Verdict on Health Care Reform

Public's made progress, but still hasn’t come to grips with costs of making health care a universal right, judges rule in mock trial. The American public is more aware of the costs of health-care reform than it was 15 years ago, but still hasn’t resolved the trade-offs associated with making health care a universal right, raising questions about the Obama administration’s goal of reform this year. This was the ruling by a panel of five “judges” in a mock trial at the National Archives in Washington, D.C., earlier this spring. “It’s clear that there’s a mandate for Congress and the president and those in the country to work on this issue and take action,” said Richard Harwood, president of the Harwood Institute for Public Innovation in Bethesda, Maryland, and chief justice of the “court.” “But it’s not clear exactly what action we ought to take and what cost and who should bear the burden.” The trial, sponsored by the Kettering Foundation and the National Issues Forums Institute, was designed to evaluate outcomes from hundreds of National Issues Forums in 39 states. Forum participants looked at how to increase coverage and contain health-care costs using NIF issue book Coping with the Cost of Health Care: How Do We Pay for What We Need? This book weighed the pros and cons of three distinct approaches to the health-care issue: require minimal coverage for all to reduce the threat of financial ruin, restrain costs in the insurance and pharmaceutical industries, and provide universal health-care coverage as a right. Recalling how a lack of public support helped doom the Clinton administration’s reform efforts in the early 1990s, the five-member court focused on two key questions suggested by the deliberations: To what extent is the public aware of the trade-offs surrounding health-care reform? And to what extent are citizens prepared to accept the consequences of the change they say they want? Attorneys Debate Public’s Readiness Arguing on behalf of the public’s maturity on the issue, “attorney” and Hofstra University history professor Mike D’Innocenzo called on three witnesses and used video clips from forums to illustrate that Americans are angry and embarrassed over the state of health care in the United States and are ready for “transformational change,” even to the point of accepting higher taxes, the rationing of care, and more personal responsibility for their own health. Loraine Della Porta, deputy director of the Massachusetts Office of Dispute Resolution and Public Collaboration, testified that forums in her state show that citizens are ahead of the politicians on reform. “I found the public has thought long and hard about these issues and is ready to do something about it,” she said. “They do see health care as a right, and we do have a unique opportunity to see this in Massachusetts because we do have some basic coverage, but folks don’t think we go far enough. In order to make better coverage for everyone there will be some trade-offs with respect to cost, and people are okay with that as long as it’s equitable. We heard that over and over again; they want to see equity and fairness.” Maxine Thomas, Kettering vice president, secretary, and general counsel and opposing attorney in the program, examined the same data and called her own witnesses to tell a different story. While agreeing that forum participants consider health care a right, she argued that the public is at an exploratory stage: concerned about taking care of children, the elderly, and the disabled, but coming up with only a “patchwork” approach, focused more on personal concerns than on how “to put together a new health-care system.” One of her witnesses, Margaret Holt, with the National Issues Forums network, was involved in four forums and said she observed participants struggle “with everything.” But she said she saw little evidence that people were willing to sacrifice in one important area. “Some would talk about others who had bad habits like eating cheeseburgers or smoking or not wearing motorcycle helmets,” Holt said, “But I didn’t see people speak to their own personal behaviors or making adjustments for better health.” Judges Raise Doubts about the Public’s Progress Despite seeing some progress in public thinking on health care, the judges overwhelmingly backed Thomas’ case. There’s evidence to suggest people view health care as a personal responsibility, Kettering President David Mathews said. “What’s less clear is how far people are willing to go to control your behavior so that it doesn’t adversely affect the rest of us,” he said. “Will cheeseburgers become a crime? It’s not clear yet.” Mathews also wondered whether the public is really ready to give up “the cherished right to litigate to reduce the costs of litigation” and accept restrictions on end-of-life care. Chris Satullo, executive director of news and civic dialogue at radio station WHYY in Philadelphia and an NIFI director, said the fact that forum participants indicated that health care should be a right doesn’t automatically translate into the acceptance of health-care rationing, especially when the issue comes down to whether someone’s mother or father would be asked to give up a “quadruple bypass so some unemployed person could get care.” “The question is whether framing it as a right is really a fuzzy platitude that gets in the way of confronting the trade-offs,” Satullo said. Gail Leftwich Kitch, executive director of By the People and MacNeil/Lehrer Productions, agreed that she hadn’t heard enough about people’s definition of health care as a right. She also expressed concern that some forum participants believed that reducing greed and profit in the system can pay for more coverage. “There’s not enough greed and profit to take care of the problem,” she argued. “That’s . . . wishful thinking.” Public Policy Implications of the Verdict President Obama’s health-care summit last spring brought together institutional stakeholders and appeared to invigorate lawmakers and others who have been working on health-care reform for years, but given the history of partisanship on this issue, Satullo questioned whether “the political system is ready for a robust debate.” But he also saw a role for citizens in a stalemate that’s come a long way since 1993. “It suggests a wonderful opportunity for the public to have a sane and broad discussion about the real trade-offs, because what you’re going to get on the Hill is not that, not even remotely that,” Satullo said. Dr. Georges Benjamin, executive director of the American Public Health Association, suggested that a lot of the debate is already happening online. “What we’re seeing is the public is not waiting for the traditional leaders,” he said. “People who haven’t thought of themselves as leaders before . . . will influence those who say this won’t happen.” Summing up for his colleagues, Harwood said that, in order to move forward on the issue, the public needs an expanded awareness of the choices they face in health-care reform, an understanding of the trade-offs and who will bear them, and additional public spaces where citizens can talk to each other in a more deliberative way so the debate won’t become “shallow and meaningless.” The question, Harwood said, is whether citizens can all step forward to think and act in the public good in order to arrive at our destination.