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It's Time to Really Engage Americans in Health Reform

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Over the last few weeks, the debate around health care reform has become increasingly partisan and volatile as President Obama and members of Congress have moved outside the Beltway to talk directly with Americans in town hall meetings.

It seems that every element of the bill engenders either wholehearted approval or complete rejection (and rage), with little middle ground. Hot button issues like end of life counseling (aka "death panels") and the public option seem to be falling by the wayside in the wake of what looks like insurmountable public opposition and anger. But, in fact, research shows that Americans, when they have a chance to work through the choices in health care reform, are actually far more willing to make tradeoffs than town hall meetings would suggest.

Note to policymakers: The general public is still at an early stage of considering what should be done about health care. That is why concerns about a public option (not to mention "death panels") can quickly gain traction. However, once Americans work through the issues and tradeoffs, they are open to significant change, more so than many experts assume. As they move along the learning curve, on balance, they support a public option and conclude that an increased role for government is necessary to address the depth of the dysfunction in our health care system.

The president can still secure public support for health reform, but to do so he has to help the public reach three key insights in sequence:

First: Everyone is vulnerable. As job losses mount and companies struggle to cut costs, more and more people are at risk of losing their coverage completely or seeing their co-pays doubled. This recession makes the need for reform even more urgent.

Second: Americans are already paying dearly, if indirectly, for today's system -- not just through premiums and co-pays, but also lower wages and higher prices. Imagine what we could achieve if the $12,000 per employee that companies now spend on insurance went instead to salaries or directly into making health care more responsive to consumers and less to insurance companies.

Third: We have to get a handle on rising health care costs. If we don't, the country is in deep economic trouble -- and everyone will suffer for it, no matter how good their insurance is today.

Once these three realizations are achieved, the public will support broad health care reform, but that understanding requires deeper dialogue than can be accomplished at town hall meetings.

I can say this with confidence because of the result of a novel type of public-opinion research conducted over the past year by Viewpoint Learning (a company I co-founded in 1999). To understand how people come to a conclusion about the complicated issues involved in the health care debate, with the support of the W.K. Kellogg Foundation, we sat down with Americans in daylong meetings, asking them to discuss alternative scenarios for the future of the U.S. health care system. We wanted to determine the sort of structure that Americans would support after working through the tradeoffs that would be required.

The participants, a representative sample of the U.S. population from three very different states, worked through a number of major sticking points including: ambivalence about the government's role in health care; concerns about restrictions on the good coverage some of them now enjoy; and how to pay for a health care system they want. As they defined the health care reforms that made sense to them, they became more realistic about the tradeoffs required to realize that vision and how to pay for them.

We saw that Americans are ready to address difficult tradeoffs and to be challenged, and become wary of one-sided "spin" and easy answers. They want leaders to honestly discuss the pros and cons of different approaches, and they want to have a voice in decisions that will affect them.

Based on our research, the kind of structure that appeals most strongly features two tiers: a first tier that provides basic, guaranteed coverage for all Americans and an additional tier of coverage that comes at the discretion of employers and individuals. It would place more emphasis on wellness and prevention and increase the number and role of general practitioners as well as nurse practitioners and other non-physician health care providers. The system would make greater use of technology, like medical identification cards, to improve quality and continuity of care, and feature more stringent regulation of the widely mistrusted insurance industry. Many of these points are very similar to the current legislation being considered in the House and Senate, and some go further.

Support for President Obama's plan for reform is eroding -- reminding many of us of what happened in 1993 when the Clinton White House attempted to overhaul the U.S. health care system. In the heat of the Clinton battle for health care reform, I analyzed 17 different polls that showed an average of 57 percent support for the Clinton proposal. Within months that support had collapsed to 37 percent. Our findings demonstrate that while the danger of repeating history is very real, it also is avoidable.

The president still has time to secure public support for health reform, but as a precondition, he must help Americans achieve three realizations: we already pay dearly for a system that does not work; we must bend the cost curve for the sake of our country's long-term well-being; and we all benefit from a system that works better. If he can do that, real health care reform, including counseling on end of life and a public option, will be within our grasp.

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