Questioning conventional wisdom

Before taking this class--what did you think were the biggest issues in health care that needed to be fixed?

What types of stories do you see daily about health care reform? What gets coverage?

What do you think of when you hear the term "health care reform"?

What are the assumptions/conventional wisdom that appears in these stories?

The Problem and the Question

Seven times in the last century presidents have attempted to guide the United States legislature to adopt some form of comprehensive health care reform. 

Seven times they have failed. 

At the Iowa Caucus in 2008, President Barack Obama promised by the end of his first term he would deliver exactly that—comprehensive health care reform. The obstacles he faces are not easy to understand, let alone negotiate.             

Navigating the health care issue in the United States is perilous on the best days. Powerful special interest lobbies dominate almost every facet of the health care system, from insurance companies and doctors to pharmaceutical conglomerates and medical device manufacturers. 

A powerful social stigma that labels universal health care as “socialism” doesn’t help either—a problem that arose in the early ‘50s and is now considered as American as muscle cars and fast food. Even America's consumer culture where more and new is better stands in his way. 

The president has pointed to rare economic circumstances, a unified Congress and a health care system that is not simply broken but falling apart at the seams as strong indicators that he can deliver on his promise. 

But it is not solely in his hands. Rather, how he responds to a collection of barriers entrenched in American politics and society will determine his political fate and the future of health care reform in the United States. 

LBJ's success

We’ll just skip right to the good part on this one, because the rest of this gets pretty complicated. After a solid decade of the American Medical Association opposing government sponsored health care, the Social Security Act of 1965 was passed in July under the leadership of President Lyndon Baines Johnson.

Johnson gets all the credit for creating both Medicare and Medicaid, but just as his “Great Society” was a direct descendent of President John F. Kennedy’s “New Frontier” agenda, Johnson’s Medicare bill was the child of the Medical Health Bill for the Aged that had been a part of Kennedy’s campaign platform in 1960.

To back things up one step further, and introduce another key player, that campaign promise was based on the inadequacy of a the one piece of health care coverage the AMA had supported—the Kerr-Mills bill. Wilbur Mills, the author of the bill, was the chair of the House Ways and Means Committee, a key position because all health care legislation had to make it through his conservative-dominated committee, blocking bills from making it to the Democrat-dominated full session.

The Kerr-Mills bill expanded medical vendor payments under state-run programs, but didn’t do enough—few people were able to access the expanded coverage.

After Kennedy was elected, the first iteration of the bill which would eventually become Medicare came into being. It was called the King-Anderson bill, but the Democrats decided to wait until after the 1962 mid-term elections before attempting it. (They had lost a number of seats in the 1960 elections.)

When Kennedy decided to move forward with King-Anderson in 1962, he found his way blocked by Mills and the other conservatives on the Ways and Means Committee. It was thought that the bill could pass if it made the floor in a regular session, but because tax legislation can only be introduced in the House of Representatives, there was no practical way of getting the bill out of committee.
To get around the stubborn Mills and his committee, King-Anderson was introduced to the Senate as an amendment to an existing tax bill. This proved to be a tactical error. Because it undermined the traditional power of the committee, dodging the Ways and Means Committee alienated five senators who had previously supported the King-Anderson legislation, and the amendment was defeated 52-48 in a July 1962 Senate vote.

Unfortunately, the question of Kennedy’s continuing to pursue health care reform was answered permanently on November 22, 1963 by Lee Harvey Oswald.

Johnson did not pursue the controversial topic of health care reform until after winning a landslide victory in the 1964 presidential election. But when he did, he found his efforts stymied, just as Kennedy’s had been, by the Ways and Means Committee, and Wilbur Mills.

Mills was, however, feeling the public support for the concept of government funded health benefits, and drafted a bill which combined King-Anderson with several competing ideas. His compromise, which would create both Medicare and Medicaid, eventually became law only after 513 differences were ironed out in the conference between House and Senate.

American Culture: Anti-Socialism and More is Better

Attacks on Sen. Barack Obama’s health care plan during the 2008 election were a common occurrence, and these attacks often included at least some mention of “socialism” or “socialized medicine” coined during Truman's reform failure in the '50s. 

American’s deep-rooted fear at the mere mention of socialism is no accident. The “Red Scare” of the 1940’s and '50s defined American culture. With a universally held enemy in the Soviet Union, concepts such as welfare, universal health care or nationalized insurance were seen as overtly communist or socialist. 

To be American was to be strong, independent, a believer in individual freedoms and wary of big government. 

The impact of this mindset is felt today just as strongly as it was in the '50s. As the only industrialized country without a universal health care system, the United States is at a cultural crossroads. Obama is attempting to succeed where no other president before him could—efficient and comprehensive reform in the health care arena. 

However, American culture is firmly blocking Obama's path. The culture gap between the U.S. and other regions, specifically Western Europe, is large, Parente explained. The difference is how citizens view government intervention and action. Just as with socialism, Americans (and Republicans) fear big government in a way unlike their European counterparts. 

Both attitudes were adopted over the past century. The “Red Scare” and escalating Cold War defined American thoughts on universal health care while the Europeans relied on their governments to rebuild after the destruction of World War II and to provide just about every service. 

“Countries like the England and Germany are much more open to and even expectant on the government doing things like providing comprehensive health care,” Parente said. “In the United States, we openly reject that thought and see the government as the enemy.” 

A deeply held resentment of government intervention is one reason why campaign rhetoric against health care reform often concedes to using such buzzwords as socialism or big government—their use is extremely effective in building coalitions and public support against health care reform. 

Still another major cultural obstacle to effective cost reform is the consumer culture of the American people. 

Americans like the shiny, the new, and the expensive. Abundance is always seen as better. In terms of health care, this means the newest drug, the newest device, the newest treatment always looks better—even if the old treatment was less expensive and just as effective. 

Sullivan said that the conventional wisdom that newer is better is one of the biggest factors in escalating health care costs. The United States government literally has no effective way to gauge the effectiveness of new treatments, drugs or medical devices. 

“Everywhere else in the world, the state says no.” Sullivan said. 

The United Kingdom's National Institute for Comparative Effectiveness (NICE) is an example of a government agency with the capability to deliver comparative assessments to new drugs, treatments or devices. Proponents are likening the newly formed U.S. Federal Commission on Comparative Effectiveness Research (FCCER) to NICE. However, critics suspect the FCCER will have no ability to enforce its findings and prevent certain products from entering the market.

The health industry lobby takes advantage of American adoration of technology and drugs, aggressively lobbying the public whenever politicians attempt to stem health care costs. When coverage of a new drug or product is threatened, cries of “health care rationing” immediately flood the country from coast to coast. 

In 2002, controversy surrounded Xigris, a drug approved by the FDA for the treatment of severe sepsis. With costs approaching $7,000 per patient, per treatment, many hospitals and medical professionals openly doubted its use. Severe bleeding and serious side effects can follow its application. Lingering concerns still exist over the drug’s value in effectively treating sepsis.  

To combat the risk of loosing sales on one of its biggest drugs, Eli Lilly hired an advertising firm to create a campaign raising ethical awareness about not using the drug. The campaign, called “The Ethics, the Urgency and the Potential” failed to include any studies on its cost effectiveness. Instead, it aggressively lobbied the public and accused the government and hospitals of rationing new, revolutionary and life saving drugs. 

At $6,800 per patient per treatment with no clear benefit, the drug is hardly cost effective.

Sullivan is skeptical that the government will ever have the ammunition to shake the stigma of health care rationing. 

“You're not going to be able to address costs without changing public opinion,” he said. 

Experts disagree whether Obama has the ability to do so. “Obama has an instinct about the American people,” Sen. Durenberger said. He thinks Obama can frame the conversation to appeal to the American people. 

Sullivan approached it from a different perspective. People can witness the failures of the health care system in their own lives, but not the effect that all these factors have on the country’s overall well-being. He likened it to the global warming/climate change debate. When the potentials harms are long down the road, the public is less concerned. 

Sullivan openly doubts Obama's ability to change public opinion. “People tell me this guy is transformative,” he said, “I've seen no evidence that he was A. Passionate or B. working really hard for something.” 

Parente also shared doubts. “If he really wants it, he should just barrel through and just get the coverage determination down. Because you’re not going to fix the cost element of it. The only way you’re going to fix the cost is to ration technology and to say no to people to get care,” he said. 

“We’re on a boat where we’re an aging society that’s fairly well to do that loves technology.” 

Not a good combination.