Category Archives: Politics

Politics and political aspects of healthcare issues and health care reform.

Healthcare Prevention – Value, Savings and Strategies

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Prevention is often portrayed as either the savior or the step-child for reforming, transforming, or saving the US healthcare system.  How prevention would specifically benefit people and society is presented in various ways to make these points:

US Doing Worse in Prevention Activities

The Commonwealth Fund recently released a study showing the US is doing poorly in reducing deaths from preventable causes. (Variations in Amendable Mortality – Trends in 16 High-Income Nations.)

From Commonwealth Funded Study - September 2011

While this study isn’t a definitive prescription for systemic changes, it illustrates the performance deficiencies of the US healthcare system – and is consistent with other reports looking at related metrics.

Prevention is a Very Effective Strategy

The American Academy of Family Physicians’ journal “American Family Physician” had an editorial last September titled, “Preventive Health: Time for a Change,” which noted that, “According to recent literature, primary prevention appears to work better than any other strategy in medicine.”  This article also had a great poster “prescribing” the formula for good health. (See below.)

Modified From "Preventive Health" Editorial AFP, September 15, 2010

[Note: I've modified it to indicate 5-10 recommended servings of fruits and vegetables. In addition, it should also be recognized that the weight goal requires a long-term strategy - while the other activities are more immediate - and an often cited weight reduction goal is 10% since people generally see that as reasonable, and a 10% weight loss for someone who is obese has been shown to improve clinical outcomes.]

Politics of Prevention

The 2010 Federal health reform law included $15 billion over 10 years for a Prevention and Public Health Fund to assist state and community efforts in preventing illness and promoting health.  However, like many things in the 2010 Federal health reform law, this funding has been targeted for elimination in order to reduce overall government spending. As the Health Policy Director for the Republican staff of the Senate Committee on Health, Education, Labor and Pensions stated during a session hosted by Politico last week, “While everyone supports the idea of prevention, there isn’t a lot of data that suggests that those programs actually reduce healthcare costs,” and this part of the health reform legislation is a “slush fund.”

Conclusions:

So like many things in healthcare, definitions are important – as are priorities and savings calculations – since what I suspect the Senate HELP Committee’s Republican Health Policy Director meant was that many prevention programs haven’t been shown to save money for Medicare or Medicaid, i.e., reduce Federal spending projections. This isn’t too surprising since Medicare is for the elderly and disabled, so prevention in that population may often be secondary rather than primary – and Medicaid faces similar “those who pay may not be those who benefit” challenges. However, such a narrow programmatic and financial mindset fails to recognize that improving prevention for the overall population can slow the growth in total healthcare spending and improve productivity. My “proof” for that sweeping statement – particularly the worker productivity piece – is that growing up in Hartford, CT it was common knowledge that the insurance companies, (most of which had their headquarters in Hartford), had the best prevention and employee wellness programs.  And this was not by chance – they knew it was good business to keep their employees healthy and productive.

Selling Healthcare Changes – Loss Aversion & Adoption of Innovations

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Healthcare issues ranging from national health reform to stem cell research have become a major force in political rhetoric – often overwhelming substantive information. This creates challenges for individuals and organizations seeking to achieve positive changes as their communications are swamped by election-driven messaging.

Creating and implementing successful communications programs in this turbulent environment is easier when the principles of “loss aversion” and the factors affecting the adoption of innovations are used constructively.

Loss Aversion & Campaign Messages: Swinging Votes Not Actions
Campaign communications – particularly negative messages – are very effective because they use loss aversion principles to leverage people’s reluctance to embrace change.

I have repeatedly heard that people need to believe they will receive a gain that is twice as large as their potential loss before seeking to make a change.  However, that 2:1 ratio is derived from some specific social psychology experiments, while loss aversion research demonstrates that the ratio varies depending upon the magnitudes of the risks and rewards for the individual.  For example, many people would willingly wager 10 cents on a coin flip if they could win 11 cents by guessing correctly – if nothing else just for the “fun” of playing, and because losing 10 cents isn’t a big deal. However, very few people would wager $1,000,000 on the same coin flip for the chance to win $1,100,000 – even though the odds and the loss-gain ratio are the same, (and in the player’s favor), because the significance of the risk is much greater.

Kahneman 1991 Loss Aversion Figure

Source: Kahneman et. al. 1991

While these principles are not unique to healthcare, their power for influencing people’s perceptions and actions is greater for healthcare issues because of healthcare’s very personal nature and most people’s impression that they have some healthcare expertise acquired through first-hand experience. [Reader Participation: Insert your story here about a friend or relative who has "educated" or "advised" you with a personal healthcare story, or how someone - perhaps a stranger - has offered healthcare advice based upon something that happened to them, or someone they knew, or they just heard about from someone else.]

The principles of loss aversion make it very, very difficult for potential short-term and individual gains to be the foundation for effective communications campaigns about healthcare improvements for the following reasons:

  1. Loss aversion means that most people are going to want to see a potential gain that is a multiple of the potential loss – and those most affected by a proposed change will see the potential loss as much more significant, and thus require an even larger potential gain in order for them to not oppose it.  (And those most affected will also be the most active and vocal in their opposition.)
  2. For most people, healthcare changes have significant levels of perceived personal risk – whether it’s changing their health insurance benefits, choice of physicians or hospitals, how they can obtain access to new or experimental treatments, or even very specific changes such as stem cell research, abortions, end-of-life counseling, genetic or autism screening, etc.
  3. While potential losses are well understood by most people – since they know what they currently have and realize that change will be “something different” – potential gains are usually much harder to visualize and believe in. (This is why the current Administration has said that under the new health reform law people can keep their current health insurance plans if they like them.)
  4. People’s trust in government and large organizations, (e.g. corporations), has plummeted in recent years, greatly reducing people’s confidence that changes advocated by these sources will actually produce the promised gains. Specifically, in “calculating” potential losses and gains most people will greatly discount potential gains from government or corporate initiatives. For example, suppose a proposed government healthcare change is described as having a gain of 10 and a potential risk of 3. [These numbers are obviously only arbitrary representations of the magnitude of how potential changes might be valued.] This change might be seen as having a gain-risk ratio of 10:3, but a general distrust of government actions could discount the potential gain to 25%, (which is about where Congress’ approval rating is right now), resulting in a perceived gain-risk ratio of only 2.5:3 – and this assumes that people don’t inflate the potential losses because of their low opinion of government, which could make the perceived ratio 2.5:6 or 2.5:9.  Clearly this is not a situation where people would eagerly support a change in something as important as their health.

This means that even for a proposed change where the best projections indicate significant benefits to many, many people, any individual or organization who opposes the change, (for political or other reasons), has a very easy time crafting messages and images that are very effective in undermining support for the proposed change.  (For example, the combination of the following phrases has been effective in undermining support for the new health reform law: “Government Takeover,” “Death Panels,” “Unconstitutional,” and “You Lie.”)

Overcoming Loss Aversion and Negative/Counter Messaging
The solution to overcoming such undermining messages that play on people’s concerns about losing what they have (and know) – as well as their mistrust of governments and other large organizations – is to present proposed changes in ways that expand people’s confidence in and understanding of the potential gains, while also minimizing the perceived loss potential.  One way to do this effectively in a communications strategy is to address the 5 factors influencing the adoption of innovations that Rodgers first described in the 1960s:

  1. Relative Advantage
  2. Compatibility
  3. Simplicity
  4. Observability
  5. Trialability
    [These are derived from Rogers 2003 book and it's earlier editions, and described by Dealy and Thomas in their 2006 book.]

Selling Health Reform as Positive Innovation
Shifting to a “selling” campaign that incorporates these factors – while minimizing the potential affects of loss aversion – moves the communications dynamic away from the slippery losing slope of loss aversion’s context to one that is more favorable to thinking about the longer-term and more tangible benefits of the proposed changes.  For example, the broad communications campaign for the bipartisanlly supported Medicare prescription drug benefit, (Part D -  enacted in late 2003, benefits started in 2006), emphasized  how much individuals would save, rather than the long-term value and security of having  insurance – which is what Part D plans are, they are insurance, not a discounted purchasing scheme. (A USA Today article stated that an average person who enrolled in a Medicare Part D plan would save $1,100 in 2006.)

The Result: While people who did purchase Part D plans were generally happy with their plans, about 10% of Medicare beneficiaries (~4.5 million people) didn’t have prescription drug coverage in 2007 despite some plans costing less than $10 per month. The large number of people who decided to not purchase this very low cost insurance is even more striking because individuals’ premiums increase by a “penalty” of 1% per month for every month between their initial period of eligibility and their enrollment date. (This penalty is to reduce adverse selection, which occurs when people wait until they are ill before getting  insurance.) Unfortunately, the number of Medicare beneficiaries without drug coverage doesn’t appear to be declining – in 2010 it was still about 10% of beneficiaries, and this compares very poorly to the very low percentage of people who declined Medicare Part B coverage.

The significant number of Medicare beneficiaries who decided not to purchase a Part D plan could be due to their aversion to a perceived loss being stronger than the positive messages used to sell the benefits of the plans.  This imbalance results from the gains being presented as short-term financial savings, (rather than the long-term benefits of having insurance), and thus didn’t utilize the factors for improving the adoption of innovations, i.e., Part D insurance plans is comparable to other insurance they have, it is not  complicated (except for the initial large number of choices), they can observe it, the plans can be tried, and the insurance provides a significant relative long-term advantage.

Bottom Line – Sell the Value & Spirit, Not the Calculation
The bottom line is that selling the value of healthcare changes – whether it’s national reform or narrow innovations – needs to encompass broader, longer-term, and tangible values, rather than short-term calculations that may be both uncertain and not believed, while also deflecting and undermining opposing arguments, i.e. capitalize on the factors that ease the adoption of innovations while minimizing people’s inherent aversion to potential losses.

And in closing, (at least for this posting), how these principles were used in a negative way to sell a non-healthcare change might be a useful illustration:

Buying a house with an unaffordable mortgage was seen as OK before 2008 because the potential for loss was believed to be very small – since prices were rising and foreclosures were rare so there was very little to trigger an aversion. And owning a home is compatible with most people’s desires and daily lives, home ownership is observable, renting is akin to a trial of ownership, brokers and agents made it all very simple, and home ownership has potentially great financial and social advantages. However, in retrospect it’s clear that purchasing a home was vastly wrong for many people – and potentially involved outright fraudulent communications – because they had been led to believe in illusory loss-gain (a.k.a. risk-benefit) calculations.

Fixing or Fracturing Medicare?

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Reducing Medicare spending has been one of the focal points in the debt ceiling negotiations, and it was reported that the President is considering throwing the idea of raising the eligibility age for Medicare into the pot as part of a stone soup recipe that might get enough Congressional Ds and Rs to swallow the end product.

Increasing Medicare’s Eligibility Age is Bad Policy and Worse Politics
While increasing Medicare’s eligibility age to reduce spending makes simple arithmetic sense using the formula Spending = Number of People x Spending per Person, like almost everything in healthcare, what is simple is often 30 degrees wrong. And raising Medicare’s eligibility age is no exception because it has significant fiscal and political problems.

First, that simple arithmetic formula ($=#($/#)) doesn’t account for the reality that older Medicare enrollees are more expensive than younger ones, so the savings from eliminating people who are at 65 and a few years older only saves a fraction of the average per person Medicare spending.

Second, raising the age of eligibility won’t eliminate all those people under the new enrollment age since some of them will still qualify because they are disabled or have end-stage renal disease – and these enrollees are more expensive than average too.

Third, eliminating the youngest (and least expensive) enrollees from Medicare will cause the Part B premium to increase because by law it has to account for a fixed percentage of all Medicare Part B spending.

Fourth, those individuals age 65+ who would be ineligible for Medicare would have to buy private insurance – or continue to be covered by their employers’ retiree health plans or state Medicaid programs. And just as they are generally less expensive than older Medicare beneficiaries, they are also more costly to insure than the average person under the age of 65.  Which means that they (or their former employers or Medicaid – which the Federal government also partially pays for) would be paying more per/person for their insurance. AND, including these individuals in the now forming insurance exchanges would raise premiums for everyone else in the exchanges. (In a report released in March, the Kaiser Family Foundation found that raising Medicare’s eligibility to 67 in 2014 would “result in an estimated net increase of $5.6 billion in out-of-pocket costs for 65- and 66-year-olds, and $4.5 billion in employer retiree health-care costs,” as well as $0.7 billion more spending by states for their Medicaid plans in 2014.)

So the final score is bad fiscal outcomes, (Medicare is saving less money than might be quickly conceived), along with a bunch of bad political outcomes: People aged 65+ without Medicare would pay the highest private sector premiums – either directly or via their former employers or Medicaid – and middle income people on Medicare would see a Part B premium increase. Of course those effects could be mitigated by subsidizing the Part B premiums and the private sector insurance (and Medicaid) costs to lessen these impacts – and the political fallout. But then what happens to those Medicare “savings?”  If that’s the “deal” that is struck, it would be a direct hit to begin fracturing the fundamental social contract that has defined Medicare since it’s founding – and subsequent whacks would likely be to incrementally increase enrollment age and otherwise cut eligibility criteria.

A Better Idea
A better solution is to actually improve Medicare – and (spoiler alert) much of what is needed to do that was contained in the ACA and the fiscal stabilization legislation.  Specifically, changing incentives for providers from volume to quality and creating support for the adoption of healthcare IT systems.  Neither of these will occur rapidly, but just as real medicine doesn’t cure people like Dr. McCoy did on Star Trek or Dr. House does on TV today, really changing a system as complex as the one that delivers the services that Medicare pays for won’t occur quickly.  The first stones on that path have been laid (e.g. ACO concepts, advanced primary care that coordinates care, similar pilots/demos, and penalties for delivering low value care, a.k.a.”value based purchasing”), and veering off that path  because it’s “hard” or not as speedy a trip as some would want, is like jumping into a turbulent river to get downstream faster without any idea where the rapids or waterfalls might be, or what carnivores (or nasty microbes) are waiting for a tasty snack.

Patient-Centered Care? Or Not?

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The term “patient-centered care” has increasingly been used to describe healthcare structures that deliver better quality care – as well as often doing so with lower costs.  And today there was a news story about how some medical schools are assessing applicants’ interpersonal skills, something that is fundamental for being a patient-centric clinician.

While there are have been numerous articles demonstrating the value of patient-centered care and concluding that it is better and should be promoted – including those looking at the ill named “Patient-Centered Medical Homes” – I’ve found myself pondering the following questions:

“What type of care have clinicians been providing if it hasn’t been patient-centered? Has it been clinician/physician centered? Or revenue centered? Or just intentionally confusing and impersonal care designed to stymie the adoption of evidence based standards of care?”

“And along those lines, is the widespread delivery of non-patient-centered care the reason why the IOM concluded that it takes about 17 years for valuable healthcare information to be adopted into clinical practice? Or why Atul Gawande found that hospitals in other countries have widely adopted surgical checklists to reduce medical errors and adverse outcomes, while only 25% of US hospitals are using these checklists?”

I’m just asking….

Health Law Is Reforming System Via Market Forces

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All the controversial rhetoric about the new health reform law is missing a huge reality:  The law is driving dramatic changes in the real world.  Almost every major health delivery system is preparing to reorganize how they provide care to hundreds of millions of Americans by becoming Accountable Care Organizations (ACOs).

Health Systems are Voting With Their Wallets
The magnitude and level of financial interest in ACOs – and proof that it is not just cautious planning – were dramatically illuminated by recent actions and a Washington Post article:

  • On Thursday, HHS released the long anticipated proposed rule for ACOs and Medicare “Shared Savings.” For the rest of the day the Federal Register’s website was nearly shut down by people trying to download the 429 page document.
  • Today’s Washington Post article, “Complicated health-care law leads to payday for consultants,” includes figures about the tens of thousands of dollars consultants are charging for strategy sessions about how to think about ACOs, and the millions of dollars in fees they are getting for actually helping health systems to become ACOs. Health systems were signing consultants up for these engagements before the draft regulations were released because of their expectations of how dramatically competition among ACOs will change their financial incentives and structures. And some of the phrases in the article highlight the level of importance being placed on ACOs: “ACO frenzy,” “Oversubscribed,” “Glittering high fees” and, “I have never seen anything quite like this in my 35 years in this business.”

Bottom Line
I could write more about the proposed ACO rule, my interactions with health systems looking to become ACOs (and the organizations helping them), and how ACOs will very likely produce significantly more savings for Medicare than the Congressional Budget Office has projected, but the bottom line looks like this:

  • ACOs are happening.
  • The Medicare ACO/Shared Savings rule will shape their form, but not their creation.
  • ACOs – and their quality/efficiency incentives payments – will fundamentally transform health care in the US.
  • This transformation will be like an avalanche as health systems compete locally to demonstrate how much more Accountable they are to patients and payers, i.e. how they provide higher quality at lower costs than their competitors down the street or across the river.
  • While the official title of the new health law is the “Affordable Care Act,” it very easily – and perhaps more accurately – should have been called the “Accountable Care Act” because it is that part of the law which will actually lead to more affordable care for more people.

As always, stay tuned and keep your seat belts tightly fastened for the upcoming wild ride. Like a roller-coaster, the fun is just beginning.

Roller Coaster

US Healthcare Spending – 2009

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With all the focus on US health spending I thought it would be useful to update the pie chart I’d posted previously that showed 2007 and 2006 National Health Expenditures.  So below is the chart showing US health spending for 2009.


US Health Spending 2009

What can be seen by comparing this chart with the previous ones is that the percentages haven’t changed very much.  Which means that the foci for cost containment still needs to be on hospitals and physician services and how they influence other types of spending.  For example, avoiding hospital admissions, and utilizing clinical services provided by non-physician professionals, etc…. More on this to come in future posts.

Rise of the Tea Party Machine (and I Am Back)

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Interpreters of the recent election results have been pointing fingers in many directions about alleged successes and failures of policies and messaging. Having run a consulting business for more than 10 years I see a parallel between how people vote and how people and organizations making hiring decisions.  That is, people voting for their elected officials are essentially making decisions about who they want to hire to run their government.

Politicians certainly want the people who voted for them last time to vote for them the next time.  This is a fundamental tenant of business success, i.e., getting your current clients to become repeat customers.  In business, a sure fire way to make a customer happy and come back is to over-deliver.  This is easier if you can also under-promise, but that’s not always possible if you’re competing with others for the same customer.  Which is why politicians almost always go the opposite way, i.e. WAY over-promising in an attempt to outdo their opponents, while also using negative messages to undermine the credibility of their opponent’s promises.

The result is that elected officials, (and by extension “government”), WAY under-deliver on their promises.  This has been true for almost every elected official, with a few  exceptions whose over-delivering was generally not due to their own actions.  (For example, the budget surpluses at the end of the Clinton Administration were largely due to a booming economy, which may or may not have had that much to do with the Administration’s actions.) And in situations where governments do deliver on promises, actions often takes longer than people think they should.  (In fairness to government agencies and officials, this is because rules for transparency and accountability require lengthy processes for implementing new programs or changing existing ones.)

Under Delivering = Political Upheavals
Over the past 10 years, perceived under-delivering has driven dramatic swings in elections. At the most fundamental level, economic and employment downturns and sluggish improvement drove Obama into office and the Republicans into control of Congress. And because it became apparent that neither party seemed able to deliver on their promises for actual economic recovery, the Tea Party has risen as a “plague on both your houses” solution.

Whether the Tea Party will survive and flourish in our political system, be assimilated, or wither and die remains to be seen. The actual outcome will likely depend upon the state of the economy, job growth, and the military situations in Iraq and Afghanistan over the next 2-6 years – as well as how the Democratic and Republican parties shift their own actions and communications about their promises.  (Although I highly doubt any politicians will start under-promising as a strategy for then being able to show how they over-delivered.)

Whether the Tea Party Machine comes to resemble Terminators, Cylons, or Borg will be determined by their own actions and the economic and political environments in which they will be competing. But what does seem clear is that if the economy and employment don’t improve then voters will continue to look for new alternatives to those who have a track record of over-promising and under-delivering.  Businesses that do this don’t last long and get pushed aside by innovators who can deliver.  Will that happen in the political marketplace?  Only time will tell.

What This Means for Health Reform
The resurgent Republican party – in part fueled by the Tea Party movement – has promised to dismantle, defund or repeal the health reform law as it’s being implemented.  But some of the specific components – particularly the basic insurance reforms – are generally liked by people on an individual basis… once they understand what they are. In this instance the Republicans have put themselves in a tough position, because if they actually deliver on their promises, they may find that people aren’t very happy with the results, i.e. no increased assurance about their ability to get or maintain health insurance. So if philosophy and a commitment to fulfilling their promises trumps political wisdom, whatever they can undo they will. But if they seek to maintain their political momentum, they will be best served by undoing or stopping only those provisions that don’t have popular appeal and/or are not fundamental to improving the security people have about their health insurance, such as the 1099 reporting requirements.

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p.s. Sorry to have not posted in so long.  I’ve been busy helping a community in the Midwest launch a community-wide multi-stakeholder initiative to transform health delivery and financing in their region. Very interesting work and a great real-world implementation of what I and others have been writing about for many years.  More on that later – and I promise to write more soon on specific health issues.  Best Wishes, M

Implementing Health Reform – The Long, Hard and Twisting Maze

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Health reform is now the “law of the land,” and “written in law.”  However, as people are quickly realizing, after a year of campaigning and more than a year of legislative action, implementing the new law will require navigating a long, difficult, and twisting path – even before any amendments are considered in this or subsequent Congresses.

Navigating the fast and slippery route to successfully implementing all the provisions of the PPACA will be daunting.  Three relatively recent laws are examples of the time and steps required for such implementation – and each of these was much simpler than the PPACA:

  • The Medicare Part D law was signed in December 2003 and the new benefit started in January 2006. This gave the Federal government about 2 years to develop the rules, sign up providing plans and facilitate enrollment by creating an exchange-like website and other resources, while the plans conducted the actual enrollment.
  • The Massachusetts health reform/insurance expansion law was enacted in April 2006. This was followed by a long series of staggered implementation steps. For example, insurance reforms, (on top of the state’s pre-existing significant insurance regulations), became effective in January 2007, and the new individual mandate started in July 2007.
  • The Federal stimulus law was signed in February 2009, and the HITECH Act part of the law included significant provisions and funding to boost the development and adoption of information technology by healthcare providers.  At the end of December 2009 a key draft rule on “meaningful use” was released, and it is expected to be finalized soon.  In the meantime, the Department of Health and Human Services has distributed funding to start the adoption of specific types of health IT.  (The April 2010 Issue of Health Affairs has a series of articles focusing on the implementation of the HITECH provisions of the stimulus bill.)

Written in Law – Not Written in Stone
The  implementation of these laws illustrates how it takes months and years after a law is signed to create the implementing rules and regulations, and to contract with organizations to actually carry out significant parts of the new law – and this is before any modifications are made by subsequent laws.

In the coming weeks and months, many entities will continue combing through the final law – which because of the circuitous path it took to Congressional passage is much more difficult to read and understand than most other new laws.  Some of the most challenging aspects of implementation will be in the states, where government agencies will have many new responsibilities and/or will need to be created. Federal and state governments, and many private organizations, will also probably need to hire people to carry out this implementation – and hiring government employees can be a lengthy process.

In addition healthcare companies – particularly health plans and insurers – will be working to determine how their business operations will be affected by new state and Federal regulations, despite the fact that those regulations haven’t been written yet.  And all but the smallest businesses will be seeking to understand how they will comply with – and possibly benefit from – the new insurance rules and financial incentives.

Overall, it is clear that the implementation will be the hardest part in taking health reform from a concept and a campaign position, to reality for individuals and society.  I know that many people in Washington DC – particularly Congressional, HHS and related health reform staff – worked very hard for many, many months in an exhausting process to get the law passed.  For Congressional staff at least, the implementation will be the responsibility of others, while Congress’ work will be to ensure that this implementation is consistent with their intent, and to work with HHS to adjust provisions according to the real-world bumps and detours in the road from here to there.

Conclusion
The cartoon below summarizes the expanding and complicated challenge of implementing health reform through the inevitably twisting and complicated path better than any combination of words could… I’ll have more about specific provisions and implementation in the coming days, weeks, and months….

MAZE-Man

Politics of Health Reform: Selling Anger or Catharsis

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With the health reform legislation process winding up, it is clear that going forward politics are – and will be – front and center, with the divide between the Democrats and Republicans as wide as the orbit of Pluto…… the planetoid, not the Disney character. This divide is depicted in black, white, and red in the National Journal’s March 13th Insiders Poll question, “If Congress enacts something close to President Obama’s latest health care reform plan, how would that affect your party in the midterm elections?”  87% of Democrats thought it would “help a lot” or “help a little,” and 100% of Republicans thought it would help them.

They can’t both be right.

Each party is banking on their ability to sell health reform their way:  Democrats will present it as a significant step towards fixing many of our healthcare system’s and country’s problems.  Conversely, the Republicans will characterize it as fundamentally evil and something that will end individual freedom and civilized progress because of “government takeover of healthcare” being run by a “healthcare czar.”

These sentiments and strategies are clear in the quotes accompanying the National Journal’s poll:

Republicans:
“The tax increases, the wild spending, and the backroom deals and threats will shock voters of all parties, producing a GOP revolt.”

“Passing the bill will help the GOP by fueling voter (especially senior) anger at an arrogant majority that knowingly ignored popular opinion.”

Democrats:
“It will help a lot of people, show that Democrats can act, and get the ‘sausage making’ off the news.”

“If it passes, people [will] see it’s not the end of the world and learn more about its benefits. The more they know about it, the more supportive they are.  Best of all, we can begin talking about something else.”

However, one Democrat in the 9% who thought enacting the law would “hurt a lot” said, “The Right hates it, the Left is not satisfied, and the middle is scared.”

Majority v. Minority – Catharsis v. Anger
 Without dissecting the merits of their positions, these divergent perspectives are due to the parties’ different roles in our two-party democracy:  The majority needs to present their actions in a way that fosters catharsis in people, (particularly in voters), by actually improving some problem. Their goal is to turn that catharsis into positive feelings about the majority party, leading to votes in future elections. Conversely, the minority party needs to create anger about what the majority party is doing or proposing, with the goal of turning that anger into….. (no surprise here)…… votes in future elections.

Thus the key for the party leadership, individual elected officials, and their communications and campaign staffs, is how to best create catharsis or anger – depending upon which side of the fence they are on.

An old friend, Dan Wasserman, the political cartoonist for the Boston Globe, in his March 2nd cartoon depicted this very nicely:

Dan Wasserman Political Cartoon - 03-02-2010 Romeny Anger
[This cartoon was also reprinted in the March, 6th issue of National Journal]

Challenges of Political and Policy Communications
How people, (i.e. voters), perceive the issues and problems – and potential solutions – is strongly influenced by how they are presented and described.  It is this communications process that builds or derails political and policy initiatives and campaigns.  No matter the long-term success or failure of the health reform law, the road from now until the November elections will be filled with messaging to instill voters with either catharsis or anger – particularly swing voters in key states and CDs. For the Democrats, creating cathartic feelings will be much, much easier as specific provisions of the law become effective.

For Republicans, creating anger will be possible from the outset. In the near term having a new law will give them a focal point for anger, with proposed regulations and rules being easy and rich targets.  In the longer term, as the new law actually improves many people’s lives, it will be harder to accomplish that goal.  However, by that time, if they can use the near term anger they’ve created to take control of one or both houses of Congress, or the White House, as the majority party they will be the ones trying to create catharsis – so some successes via implementation will be to their benefit.  In addition, if that happens, for political reasons Republicans will not want to repeal or significantly unravel the new law since continued implementation of health reform – without dramatic alterations – will deny Democrats one of their main campaign issues that they have historically used to generate anger among their base and swing voters.

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Post Script: Turning Anger Into Productive or Destructive Action
[Omitted for space considerations.]

How Long is the New Health Law?

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With the House of Representatives passing the Senate’s version of the health reform legislation tonight, it can now be signed by the President.  An historic step by any measure. While one of the criticisms leveled against the bill has been its length – typically cited as 2,409 pages – I recently pointed out to someone that the 2,409 page length is because the bill is printed to make it easy to read by using a large font, leaving lots of space between the lines, and sequentially indenting subsections to make the overall structure clearer.  (Below is one page from the printed version of the bill.) However, by changing the font and reformatting it, I was easily able to make the entire bill fit on 60 pages.

So how long is the bill? It all depends.  But certainly the 2,409 page length “fact” – and similar figures – will be tossed around as pseudo-quantitative arguments that the new law is too complex, which will be another example of fun with facts in support of political positions.

Page 448 of Health Reform Bill