changes that improve both the practice of medicine and squeeze the 3rd parties to the benefit of us and our patients. The public yearns for that. They could care less about the profit margins of big pharma, or Insurers or any of those other 3rd parties.
They however don't want to see their PCP go out of business or take up an employed position because the private practice of medicine is not worth the hassle and costs, and then they have to seek care at the local indigent clinic, which then gets amply subsidized by Democrats. Mr Obama and policy makers need to understand that. The ACP needs to make sure that its policies do not lead to generalists working for CHCs/FQHCs with a bunch of midlevels that they "supervise" in a universal system that is deemed an "advanced medical home".
Current policy will lead to that.
I want to employ mid-levels and be ultimately accountable to my patients not work alongside mid-levels in indigent clinics and answerable to my employer. If my experience is anything to go by, I believe that is what even the most illiterate/indigent patients want also.

Jay Larson MD said...

Excellent points by the previous bloggers. To really get public support, politicians need to support and elicit support from the most overlooked, yet most important part of the system…a caring primary care physician that has the patient’s best interest at heart. Unfortunately, the commercialization of medicine has corrupted the physician-patient relationship.

Though not “organized” such as the AMA, there still are plenty of caring primary care physicians out there scattered across the country. Yes, the numbers are dwindling, but these physicians are not totally gone. These physicians are the part of the health care system most trusted by the public.

Yes, health care insurance reform is needed, but the only way to bend the cost curve is to base the system on caring primary care physicians that spend time with patients. How many tests could be avoided if a careful history is done? How many malpractice law suits would disappear if patients felt that the physician was trying to do the best for them? How can a physician do this in 10 minutes?...impossible.

The health care debate has brought out some very vocal people with strict ideology. Ideology without critical thinking is a dangerous thing. Hopefully these individuals will not stop the process of health care reform by destroying public support. This system is broken. This system needs to be fixed. Lets not forget this.