How politics distort Americans' perception of health reform

By Tom Sullivan
11:33 AM

You’ve heard the litany of twisted health reform clichés at backyard BBQs, cocktail parties, and family functions. Indeed, boiling more than 2,000 pages of legislation and legalese into phrases like “socialized medicine” and “death panels” or from the opposing camp “lower care costs” and even “jobs for Americans” is bound to obscure more than a few facts.

And politicians from both parties spitting one-sentence soundbites like so many propaganda slogans only makes things more chaotic.

“There are a lot of misperceptions about reform. Just like anything that goes through the sausage making process in Washington, D.C. there’s the good, bad, and the ugly that comes out,” says Brian Ahier, health IT evangelist at Mid-Columbia Medical Center and a City Councilor in The Dalles, Oregon. “The general public tends to paint that with a really broad brush without understanding the distinctions, the nuances of health reform.”

Politicians on both sides have done little to help the public understand those intricacies. Republicans are seen as engaging in “obstruction on steroids,” as Senate Majority Leader Harry Reid said this month, while the Democrats have largely failed to even explain the goals and potential benefits of the Patient Protection and Affordable Care Act (ACA) to American voters.

“The actual performance of ACA supporters in explaining the law and making the case for it to the American public to date has been uneven at best,” explains Henry J. Aaron, the Bruce and Virginia MacLaury senior fellow at the Brookings Institution. “During the summer of 2009, the Administration lost control of the narrative about the bill and has been fighting an uphill struggle ever since.”

If past is prologue, three Republican candidates – Mitt Romney, Newt Gingrich, and John Huntsman (before leaving the race) – all share a history of dreaming up or signing into law health programs at the very least resembling pieces of President Obama’s law.

[Newt Gingrich and health IT: Then, today, and the contentious time between.]

But at this stage of the primaries all of the Republican candidates are trying to appear more conservative than the next, and either remain elusive or vague about any healthcare intentions other than claims that, if elected, repealing the Patient Protection and Affordable Care Act will be among the top agenda items.

“That’s an attitude typical of many Republican candidates, where they stick to dogma, philosophy, and political assassination and ignore the true merit of anything,” says democrat Alden Wolfe, vice chairman of the Rockland County, N.Y. Legislature (pictured at left). “If Obama came up with the cure for cancer, they would somehow find fault in it. So that’s where politics divert the sense of reality. It’s the nature of the game.”

Spartanburg County South Carolina Tea Party leader Karen Martin disagrees completely. “That is just another example of a Democrat using a straw man hypothetical to avoid arguing the real issues,” Martin says. “That’s a ridiculous statement with no facts, no research, it’s just the emotional ranting of someone who does not have a solution to the problem.”

What is clear: Healthcare is a sharply divisive issue, and to many, if not most Americans, a concise definition of health reform and the commonalities conservatives and progressive share, are lost amid the politicking.

A noble goal: The triple aim
In terms of communication outreach to get the message across to Americans, names and words matter, and the Patient Protection and Affordable Care Act (PPACA) does not quite paint a clear picture of the health reform superset that also includes the Health Information Technology for Economic and Clinical Health (HITECH) Act and industry momentum around health IT.

“Despite some shortcomings, no bill is perfect, the ACA is a good bill that the administration and its supporters in Congress should go all out to explain and sell to the American people,” the Brookings Institution’s Aaron explains (pictured at left).

Indeed, a carefully crafted slogan actually does exist in the triple aim of patient-centered care at a lower cost that improves population health.

“But that is still in a silo by itself and hasn’t been understood and adopted by all sectors, meaning obviously the healthcare industry, but also the supporting service industry, insurance, workforce development, we all need to be intertwined and everyone understand that they need to really support the triple aim goals,” says Kim Lamb, executive director of the Oregon Health Network. “Those triple-aim goals, in fact, are in everyone’s best and common good.”

What’s more, the triple aim by nature is also arguably fiscally and politically conservative.

“Absolutely. Again, this is just politicking and framing it in a way that’s black and white, good vs. evil, right or wrong,” said Kevin Pho, MD, also known as KevinMD in the blogosphere and on Twitter. “And really I think we need to come together and use both conservative and progressive ideas to solve our problems because the enormity requires ideas from both sides of the spectrum.”

[Q&A: KevinMD on the practicability of repealing the health care reform law.]

Everyone interviewed for this story, regardless of party affiliation, agreed that the triple aim is a goal worth pursuing. Even the anti-PPACA John Graham, director of healthcare studies at the Pacific Research Institute, says the triple-aim is “common-sensical, a desirable objective of any sane person. But the question is do you achieve it by increasing the central direction of the government?”

That will be among the questions facing the Supreme Court in late March when it hears arguments in the case Florida et. al. vs. United States Department of Health and Human Services, the lawsuit over the individual mandate, among other aspects of the PPACA.

Which individual mandate?
The individual mandate within the Affordable Care Act has roots both conservative and progressive. The idea dates back to the late 1980’s, with institutions such as the Heritage Foundation backing it. The Heritage Foundation, however, has since rescinded that support.

But then the Republican Mitt Romney instituted statewide health insurance during his term as Massachusetts Governor, signing the Massachusetts Healthcare Law in 2006, legislation that included an individual mandate.

And a mid-January study from the Robert Wood Johnson Foundation noted that insurance premiums could rise by 25 percent if the federal health law is implemented without the individual mandate.

“To hear the Republican candidates go against it is a little bit ironic. If you look at the concept of individual responsibility, that kind of goes hand-in-hand with the individual mandate,” Pho adds. “It shouldn’t be as controversial as it is, but I think it is a way for the Republicans to find an excuse to try and repeal the Affordable Care Act.”

Not that the Democrats are faring any finer in this health reform quagmire. According to a mid-December survey by Pew Research Center for the People and the Press, “Two-thirds (67%) think most members of Congress should be replaced. This exceeds – by double digits – previous highs set in 2010, 2006 and 1994 … Republicans and Democrats overwhelmingly blame the other party’s leaders for Congress accomplishing less.”

And health reform, at least since President Obama signed the bill into law in March 2010, no doubt is among the “less” Americans believe Congress is accomplishing. Once again, the individual mandate serves as a significant piece of the legislation that Republicans vehemently oppose and the Democrats struggle to explain in dollars and common sense.

The most contentious issue: Cost
While the triple-aim and individual mandate scramble party lines, the cost of healthcare is a more divisive matter altogether.

“In order to become elected or stay elected, there are different messages that are portrayed, there are scare tactics utilized by both parties to facilitate the political makeup or agenda,” said Dr. Marianette Miller-Meeks, director of Iowa’s Department of Public Health, and a former Republican candidate in her state’s 2nd Congressional District.

President Obama’s claims that health reform will lower care costs is seen by those on the right as among those political tactics. Pacific Research Institute’s Graham (pictured at right) said that a number of estimates, in fact, point to rising care costs.

[Q&A: John Graham on ACOs and the 'cartelization' of healthcare.]

“Health costs have gone up since the act was passed. The major perks of the act haven’t kicked in but health costs are up by a couple of grand or so a family just in President Obama’s three-year tenure,” Graham adds, emphasizing that Obama promised “costs were going to go down by the end of his first term. That’s obviously not going to happen; it might have just been a campaign speech.”

Amid criticisms of cost, though, John Clayton, vice president of communications of the pro-health reform New Hampshire Hospital Association (NHHA), says that the notion of improving patient care falls by the wayside.

“The patients are being lost in the discussion about dollars and the deficit, as opposed to quality of care, the necessary improvements that hospitals need to make to deliver the kind of care that our people are going to require in the future,” Clayton said. “And we are an industry that needs to be looking forward at a time when many of our elected leaders want to go backward to a rose-colored past that doesn’t exist anymore.”

Patient- or payer-centered?
Economic realities dictate that some budgetary cuts are necessary, and President Obama has about a half-trillion dollars of Medicare and Medicaid reductions in the legislation, of which Graham says “I’m very doubtful that the Medicare cuts in Obamacare are really going to happen in the intermediate term. The doctors already don’t get their scheduled cut, so will the hospitals successfully lobby against the cuts they got?”

Lest the American public not widely recognize the role lobbyists played in creating the Affordable Care Act, health IT evangelist Ahier reminds citizens. “The problem really is that the legislation is poorly crafted. And the reason why is because Scott Brown was elected to the Senate and they wouldn’t be able to accomplish anything in conference committees so the House had to take the Senate version of the bill and vote it up or down, rather than be able to change it,” he explains.

The law as signed by the President was not the intended outcome, Ahier adds. To cram it through the Senate, politicians had to tack on politically unpopular pieces – recall the Cornhusker Kickback, under which Nebraska somehow lassoed a permanent exemption from Medicaid expansion while everyone was watching the rodeo. And that’s just the most egregious example.

“It always makes me suspicious when you’re doing health payment reform and the insurance industry says ‘okay, yeah, let’s do this.’” Ahier continues. “Honestly I think that finally swallowing that whole thing like we did may have turned out to be certainly not in healthcare’s best interest.”

That sentiment resonates with Spartanburg Tea Party leader Martin as well, who adds that part of the reason so few truly understand the Affordable Care Act is because the problem it set out to solve was never clearly defined.

[S.C.: Where the Tea Party stronghold reigns over healthcare matters.]

“America did not have a healthcare crisis. We have the best healthcare ever in the world and the only person that could question that is someone pushing reform out of dubious political expediency. Our healthcare system is phenomenal,” Martin said. “What we do have, because of the way our insurance is set up, by routing through the employer, by using HMOs, these third parties to keep patients financially distant from their doctors and not understanding what they’re actually paying for services, we have a health cost crisis. That’s what we have. The way to solve that is a free market.”

Not everyone agrees. OHN’s Lamb argues that, yes, there are problems with health costs but America also has a very apparent and significant healthcare problem.

“I would point to all the chronic conditions as disagreement. If we didn’t have a healthcare problem, we wouldn’t have all the chronic conditions, so we’d be much more preventative in nature, and we wouldn’t have a sick care program,” Lamb says (pictured at right). “We’d be keeping people out of the hospital, out of those types of diseases before they got there.”

Cost not the paramount consideration
The polarizing dialogue will continue through election season and after as Democrats and Republicans fight tooth-and-nail to not only sculpt the future of healthcare but, perhaps as important, dominate the narrative around it.

“The fact that the quite reasonable provisions of the original bill regarding counseling end-of-life care were libeled as ‘death panels’… illustrates the loss of control over the narrative,” Brookings’ Aaron explains. “The job of winning the public will be hard, but, in my view, it is a fight that cannot be shirked and that if waged with vigor, determination, and honesty can be won.”

State legislator Alden Wolfe sees emerging evidence that the American people are starting to better understand healthcare, despite the efforts of politicians.

“I think perhaps Americans are waking up and realizing that there are good things associated with the health reform legislation,” Wolfe says. “It’s not just the cost, but the availability of care that is most meaningful. I think people may be starting to realize that the federal healthcare legislation is doing what it’s supposed to do, and that is making healthcare more available to a wider stratum of society.”

And that is, after all, what the PPACA and the triple aim are designed to accomplish.

But as candidates vying for office from the White House down to local levels continue campaigning on rudimentary mottos that do little to further public understanding of health reform, many Americans are left scratching their heads — some of them spitting-mad at the federal government about goals that are, in many ways, both progressive and conservative at the same time.

For all of our primaries coverage, visit the Elections 2012 page.