Tuesday, June 16, 2009

Turning the Republican Attack on Health Care Reform on its Head

We're entering the sound bite period of health care reform.

Frank Luntz, the guru of Republican phraseology and the ventriloquist behind the Republican lock step warnings against a "government takeover of health care," has given the Republicans a powerful sound bite. The Republicans are marching to the drum of a 28 page memo Luntz wrote for the Republican leadership. It's a brilliant text book of clever wordsmithing.

I've taken three of Luntz's list of "10 rules for stopping the 'Washington takeover' of health care" and tried to imagine how the president could parry the attacks that are now underway. First I quote from Luntz's memo. Then I've put the words I imagine the president using into bold italics:
Luntz: "Humanize your approach. Abandon and exile ALL references to the “healthcare system.” From now on, healthcare is about people. Before you speak, think of the three components of tone that matter most: Individualize. Personalize. Humanize."

The president has made a good start humanizing and personalizing the issue of health care costs. We (the American public) need to understand that less spending (done right) means better health, not worse. Here's how the president could follow Luntz's advice: "Out of control health care costs are a cancer. They've pushed our economy to the brink of collapse and they're ruining the health of the country. Losing a job hurts our health. Losing a home hurts our health. Getting a grip on runaway spending will be good for our health and our economy!"

Luntz: "Healthcare quality = 'getting the treatment you need, when you need it." That is how Americans define quality, and so should you. Once again, focus on the importance of timeliness, but then add to it the specter of 'denial.' Nothing will anger Americans more than the chance that they will be denied the healthcare they need for whatever reason. This is also important because it is an attribute of a government healthcare system that the Democrats CANNOT offer. So say it. 'The plan put forward by the Democrats will deny people treatments they need and make them wait to get the treatments they are allowed to receive.'"

The president has a tough challenge here. The public believes that more care is better care and less care means worse health. Wise physicians know that "getting the treatment you need, when you need it" means care that would be significantly different in nature (more primary care, less specialty care) and quantity (more time with the doctor, fewer procedures) than what we have now. Here's how the president could follow this piece of Luntz's advice: "Wise doctors - the kind of doctor we all want to have for ourselves and our families - know that the best medicine involves more listening and more healing attention then they can give now. We must stop forcing them to do tests and procedures that aren't needed. Tests and procedures that are done because doctors are afraid of being sued or because they can't take the time that's needed don't just drive up costs - they cause harm by all the complications that can occur.

Luntz: " 'One-size-does-NOT-fit-all.' The idea that a “committee of Washington bureaucrats” will establish the standard of care for all Americans and decide who gets what treatment based on how much it costs is anathema to Americans. Your approach? Call for the “protection of the personalized doctor-patient relationship.” It allows you to fight to protect and improve something good rather than only fighting to prevent something bad."

The president has to undermine the argument that whatever the individual physician wants to do is the right thing. We know that close to half of the care delivered deviates from what the best physicians would do. And we know that when Michigan routinized what was done in its intensive care units potentially fatal infections were almost completely eliminated. Here's how the president could use the tactic Luntz proposed to the Republicans: "We want our doctors to have the best information about what works. That's what let's them cure our cancers and relieve our pain. Our plan invests in research to tell them which treatments work, which don't, and which actually cause harm. Our doctors want this kind of knowledge so they can do what they went into medicine to do!"
I'm a doctor who's interested in ethics, not a sound bite machine. I'm no Luntz. But I think the president can perform jiu jitsu on Luntz's tactics and turn the force of Luntz's practical advice in the direction the health care system really needs!


eric said...

Jim--President Obama took your suggestions. Above is a link to his speech to the AMA. The reaction of the AMA responds to a concern you state in today's post. --Eric

Jim Sabin said...

Hi Eric -

Thanks for the link!

For the President, speaking to the AMA isn't quite as much of a challenge as speaking in Cairo was, but it's a bit in the same direction. I thought his AMA speech was a good one. I hope that his extraordinary communicative abilities plus his intelligence will allow him to be a true leader of national reflection about health care.



Tim J. LeClaire said...

The problem with a public plan that competes with private insurers is that the Obama Administration intends for it to be the only plan. And, in a matter of time it will not have to outperform the private plans. If the public plan pays providers what it is paying for other government plans now, it will in effect pass on the difference to the private plans - until they collapse! With subsidies to artificially lower the "premium," of the public plan, and no accountability to a budget, the public plan will attract enrollment from the private plans, and reduce their revenue until the private plans cannot pay providers any more than Medicare and Medicaid pay them. What this plan overlooks is that private plans have had success with cutting costs and improving the health of the 200 million Americans with private insurance primarily purchased by employers.
It is a revenue stream grab. It is no secret that the government NEEDS control of 15%+ of the GDP (paid for Healthcare) to pay for other programs.
I am not fundamentally opposed to this scenario - but call it what it truly is! It is a single payer plan. The plan is for private insurance companies to be driven out of the system. And, while we are telling the truth, tell us what the public plan looks like. How will it save money and help us get healthier? Hopefully, we can salvage some of the private plans’ collective knowledge for promoting wellness before they are eliminated.

Jim Sabin said...

Hi Tim -

Thanks for this comment. It covers a lot of ground!

It may well be that for some folks in the Obama administration the public option is a stealth way to get to a single payer plan. Zeke Emanuel's proposal, though it was written before he joined OMB, is built around the concept of multiple insurers.

If the public plan controlled costs simply by lowering reimbursement it would not be a boon for the health system. Medicare has not yet been allowed to be innovative in using its clout to push hard for improved care, and if a new public plan were similarly constrained I wouldn't see it as worthwhile.

I wish I could agree with you that private insurers have been able to control costs. When they did so in the 1990s the backlash was fierce, and they retreated - understandably - from managing care since then. There's been so much villification of insurance in our political discourse that I can't see the public granting legitimacy to insurers to make tough choices about whether or not to pay for marginally beneficial treatment.

If the administration's intent is to get to a single payer system by way of a new public plan that would gradually kill off private insurance I agree with you that in principle telling the truth would be the preferable approach. My GUESS is that this is not the administration's intent. As I said in my posting, I believe that a public plan would have more leeway to engage seriously with cost management than private insurers do. Good private insurers could do the job well, but being trusted to set limits fairly is half of the job, and we - the public and our political leaders - have demonized insurers too much for that trust to be available.



Anonymous said...

I KNOW ALL ABOUT NATIONAL HEALTHCARE! – IT’S A JOY!!!! And as a wealthy individual, I can vouch that it did not take away from our way of life in UK. Au contraire, it gave us freedom from fear, always! The government never decided whether or not we required a heart transplant, believe me, it was the doctor! We carried catastrophic insurance for serious injury, minimal expense, but for countless doctor visits such as cuts, stitches, accidents, mammograms, blood checks etc… it was superb. Not perfect, but isn’t occasional human failing inevitable as humans. And believe me, care was just as good if not better. Conversely, living in the States, always holding comprehensive insurance, at great cost, with high deductibles, I end up paying for every health check in addition. What kind of service is that? I’m slim and healthy. However, one hour in emergency with a simple back spasm from hiking cost me $2500. Placed on every conceivable machine in the ER, presumably to bring up hospital shortfalls to compensate for my friends without insurance! Bless their hearts and livers. What kind of justice is that! – America, please do yourselves a favor? Place a cap on lawsuits – if the doctor cuts off your pinky instead of your toe, you deserve compensation, but not multi millions. Save that money to see youngsters through medical school – we will have more good doctors. Another pitfall, if America insists on eating fast food, then lets encourage fast food chains that offer health-building alternatives. America, you deserve freedom!

Jim Sabin said...

Dear anonymous -

Thank you for your bi-national comments. Your description of your emergency room adventure is, alas. not rare. A family member of mine got a cut that she recognized needed some stitches. Her primary care doctor's office was closed, so she went to the emergency room. Her bill for the 10 minutes there was came in at 3 digits, not 4 like yours, but just barely.

It must seem strange for someone accustomed to the NHS to hear the disinformation we Yanks spread about care in the U.K., Canada and any other country that might be used as an example to prod ourself to make changes.