In today’s Dose:
Health care reform
(Use of language to oppose health care reform; Goozner on media and the uninformed electorate; Doctor blames patients; Doctor importunes Obama and Congress; Doctors salaries doubled in Iran; Another Atul Gawande interview; Political scandals and evangelicals)
Health care reform
- There’s an interesting article in the Washington Post on the importance of language in current health care reform arguments.
Last month Frank Luntz, a prominent GOP pollster, circulated a memo advising Republicans on effective language to use against health care reform. Be on the side of “reform,” he said, don’t attack the popular president, talk about a “takeover” by “Washington bureaucrats” and about forcing patients to “stand in line” for health care. This has been the message in the television ads sponsored by Conservatives for Patients’ Rights.
Drew Weston
Source: Emory University
The Post‘s story on language is by Drew Westen, a psychology professor at Emory University. He’s the author of a book on politics and the art of persuasion, The Political Brain: The Role of Emotion in Deciding the Fate of the Nation
To win the health care reform debate, Westen advises Democrats to concentrate on four points. The first involves telling a story. The Harry and Louise campaign, for example, was an insurance industry story the public could easily grasp. Frank Luntz, in his advice to Republicans, recommends the story “you can’t trust ’em.” When speaking of Democratic initiatives, the thing for Republicans to stress is:
Watch out for these guys. They’ll tell you they just want to include a government plan as one option among many. But their real agenda is a single-payer system, where you won’t have any choices because they believe the government knows what’s good for you.
The trick for Republicans is to make middle-class Americans, who want health care reform for all the right reasons, “fear the devil they don’t know.” Republicans should talk about long lines at the pharmacy and even longer waits to see a doctor.
Fortunately, Weston says, Obama is a good story teller.
The second and third points are to focus on principles and be emotionally compelling.
In a May 11 speech, Obama spelled out the principles that have become his mantra. “Whatever plan we design upholds three basic principles,” he said. “First, the rising cost of health care must be brought down; second, Americans must have the freedom to keep whatever doctor and health care plan they have, or to choose a new doctor or health care plan if they want it; and third, all Americans must have quality, affordable health care.” Lower cost, freedom to choose and coverage for all Americans — that’s memorable, principled and emotionally compelling.
The flaw Weston finds in Obama’s story telling is that he doesn’t confront the opposition:
In his AMA speech, he never called the group on its opposition to Medicare in the 1960s. Nor did he mention that the insurance and pharmaceutical industries blocked reform for decades, even as their profits rose with skyrocketing premiums and out-of-pocket expenses. Whether Obama can win through inspiration and without benefit of populist anger or anxiety is unclear — especially when the other side is selling fear.
The final point is to send clear messages and to know what message you’re sending. This is where Obama and the Democrats fall down, according to Weston.
Every word we utter activates what neuroscientists call networks of association — interconnected sets of thoughts, memories and emotions. Consider the term “universal health care.” Every time Democrats use it, they reduce the chance of reform. Why? Because it evokes precisely the associations that conservatives want to evoke: socialized medicine, government bureaucracy, impersonal clinics and lack of choice. …
Unfortunately, “public option” shares the negative connotations of “universal health care” — with additional associations to low quality and welfare. It’s no accident that Republicans have seized on this, because the longer people hear about the “public option,” the more they are likely to associate the entire plan with government control. …
Reform advocates also set back their agenda every time they talk about “the uninsured” or “the underinsured.” Those phrases turn an “us” into a “them,” which decreases empathy and activates what social psychologists call the “just world hypothesis,” the idea that somehow people get what they deserve. It also activates the “welfare” network, tainting by association people who work full-time or want to work but still can’t afford insurance. …
To the average American, a family doctor for every family connotes something warm, comforting, human and nostalgic, whereas universal health care connotes something cold, sterile, distant and creepy-futuresque.
This makes so much sense, and it’s important. The article was published in today’s Post. Just as Obama and his staff read and absorbed Gawande’s New Yorker article on McAllen, Texas, I hope this article finds its way into the White House.
Meanwhile, should we use a different term for the “public option?” At this point it would be difficult to change the entrenched vocabulary.
- Merrill Goozner was quick to point out what’s discouraging and depressing about Weston’s assumptions.
Nowhere in the article does Westen pay homage to the democratic ideal that an informed electorate has a role to play in policy debates like health care reform. Nor does he lament the passing of an informed electorate. Such statements used to be a staple in discussions about political messaging and the impact it was having on policy debates. …
Today, few media outlets even bother to explain the intricacies of policy choices. Politicians, the special interests and the communications experts who craft their messages can safety assume the public will have a poor grasp on reality. Marshall McLuhan has been turned on his head. The message is now the medium.
- Steven Pearlstein, of the Washington Post, has written two columns (June 10, June 17) recently that blame doctors for the problems with our health care system.
If we really want to fix America’s overpriced and under-performing health-care system, what really matters is changing the ways doctors practice medicine …
The basic view from behind the stethoscope is that health care would be a whole lot better if only the docs were given free rein to treat their patients, organize their practices, run the hospitals and set their own fees.
Surgeon Alan Kravitz has responded by pointing out the role of patients.
[Pearlstein] relieved health-care consumers of any role in the exorbitant cost of medical treatment. One would think that the doctors he wrote about work in a vacuum, dispensing unnecessary tests and ineffective treatments to an apathetic public. …
[M]uch of the over-utilization occurs at the behest of patients. Insurance has largely removed any incentive for patients to be efficient with medical resources. Many patients feel that their insurance card is a medical credit card — with the bills being sent to someone else.
Are patients willing to accept a generic or alternative medication against their wishes? Would they be willing to accept “no” as an answer when inquiring about an expensive procedure or test? Would they want physicians to be able to limit the end-of-life care available to a terminally ill family member? Would they want unlimited access to specialists curtailed?
[D]octors are not providing the “supply” into a vacuum.
- Here’s another opinion from a doctor on what ails our health care system, this one from endocrinologist Mark Sklar. It was published in the Wall Street Journal and is addressed to President Obama and Members of Congress.
Sklar first gives his thoughts on the reasons costs are increasing, and then comments on the income of physicians.
[C]osts have increased for a few reasons. First, there are simply more patients in the system. The baby-boom generation has gotten older and now requires care for chronic medical problems. Second, we have unparalleled levels of obesity in our country. This has led to a massive increase in diabetes, hypertension and other chronic problems. …
You may find this hard to believe, but when I first started practicing medicine in 1990 I received more payment for an office visit than I am currently receiving. This has occurred despite the increasing cost of practicing medicine, which is the result of rising malpractice premiums, rents, staff salaries, professional membership fees, license fees, and costs needed to comply with various new regulations. What other profession has experienced a reduction in reimbursement over the last 20 years?
He argues that if doctors were reimbursed more for office visits, they would spend more time with their patients and that this would lead to fewer referrals to specialists and lower costs.
Currently, harried primary-care physicians don’t have the time to delve into medical problems with a hint of complexity. So patients who could be dealt with if more time was available are referred to specialists or expensive radiology studies.
He goes on to discuss mandating physician participation in a government-run health plan, electronic medical records, the size of medical practices, multispecialty practices, oversight of fraud, and malpractice.
- Joe Klein, reporting from Iran for Time Magazine, reports that Ahmadinejad doubled doctors’ salaries on June 23. This is cited as an example of how Iran’s government distributes revenues downward, normally to the working classes, as a means of pacifying the population.
For over a year, doctors in Iran, and human rights activists worldwide, have been justly outraged over the imprisonment of two doctors, Kamiar and Arash Alaei, who treated AIDS patients. [The link here is sometimes blocked. The page flashes on the screen for a moment, and then the connection is interrupted. But sometimes it can be accessed.]
After a perfunctory trial in December 2008, Kamiar and Arash were convicted of “communicating with an enemy government” and sentenced to three and six years, respectively, in Evin Prison in Tehran. The Alaeis’ crime: traveling the world and liaising with health workers across the globe to find solutions to the HIV/AIDS pandemic. Said Sarah Kalloch, Director of Outreach at PHR: “Iran can not equate public health diplomacy and the quest for shared solutions to the world’s shared disease burden to treason. It is a dangerous and maddening fallacy and a danger to the people of Iran to keep science stifled and scientists in jail.”
Doctors in Iran are currently required to report any injuries that appear related to protests to state security.
This puts doctors in Iran in a desperate position: obey the state or care for their patients. … “The Iranian Government must allow health professionals to treat patients regardless of their political leanings. Doctors have an ethical duty to prevent and limit suffering of patients in their care and a duty to practice medicine in a neutral way without fear or favor.”
Here’s a story on the Iranian doctors from The Lancet.
- Here is yet another interview with a doctor very much in the news recently, Atul Gawande. This one is from Ezra Klein and appears in the Washington Post.
In his recent NPR interview (see last Thursday’s Daily Dose), Gawande mentioned that he was expecting “brickbats.” According to Klein, Washington doctors held a press conference to rebut Gawande’s claims. Gawande has published a response to criticisms in the New Yorker.
In 1994, Gawande worked for Rep. Jim Cooper and in the White House. Klein asked him about what’s different between now and then.
The big question is what has really changed since 1992 that means anything for reform? Two things that matter on the political side and then a couple on the medical side. The big things on the political side is that we’ve stretched the economy and our budget much thinner with the damage from health care costs. The sense that both people in business and citizens have is that we’re really in danger here. That’s not something people felt as palpably in 1993. I think that sense of danger has concentrated attention.
On the medical side, there is a much greater sense of dissatisfaction in our work lives. We’re working incredibly hard to make the system work for our patients. But it doesn’t work very well for them or us. Some of that is the march of science. The increase in coordination and complexity makes it impossible to do this stuff out of your office. We’re not in a system that’s well equipped to make this a satisfying way to spend your time. …
I think the extreme complexity of medicine has become more than an individual clinician can handle. But not more than teams of clinicians can handle.
- Health care reform depends so much on political maneuvering. I thought this story from the Los Angeles Times had an interesting perspective on the future of Republicans. It argues that the recent sex scandals of Governor Mark Sanford in South Carolina and Senator John Ensign of Nevada will lead to evangelicals no longer supporting the Republican party. They won’t necessarily vote Democratic. They just won’t vote.
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