Key to Healthcare Reform Is an Honest Discussion With Voters

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.

Across party lines, voters identified affordable premiums and low, out-of-pocket expenses as the two most important things they consider when choosing a healthcare plan. It is not surprising, therefore, that throughout the survey, voters consistently raised concerns about out-of-pocket costs and the potential for higher taxes as factors making different proposals less desirable.

Another important piece of good news is that the tools for providing this education and facilitating this dialogue are abundant. The new administration has proven effective at utilizing all of them—from direct online video addresses to Web-based information to twittering.

The administration should be applauded for establishing regional health summits to discuss healthcare, town-hall style, with voters. These summits should continue and should be used not simply as an opportunity to rehash problems, but talk about the tradeoffs that will be inherent in potential solutions.

Others who will be called upon to provide leadership in shaping policy should also engage. Whether members of Congress, local chambers of commerce or civic organizations, those who are able should convene forums and engage in informed dialogue about potential solutions and the need for change. Voters should be encouraged to study, select and then get behind specific proposals.

Leaders in all sectors of the discussion—policymakers, consumers, providers, businesses, insurers, patient advocates—must help raise the level of conversation to an honest, straightforward exchange about the system and what change will mean to individuals.

Health policy is inextricably linked to how well we age as a nation. Added years can be a gift or a burden to humanity depending upon how they are used. To the extent that long-lived people are physically fit, mentally sharp, and financially secure, societies will thrive. To the extent people grow frail, dependent, and impoverished as they age, everyone's well being will be diminished. Universal, equitable, affordable healthcare can make the difference.

An informed nation must take action.

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