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Framing the Health Care Reform Debate: Who Do You Hate? Or, Who Do You Hate More?

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A 14-year-old boy, "Jimmy," has been seriously depressed and is receiving inpatient treatment in an adolescent residential facility because he is suicidal. His father, a state employee, has private health insurance through work that is paying for the care. The insurance company determines that Jimmy's care is no longer "medically necessary," a term that is defined on a case by case basis by the private health insurance company itself. It orders that Jimmy be discharged even though Jimmy's medical chart documents that he has been showing clear and unmistakable signs of still being suicidal.

Unaware of the suicide risk and reassured by the medical assessment, Jimmy's parents take him home. Less than a week after his discharge Jimmy takes a gun up to the roof of his home and blows his brains out. His father finds him in the morning. Jimmy was their only child.

I spent over 10 years providing legal representation to families, including Jimmy's, who were victims of our current private health insurance industry with its self-serving determinations of what care is and what care is not "medically necessary." The insurance industry tries to dismiss the dozens of cases like Jimmy I saw as "anecdotes." But the financial incentives of the private health insurance system in which one makes more money if they provide less care makes these "anecdotes" inevitable.

Right now, the very same insurance company that made the medical necessity determination about Jimmy's care is spending millions of dollars to convince Americans that Americans' health care will be jeopardized if America does not continue to let the private insurance industry run our health care system. Up until now Obama has been letting them get away with it.

If the Obama Administration does not tap the deeper strata of the mind at play in the health care issue, it will lose. It will lose for the same reason the Clinton plan did.

I first lobbied Congress for health care reform in 1963 and have spent my entire adult life in the health care arena in multiple capacities. In 1993 I ran the American Psychological Association's Health Care Reform lobbying effort.

Contrary to public misperception the Clinton Health Care Plan effort was remarkably open and, as a result, I got a very good view of the process.

From the beginning it was clear the health care reform battle was going to be a race between the health insurance industry's ability to portray the plan as a government run health care plan versus the Clinton Administration's ability to tap public hatred of the health insurance industry to motivate people to demand change. It was not much of a race.

The health insurance industry's approach was quite simple. They pushed as hard as they could to shape the bill in the light most favorable to them. They then turned on the Administration and killed the bill. Ultimately, in a remarkable in-your-face gesture, the health insurance lobby blamed Ms. Clinton's reluctance to deal with them as the cause of the initiative's failure.

The "Harry and Louse" ad campaign showing a typical American couple concluding that the Clinton plan was just a big government health care plan is the symbol of the insurance lobby's successful effort. Personally, I was more impressed at the time when the Health Insurance Association of America was able to hire the highly respected ranking Republican member of the House Ways and Means Subcommittee on Health, William Gradison and Chip Kahn, the chief minority staff member, directly out of their Congressional positions to run its lobbying efforts. It was after that that the Harry and Louise ads started and the health reform effort collapsed.

The Clintons never did try to tap populist sentiment against health insurers. Instead they tried to bring the insurance industry into the fold through accommodation, just as Obama has done to date. Understandably, both Clinton and Obama felt that it was better to compromise with the powerful interests rather than risk losing to them in a political head to head.

There is a sad irony to Obama following in the Clintons' footsteps in this regard, however. While ostensibly Obama's election was about bringing people together, it was in reality a much more dynamic populist movement made possible by his grassroots fund raising from the internet and his ability to tap the powerful grassroots abhorrence of the Bush years. Clinton's game, in contrast, was middle of the road consensus politics.

In health care reform, it is Obama's grassroots organizing and populist support, the skills that got him elected, that are the country's only real hope for meaningful health care reform.
There are two potential populist themes in health care. One is long articulated and long recognized in every initiative for health care reform -- contempt, fear, and loathing of "government run" health care. The other is only vaguely appreciated and almost totally unharnessed politically -- contempt, fear, and loathing of big health insurance companies.

In the current political milieu, government run health care is something to be avoided at all costs while the antipathy to private health insurance is at most occasionally acknowledged but never harnessed as a meaningful reason for reform. As much as Americans hate private health insurance companies, it does not really factor into the current health care debate. And make no mistake about it, that hatred is the populist antidote to the hatred of "socialized medicine."

The true question facing Americans is not whether they want the government with all its real or imagined inefficiencies making decisions about their health care; it is a question of whether they want the government making that decision or whether they want private insurance companies driven by profit motives to continue making the decisions.

The question of whether you want "government run health care" is a very different question from whether you prefer government run health care or private insurance run health care. Yet, the American public has not been forced to confront the real choice by either Clinton or Obama.

If Obama is to win a meaningful health care reform, as opposed to a face saving bill of meaningless window dressing reforms, he must make that the question Americans realize they are answering, like it or not. If he does not, there will be no meaningful health care reform. There will only be more bills like the 1996 HIPAA which promised to end preexisting conditions and portability issues but, instead, simply imposed a gigantic paperwork system on top of the health care industry, addressing issues like privacy which have nothing to do with either access or quality of care at all.

Understandably, both Clinton and Obama have recognized that to take on the insurance industry directly risks defeat of their program. They are absolutely right about that risk. The problem is that not taking that risk, absolutely guarantees the defeat of a meaningful health care bill.

Viewing health care reform simply as a policy matter to be argued on policy merits is a loser's perspective. The question is who do you hate more your government or your insurance company? It is a populist issue.

I stayed in close contact with Jimmy's parents for five years after his death and have had much more sporadic contact with them since that time. You do not want to know what their lives have been like since Jimmy's death. What they do want you to know, however, is that private for profit health care insurance is not the answer for any of us or for our loved ones. Until we have a system of care that takes profit out of health care decisions, we will not have affordable, accessible, quality health care.

Bryant L. Welch, J.D., Ph.D. is a clinical psychologist and attorney. He is the author of State of Confusion: Political Manipulation and the Assault on the American Mind (St. Martin's Press, 2008).