Key to Healthcare Reform Is an Honest Discussion With Voters

Costs and trade-offs of the current system, as well as any new one, must be transparent.

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Laura Carstensen is the Fairleigh S. Dickinson Jr. Professor in Public Policy, a professor of psychology, and director of Stanford University's Center on Longevity.

Many health policy experts in Washington believe the next two years present the best opportunity in more than a decade to accomplish large-scale health reform. Indeed, the timetable of some congressional leaders falls more within the next six months. It is critical that problems in our current healthcare system be addressed. Access to quality, affordable healthcare is fundamental if Americans are to live healthier, longer, more independent lives.

However, the simple fact is this: The degree of national concern about the problems in the system has not been mirrored with equally thoughtful conversation about the spectrum of solutions or the trade-offs required. If the outcome is to be more successful than the last time the nation took on large-scale healthcare reform, it is time to talk in depth about solutions, not just problems. It's time to extend the discussion out of Washington and engage the public about the options for change and what they mean.

A nationwide survey to be released this week by the Stanford Center on Longevity shows that when the issues and tradeoffs are clearly articulated, the voting public understands the issues and raises legitimate concerns. Voters voice great concern about both access and cost. Democratic respondents are relatively more concerned than Republicans about universal access to healthcare; Republicans are relatively more concerned than Democrats about cost. But there is bipartisan concern about both. The voters are correct. To increase access without controlling costs would drive the system to collapse under its own weight. Indeed, it will do so even without greater access.

Why then is health reform so hard? The answers may lie in psychology more than economics. While 62 percent of Americans feel the healthcare system works well for them, 68 percent believe it does not work well for most Americans, a fairly consistent finding in surveys and polls of the past.

More revealing, however, is that while voters believe healthcare reform should be among the top priorities of lawmakers, the majority question whether the advantages of specific potential solutions justify the risks of changing the system. When people feel personally comfortable with the present system even though others are not, change for them is very risky.

When respondents were presented with specific solutions—from expanding existing federal programs to universal health vouchers—59 percent of Democrats and 73 percent of independents questioned whether the advantages of these proposals justify changing the system.

The need for more education and dialogue with voters is converging with a sobering reality within one important potential source of information—the news media. In a recent survey by Kaiser and the Association of Health Care Journalists, nearly 9 in 10 healthcare journalists say healthcare coverage leans too much toward short, "quick hit" stories, and 70 percent say there is too little coverage of healthcare policy.

But as the failed effort of 1993 proved, champions of reform must bring the public along with them in their quest to improve the system. Educating and discussing reform with the public is an essential—not an optional—component of achieving change.

There is some good news here for reform leaders. First, the voting public grasps the issues and tradeoffs involved. Second, the concerns they have and the questions they raise are reasonable. They need answers and want safeguards. And they deserve them. Lawmakers and advocates will have to explain the true costs of insuring all Americans. They will have to explain how safeguards will prevent corruption of the system. And they must demonstrate how quality will be preserved.

Most fundamentally, a discussion of healthcare with consumers must address the issue of personal cost. Policy makers must do a better job of making current costs transparent so that voters understand how skyrocketing healthcare costs affect them today even though they may have insurance. They need to explain that employers don't simply "pay for" their healthcare, they do so by reducing wages. Advocates for increased access need to explain to voters why the same healthcare costs more in the United States than anywhere else in the world. And then offer solutions to contain cost.

Updated on 5/12/09: An earlier headline was replaced.