Do Americans view health care as a communal resource that should benefit everyone or do they view it mainly from the standpoint of “what’s in it for me”? Do they view themselves as citizens, working together for a “greater good,” or as patients and consumers of health care; worried about retaining access to all that medicine has to offer?

The answer, according to a recent article by David Nather in Congressional Quarterly, is that most Americans are aware that “[w]hat’s good for the health care system as a whole often looks very different when it’s their own health at stake, or the health of someone in their family.”

Because the public is worried about sacrifices they may have to make to further the “public good,” Nather writes that Obama’s biggest challenge in maintaining support for health care reform will be to make sure that “Americans don’t think they will personally lose out in an overhaul of the way medical services are delivered—through higher costs to themselves, lower quality of care or simply inability to get the care they’re convinced they need.”

Nather says that in his speeches at town hall meetings and talks around the country, Obama is focusing too much on discussions about the financial aspects of health reform and on the benefits for all that will result from slowing spending on health care:

“His health care philosophy is rooted in principles that are decidedly not focused on the individual, but rather are designed to benefit the system as a whole by lowering costs.”

Much of the discussion about health reform has been about cost, specifically about how the government plans to finance a $1 trillion-plus program to cover most Americans. The debate has revolved around issues such as employer mandates, individual mandates, and new taxes on employer-provided benefits or on the rich. Advocacy groups supporting “health care for all” and other reform efforts talk a lot about the uninsured, the underinsured and those who are at risk of losing coverage because of the souring economy. The implied reasoning is that health care reform will lead to more affordable, more inclusive and secure insurance coverage.

But still, many Americans who have insurance worry that health reform might have a negative impact on their own coverage.  Nather quotes Jim Kessler, vice president for policy at Third Way, a messaging and policy group for centrist Democrats:

“There is one central challenge in this debate, and all of the other challenges stem from it. Right now, the middle class cannot answer the question, ‘What’s in it for me?’ That is the No. 1 public relations challenge right now.” 

Kessler believes that President Obama must address that question.

Surveys have shown that some 58-70% of Americans (depending on how the questions are worded) support comprehensive health care reform. Yet, according to Nather; “[t]he surveys also found that people are nervous about what an overhaul could mean to them personally — the same dynamic that contributed to the failure of Bill Clinton’s drive to change the health care system at the start of his presidency.

“In the ABC-Post poll, 81 percent said they were concerned that an overhaul would reduce the quality of their care, 84 percent worried that it would increase their medical costs and 79 percent feared that it would limit their choices of doctors or treatments. In all cases, more than half of those surveyed said they were “very concerned” about those outcomes.”

Nather thinks Obama should fine-tune his health care message to assuage these concerns. I disagree.  It is premature to begin discussing the specifics of universal coverage. These are decisions that ultimately should be made by health care professionals, based on medical evidence.  Arguing about the details of coverage now will just hold up the process of passing important legislation that most people understand we need. Those who want to turn the conversation to focus on specific (and often controversial) treatments such as abortion or drugs for erectile dysfunction are just trying to derail that process.  

Right now, we should concentrate on passing  health reform legislation that outlines the basic structure of a more inclusive health care system, describes how it will be financed, and provides a broad outline of the basics that must be covered by any insurance plan.

Reform Equals Security      

The President has consistently told the public that if they are happy with their current health plan, the government will not interfere.  But, unless we pass legislation that begins to rein in health care spending by weeding out the greed and waste in the system, health care premiums will continue to climb—and in the not-too-distant future  many Americans will find that they simply cannot afford to keep the insurance  that they have.

The president has promised that reformers will squeeze out the waste in the system by using comparative-effectiveness studies too ensure that Americans are receiving the highest quality care. Through his group Organizing for America, Obama has amassed powerful grassroots support for reform. Instead of reassuring voters that reform won’t take away the benefits they’ve enjoyed under the current system, Organizing for America is launching a new campaign to drive home just how much we have lost—and stand to lose—if we don’t pass reform. Check out this site for a preview of this ad campaign that basically advances the theme that “it can’t get any worse than this.”

Obama needs to keep talking about the threat to personal and economic security that Americans are facing under the current health care system. He needs to keep talking about how easy it is to lose coverage—even for middle-class people—and how many of us are just one catastrophic illness away from bankruptcy. It’s become increasingly clear that through job loss and companies electing to drop coverage, the middle class is at risk of losing their health benefits.

Sixty-two percent of the American public believes that the current economic downturn makes it more important than ever to take on health care reform, according to a report that came out in May from the Center for American Progress: 

“We estimate that 2.4 million workers have lost the health coverage their jobs provided since the start of the recession, based on data from the U.S. Census Bureau and the Bureau of Labor Statistics. Approximately, 1.3 million of these losses have occurred in the last four months. More than 320,000 Americans lost their employer-provided health insurance in March alone, which amounts to approximately 10,680 workers a day.”

And 2.4 million represents only the employees who lost coverage; it doesn’t include the spouses and children of those employees who also have to scramble to find new coverage

As Citizens, Americans Understand that We Must Set Priorities

Despite the countless polls that have been conducted over the last year on how Americans feel about health reform, very little work has actually been done on determining whether an emphasis on the “greater good” of health reform will trump concerns people have about how reform will affect them personally.

While some argue that the President must answer the question “What’s in it for Me’  The Center for Healthcare Decisions, (CHCD) suggests he ask the public to think about  “What’s In it for Us?” and “What Matters Most?”

“As individuals what we want and expect is the world—everything,” explains Marjorie Ginsburg, the executive director of the Sacramento-based group. “We’re trying to get people to think more collectively, not just about me and my family. We’re asking them to take off their patient/consumer hats and put on their citizen hats.”

The Center’s goal is to make people aware that health care dollars are finite, and thus, as a society we will have to set priorities when deciding which treatments must be covered –and which are optional–or might  require higher co-pays.

To that end, the Center launched a study titled “What Matters Most.” Researchers offered some 1,000 California residents a series of  “medical vignettes” that described a range of conditions and problems. (For example, in one case a man with very poor eyesight was finding it difficult to play sports while wearing his glasses. He wanted laser surgery to correct his vision). Respondents were then asked two questions about each vignette:

1)    On a scale of 1 to 10, what priority would you give to cover this if you were designing a health plan for a general population in California?

2)     Given that the more that health insurance covers, the more the plan may cost you and others, would you want health insurance to cover this service or not?

After the survey, the respondents went into discussion groups where they worked through some of their choices.

According to Ginsburg: “People really rise to the challenge, when asked to make decisions about what should be in and what should be out,” as far as covered benefits. They begin to see health care as a shared resource and are comfortable making choices when it’s clear that resources are finite. Her takeaway message is that Americans need to feel involved and have their voices heard before they can embrace the concept of making these decisions.

The work being done at CHCD is important, but Ginsburg believes that the results from “What Matters Most,”—and public discussion on that topic—will be most appropriate in the next phase of reform, after a plan is passed by Congress.  At that point, a panel of physicians, medical researchers, and patients’  advocates will begin the process of looking at which treatments work—and which don’t—for patients who fit a particular medical profile.

But for now, taking the discussion down to this personal level will only lend credence to the Conservative’s fear-mongering on health care rationing. Check out this clip courtesy of Media Matters of Rep. Paul Broun, (R-GA)
saying that by allowing national health care programs, Britain and Canada don’t “have the appreciation of life as we do in our society, evidently.” Talking about a public plan here in the U.S., Broun goes on to say;
“A lot of people are going to die. This program, of a government option, is being touted as being this panacea. The savior allowing people to have quality healthcare at an affordable price is going to kill people.”

The administration has said that the only care that will be “rationed,” is care that is wasteful, harmful and has little benefit. But Nather says all the talk about comparative-effectiveness is scaring people. He quotes Obama as saying:

“If there’s good evidence out there that shows that the best way to treat your illness is to give you the blue pill, and instead, right now, you’re getting prescribed the red pill that costs twice as much, I think that you and your doctor, having that information, are probably going to decide to go with the cheaper pill that does just as good of a job,” Obama said at the town hall. “And that will save you money. That’s not rationing. That’s being sensible.”

Here ,Nather asks, “[W]hat happens if the patient wants the red pill instead of the blue pill”?

My answer: Do we really care?

We Already “Ration” Care –In the Worst Way Possible

First of all, to suggest that patients currently have that kind of autonomy is disingenuous. For years now most of us have been covered under prescription plans that use some sort of “tiering” or formulary to decide which drugs are covered. If we want the red pill we will most likely have to pay out of pocket for it. The same is true if we want to stay in the hospital another day or want to see a highly-recommended doctor who is not in our network.

Americans will not fear “rationing” so much if they are made aware of how much rationing currently goes on under today’s system. According to this report from NPR,

"In America, we strictly ration health care. We've done it for years," says Dr. Arthur Kellermann, professor of emergency medicine and associate dean for health policy at Emory University School of Medicine. "But in contrast to other wealthy countries, we don't ration medical care on the basis of need or anticipated benefit. In this country, we mainly ration on the ability to pay. And that is especially evident when you examine the plight of the uninsured in the United States."

The uninsured get only half the care that insured Americans get; forgoing check-ups and preventive screenings like mammograms and colonoscopies, not filling prescriptions, and waiting longer  (so they are now sicker) to see doctors. This is rationing, clear and simple and it isn’t only an issue for those without insurance.

For those Americans who look at health care reform as achieving “the greater good,” doing away with these inequities in care are reason enough to support Obama’s plan. But what about those who understand that expensive, unnecessary care should be restricted—for others, maybe—but worry about the prospect of being denied that “red pill” that might be their last, great hope for a cure? How do the Democrats and Obama convince this, perhaps sizable (although no one has successfully measured it) group that “the greater good” includes them too?

The answer is to stick to Obama’s plan of talking about cost and security. Without healthcare reform, spending will continue to spiral, along with insurance premiums. More employers will drop benefits or raise the share of the premiums that employees must pay, and more Americans will find themselves uninsured.  At that point, it won’t be a matter of whether you get the red pill or the blue pill, it will be a question of whether you get any pill.