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Drew Westen Headshot

Why the President Has Been Losing on Health Care, and What He Needs to Say

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Pundits have offered a range of reasons for why health reform that was wildly popular and on which the President and two houses of Congress were elected has turned so far south in public opinion: The White House overlearned the lessons of the Clintons by letting a dysfunctional Congress try to create the legislation on their own. The President failed to lay out a clear plan and only suggested a set of principles. The White House emphasized cost, when most people who vote are more concerned with security and stability of their insurance and when the emphasis on cost ultimately drew attention to the weakest link in the effort to reform health care. The White House didn't stay on message.

True enough. But none of these gets at the root of them all: The White House didn't stay on message because it didn't really have one.

All it takes to understand why things have gone as they have is to ask two simple questions. First, "What story has the administration told the American people about what the problem is, what caused it, and how the cause naturally leads to a particular solution?" And second, "What story have the Republicans told about 'Obamacare' and why it's the wrong medicine?" When you ask those two questions, it's obvious why nearly 70 percent of Americans now say they are confused by the whole debate.

The GOP story is simple, memorable, and values-driven. It is a variant of the story conservatives have told and retold so many times since Ronald Reagan famously asserted that "government is the problem, not the solution" and "Democrats have never seen a social program they didn't want to fund or a tax they didn't want to raise." The story goes like this:

The Democrats want a government takeover of our health care system, because they believe government bureaucrats know better than you do what kind of health care and health insurance you need. They want to put a government bureaucrat between you and your doctor. They will ultimately set up rules for when you live and when you die, because government spending always mushrooms, and some board of bureaucrats is ultimately going to have to decide when to pull the plug on grandma. And the same that's true of end-of-life decisions will be true of beginning-of-life decisions: They will publicly fund abortion, and they will decide which babies born premature or with birth defects are worth saving. And because there's only so much money to go around, they'll raise taxes on the middle class and cut Medicare benefits to seniors. And all of this talk of a "public option" just gets at their real motives: to drive out the private sector entirely, so we all have the public option, which means taking away our freedom to choose, because ultimately they don't believe in the free market, and they don't believe in the American ingenuity that has created the greatest medical care on earth. We all agree that we need reform and we'll have reform, so that people with pre-existing conditions don't have to worry about getting health care. But we don't need socialized medicine to accomplish that. We need to use the principles of free market capitalism, because if we just followed those, we'd have government off our backs, efficiency, and freedom to choose.

Not a bad story: easy to remember and easy to pin even outrageous claims on, because they can be attached both to an existing narrative and to some small grains of truth. This story accomplishes precisely what every introductory business school student will tell you are the two essential elements of good branding: define your product (a free market approach) and differentiate it from its competitor (government takeover). Every American who's been even marginally following the debate could tell you the essentials of this story.

Now try to tell the story the administration has been offering about health care reform. I can't for the life of me pull together a coherent narrative, but I'll give it my best shot:

46 million people don't have health care in this country. Hmmm....that's no good--we need a story that appeals to the middle class. Okay, scratch that. Costs for the average person are rising out of control. So we need to cover 46 million more people while cutting costs at the same time. Oh, that's a little hard to believe...Electronic records? That will save a few billion a year. And doctors should stop giving unnecessary tests, because we've all had the experience of going to the doctor and having our doctor foist on us unnecessary tests--haven't we? Hmm....that didn't seem to resonate. Okay, try this: We should tax the really good plans that some middle class people get from their employers because...we don't like middle class people to have really good plans? Wait--I promised I wouldn't tax the middle class--and taxing good employer-based health insurance was John McCain's plan that I attacked, correctly, because it will just give employers an incentive to stop offering decent health insurance. But we'll float that again a couple times and see if it works, because we have to cut costs somewhere since we promised the pharmaceutical industry that if they'd forgo 8 billion dollars a year and run some commercials for us, they'd get 46 million new customers and we wouldn't make them negotiate prices. Oops--I ran during the campaign against that, too, since that's one of the most obvious ways to cut costs that everyone understands. Never mind. Okay, you see we have this thing called the public option. A public option is essential to creating competition in the health insurance market. Okay, maybe not essential. Maybe a co-op. Or maybe a trigger, so when this all starts in 2013, if it doesn't work out, maybe someone will pull the trigger by the time we have another Democratic White House and Congress, say, in 2020. And we should seriously consider a trigger because Olympia Snow likes triggers. We shouldn't really have a public option anyway because Congressional Republicans don't like it, and we have to have a bipartisan solution, even though voters thoroughly repudiated the Republicans in the last two elections, because true virtue lies in mixing the bad ideas voters repudiated with the ones they voted for. And health care for all is a moral imperative, because I'm talking to an evangelical audience today, and our internal polling says they like that kind of thing.

If you think that's a parody of what the public has heard, then try again to answer a simple question: What's the administration's story about why we need health care reform? Why have things gotten so bad that we need massive reform rather than a band-aid? What's the root of the problem with the way things work now? Who are the culprits? Is someone profiting from the misery of the millions of Americans who don't have insurance or from the anxiety of the rest of us who have no idea what our health insurance will look like next year at this time other than that we'll pay more and get less?

Note the difference between the Republican's narrative, even when the GOP is at an all-time low ebb and the administration started with sky-high public support and good will. The Republican story has antagonists and protagonists. It has motives. It lays out the dangers in a really compelling (if not always accurate) way. It doesn't do a good job of laying out solutions, which would make it a much better story. But its "solution" draws on the familiar theme that the free market, if truly unfettered, would solve all our problems--a theme the administration has not, remarkably, bothered to attack, even after the financial meltdown that swept it into office.

In short, the Republican story has what psychologists call narrative coherence. It's a story. The administration, in contrast, has no real story. It isn't even clear on what it's trying to reform--health care for those without it? health care for those with it? health insurance (the latest formulation, at least until Wednesday night)?

So with all the time the White House had to develop and test a narrative they could be assured would win by 25 points before they ever rolled anything out (something I can tell you with certainty is possible to do, because I led the messaging efforts of the major health reform nonprofits in 2008 to develop just such narratives, and we had several that beat anything conservatives could throw at us), why didn't it? And why doesn't the average American know that the Republicans have been fighting every effort to make health care affordable and available for Americans for over half a century (using precisely the same arguments they are using now), just like they fought Social Security (and called it, too, "socialism") 70 years ago?

One possible explanation is that it's hard to offer a coherent story if you aren't committed to the elements of your own plot. But there's another reason, which is the same reason the President had a tough time explaining to the American people why a massive stimulus was essential to get us off the precipice after Bush had taken us to the edge, and why deficits were not only going to be with us for a few years but for the next two or three at least were going to be good policy, not something to apologize for: It's impossible to tell a coherent story when you just can't get yourself to blame anyone for anything, no matter how much damage they've done to people's lives (except an occasional rebuke to "the left" to stop making trouble for bipartisan champions of reform like Chuck Grassley). Pointing fingers just makes this President uncomfortable. He'd rather give away a few hundred billion dollars to the pharmaceutical industry than to take them on, even if that means he may have to tax the middle class to make up the difference--and cost dozens of House seats in the process, by putting Democrats in districts that shouldn't have been vulnerable into the bind of choosing between losing because they undercut health care reform and losing because they broke the promises they made along with the promise to enact it.

The problem with the White House's approach is that you can't galvanize public support to fix a problem like health care from the ground up if you refuse to make clear to the public why they are losing their health insurance, why their costs have been going up as their coverage has been going down, why middle class people with stable jobs are--and should be--worried that they won't have the same quality insurance next year that they have this year, and why people are afraid to leave a "safe" job to start a business--undermining the engine of American prosperity--because they might not be able to get health care for their family because someone has a "pre-existing condition."

The President's greatest strength--his cool under fire--is starting to look like his greatest weakness. He came into the White House at a time when transformative change was possible. The public, including the Independents and moderate Republicans who voted for him, were clamoring for it after eight disastrous years of Bush Republicanism. People "got it" that they'd lost half the value of their 401ks, pensions, and homes (if they were lucky enough still to have them) because unregulated markets had failed. They "got it" in a way they hadn't gotten it for over half a century that if you don't have government at your back, it's just a matter of time before you'll have calamity at your doorstep.

They were scared, and they were angry. But the President refused even to utter the words "Bush," "Republican," "economic extremism," or any phrase that denoted the Republican economic ideology that brought us to the brink of a second Great Depression and is now threatening a jobless recovery. To my knowledge, the President has never mentioned, in the two-thirds of a year he's been President, that he's a Democrat. I don't think he's ever uttered the name George W. Bush. And he's deliberately blurred the lines between a Republican party that has gone so far off the deep end that no one in their right mind wants to swim out to give it a life preserver and a Democratic party the American people were once again willing to look toward for leadership. Obama refused to connect what the Republicans had done in their eight years of dominance in Washington with the anger and fear people were legitimately feeling and to make clear that we should never again fall prey to the dangerous ideology of unregulated greed.

And in so doing, he looked seriously out of touch, seemingly unable to feel what most people feel after being fleeced, and handed populist anger over to right-wing Republicans, who promptly turned that rage back against their favorite target (government), the deficits they created and the deficit spending their policies necessitated, the Obama administration, the President's race (as expressed in the birther movement and rallying cries of, "I want my country back!"), and, of course, Obama's proposed "government takeover" of health care.

In this respect, compare Obama and Franklin Roosevelt at a similar juncture in our history. Roosevelt was genuinely outraged at the entrenched interests that had mass-produced misery and unemployment in his country, and he channeled the legitimate anger and fear of the American people to galvanize support for his New Deal. He made no bones about who had caused the Great Depression and who was trying to block legislation that might get us out of it. And he made no bones about the fact that if the private sector was going to lay off employees at a record pace, the federal government was going to put them right back to work building an infrastructure the country needed in the long run and give laid-off manufacturing workers a badly needed salary for a hard day's work until the private sector could get its act together again. You could make a pretty good case that this is precisely what Obama should have done (and still could do) instead of converting hundreds of billions of stimulus funds into Republican tax cuts, ultimately contributing to the mass layoffs of state and local employees we are now seeing that are undercutting the economic recovery and creating new unemployment when we should be creating new employment.

But Obama, unlike FDR, just can't seem to get himself worked up enough to experience or express anger when it's appropriate. He looks more like Michael Dukakis when posed with that hypothetical question about his wife being raped and murdered (to which he responded, to borrow Bill Maher's apt paraphrase, "Whatever"). But this time, it's our financial security that has been assaulted, it isn't hypothetical, and President Obama has furloughed the rapist and put those who sat idly by in charge of public safety. The White House then wonders why the American people are no longer so comfortable when the President says "trust me" with their health care, after appearing to cut sweetheart deals with the pharmaceutical industry that look a lot like the deals he's cut with the bankers who continue to throw people out of their homes and deny small business owners lines of credit while paying themselves outlandish bonuses with taxpayers' money.

Nor does the White House believe in hitting back when someone hits it, or inoculating against obvious attacks that everyone knows will be coming from the other side. Instead, it assumes that the silliness of those attacks is self-evident and you don't have to deal with them until two weeks after it's clear from your polls that they're working. This is vintage Dukakis, vintage Gore, vintage Kerry. The conservative attacks are indeed absurd when taken at face value. But they activate fears by association that are worth thinking far more seriously about how to defuse.

"Death panels" provide a case in point. The idea of "death panels" is, in fact, ridiculous, particularly when linked to sensible policies like counseling about end of life decisions. But what lurks behind the fear they evoke is that the average American does understand that end of life care is one of the most significant costs that is burdening our system, and their fear is that greater government control of costs will mean greater governmental influence on decisions about when we've spent enough on grandma. The fear is exacerbated when the administration talks about funding insurance for 46 million more people in part by cutting billions in "waste" from Medicare, and fails to drive home, over and over, that insurance companies are already making those decisions, right now, all the time.

And despite the fact that the White House messaging machine has been trounced by a set of words and phrases that have virtually all come straight from a conservative talking points memo on health care by Frank Luntz-- "government takeover" and "bureaucrats between you and your doctor"--what has become clear is that the White House, which had access to that memo (and hence plenty of time to devise and test antidotes to it) because it was leaked, fundamentally doesn't believe that the words you use really matter all that much. The White House was aware of research on ways of talking about "the public option" conducted over a year ago that beat language like Luntz's by 25 points, and it was warned explicitly against using the term "public option"--with all its connotations of socialized medicine, poor quality, and single-payer health care--publicly in a Washington Post op-ed just weeks ago. But it apparently ignored both the data and the warnings. The result was just as predicted: a firestorm that has sent support for health care reform tumbling. Yet somehow now the "public option"--rather than the messaging team that put the mess in the message--is on the chopping block. It is no wonder that the average American readily confuses "the public option" with a single-payer, government-run system. The two sound like the same thing, as Americans have repeatedly heard that the choice in this debate boils down to market solutions vs. "government-run health care supported by liberals in the President's party." Making matters worse, the White House itself has at times branded the "public option" as a radical liberal concoction of his party's left wing, which it wishes would back down.

The problem, however, is broader than health care, and it is going to follow the White House to every issue it tackles, leading it to settle for half-solution after half-solution at every turn unless it changes course: A year after the Republicans brought the economy to the brink of a Great Depression through a radical ideology of unregulated greed, the President has not offered the American people an alternative narrative to "government is the problem, not the solution." He's never said, as Roosevelt did repeatedly, what we should have learned from what happened on Wall Street--which happens to be the same thing we should have learned when gas prices hit $4.00 a gallon (and will again), or when parents had no idea which toys they were buying their young children were filled with lead, or when thousands of people started losing their health insurance every day and tens or hundreds of thousands every week: that unregulated markets are the problem, not the solution, and that unregulated greed is not only bad ethics but bad policy.

With the election of Barack Obama and a solid Democratic majority in Congress, we faced an historic moment when the nation was poised to hear an alternative vision about how we, as a nation, are actually capable of coming together to govern ourselves--to protect ourselves against those who would threaten our economic security just as surely as Al Qaeda would threaten our national security--and when the country had so thoroughly rejected the right that its only remnants left in Washington were two Maine Senators who should have been told in no uncertain terms that if they vote with the Republicans against a robust stimulus bill, a robust health care bill, a robust energy bill, or a robust financial regulatory bill, they will find themselves joining the ranks of the unemployed their party has created--not giving them the power to veto any provision that does not suit the fancy of the extremist majority in their party who they are free to bring into policy decisions like a Trojan horse. Yet in this historic moment, when the ideology of the right has been discredited with even moderate Republicans, the White House has determined that the best way to win the center is to tack right--right into the eye of the storm voters have said they have no interest in sailing back into. The result has been a dramatic drop in the President's approval rating, especially among Independents. Sometimes, the best way to win the center is not to move to the center but to move the center.

And this was one of those times. There is one trait the public admires about the right, and rightly so: Its leaders often say what they believe and do what they say. George W. Bush firmly believed that any government is oppressive government, and he and his party did everything they could to destroy it. He and his colleagues in Congress firmly believed that redistribution of wealth from the middle class to the upper one percent is fair, just, and good economic policy, so they redistributed wealth from the middle class to the upper one percent. They strongly believed that no one knows better how to regulate an industry than its lobbyists and captains, so they put industry lobbyists in charge of regulating everything from energy to banking. And we have seen the results.

What President Obama needs to learn from conservatives like Ronald Reagan is not how to compromise his principles with theirs when the American people have "just said no" to conservative policies and ideology. Reagan had no desire to "split the difference" between his conservative ideology and the Democratic Congress, and when the Congress got in his way, he simply went over its head, straight to the public. Obama has the same kind of rhetorical power to move the electorate if he can overcome his aversion to conflict, and he has the advantage of a Democratic Congress if he can overcome his obsession with finding the golden mean between the failed ideas of the past and the ideas the American people elected him to enact.

President Obama needs to do what FDR and Ronald Reagan did: articulate his principles and follow them, not try to guess at what half-measures he could settle for if he avoided the fight altogether. He needs to lay out a progressive vision for America, just as FDR laid out a progressive vision that led to a realignment that lasted for generations and just as Reagan laid out a conservative vision that did precisely the same thing from the other side. It is one thing, as Obama does so well, to reach out to voters in the center by speaking to values all Americans share, such as fairness, accountability, and personal responsibility. But it is another to shift to the right to win the middle in an era in which voters in the center found the right so wrong. All that does is signal to Independents that he is just another politician and not the person with principles they thought they had voted for.

The way to win the center is not to continue firing gay Arabic speakers in the armed services and comparing their sexual orientation to bestiality. It is not to issue center-right proclamations at Notre Dame about the need to decrease abortions while failing to mention that the best way to do that is to teach our children about birth control and make it available to people whether they are rich or poor, so they can decide for themselves when to start their families. It is not to continue the policy of sending terrorism suspects to countries friendly to torture. The way to win the center is not to stay silent as right-wing militia members circle Obama's own town hall meetings and speeches with loaded weapons that most law-abiding gun owners find abhorrent. The way to win the center is not to coach Supreme Court nominees to mouth conservative legal philosophies that would have prevented Brown v. Board of Education or Roe v. Wade and to tell civil rights leaders to stay silent as conservatives stoke the flames of white resentment by offering the New Haven firefighters case during the Sotomayor hearings as Exhibit A of quotas and "reverse discrimination" (when it was actually an example of neither). And the way to win the center is not to express condescension toward those who elected him, dismissing their concerns about his apparent willingness to compromise on virtually any issue of principle, including genuine health care reform, as "getting all wee-weed up," when in fact it is his messaging team that is pissing away the best chance in 70 years to effect real change in America--whether in health care, banking, or energy.

The President's speech today on Labor Day was a hopeful signal that perhaps the White House has had a change of heart on strategy, that it plans to return to the principles that are at the heart of genuine reform, and that the President plans to become more aggressive with his opponents, just as he did this time last year when he fell behind John McCain for the first time in early September. In fact, there is a very simple story he can tell on Wednesday night that places his plan--and the "public option"--right in the mainstream of public opinion, where it actually is. That story would go something like this:

There are those on the right who believe that government is always the problem, not the solution, and that the best way to provide health care in this country is to leave insurance entirely to health insurance company CEOs and bureaucrats, free of any rules of the road, to decide who to cover, what to cover, and how much to charge for it. That's what we have now, and if you're wondering why your rates have doubled or you've lost your insurance over the last few years as their profits doubled, it's because there are only three ways they make their profits: increase your premiums and out of pocket expenses like co-pays, discriminate against the ill by excluding people with "pre-existing conditions," or deny a third of claims for procedures your doctor ordered. If you think that's a good system, support the Republicans, because they've been fighting to keep that system for decades. They fought against Medicare, calling it socialized medicine. They even prevented children of people who work for a living from getting health care because it would have interfered with the rights of health insurance CEOs to haul in hundreds of millions in bonuses as children went without insulin for their diabetes or penicillin for their ear infections.

There are those on the other side of the political spectrum who believe that the best way to provide every American with the quality health care Americans who can afford it now can get is to have a single-payer system for everyone, young and old, like Medicare, where the government provides everyone insurance. There's something to be said for that approach, which some in my party support. It's the system they have in every other Western democracy, it costs a fraction of what the health insurance companies in this country charge, and no one is left out.

But I don't happen to support that approach, because, like most Americans, I worry that one size doesn't fit all. So I support a uniquely American approach that is somewhere in between, reflecting the values of the American people: that we should all have choices; that we need genuine competition so that health insurance companies have to compete to provide the best care, not the least care; and that no one should be denied health care in this country so some company can make a profit off their death or disease. That's why I believe we need government to set high standards for any company that wants to sell an insurance policy--just like we require safety standards for appliances--and prevent them from denying legitimate claims or cherry-picking who they will or won't cover. And that's why we should make insurance companies compete not only with each other but with a couple of plans they don't control, so that if they continue to offer substandard care or continue to require you to make those 45-minute calls just to reach a person, the American people will have a genuine alternative. The choice of multiple options is a lot like what members of Congress get, and if it's good enough for members of Congress, it should be good enough for the people who pay their salaries.

If there's a moral to this summer of medical discontent, it is a simple one: The first job of a leader is to know where he wants to lead, based on his values, not political considerations. The second is to strategize about the methods and the message most likely to move the nation in that direction. Voters know when their leaders are putting strategy first and principles second, and they don't much care for it.

There is no doubt the President can get a compromise health care plan through Congress. He has enormous majorities in both the House and Senate, and they all know the stakes. But doing so would leave him with a compromised Presidency, in which a small minority of Republican lawmakers knows they can bully him at will into half-measures on any issue, and that he'll settle for Pyrrhic victories with the rationalization that he has achieved incremental change.

But the American people didn't vote for "small change we can believe in." And I don't think that's what this President wants--or needs--to be his legacy. Whatever the merits of the "public option," it has come to stand for something much larger: Whether this President really means what he says, and whether he's going to put the public interest over the private interests that dominate Washington and have dominated health care for far too long. We'll probably know Wednesday night.

Drew Westen, Ph.D., is Professor of Psychology and Psychiatry at Emory University, founder of Westen Strategies, and author of "The Political Brain: The Role of Emotion in Deciding the Fate of the Nation."