Selling Health Reform: A Work in Progress

William A. Galston
Bill Galston
William A. Galston Ezra K. Zilkha Chair and Senior Fellow - Governance Studies

September 10, 2009

As Barack Obama ascended the podium to deliver his pivotal health care speech, he faced a number of key challenges: to regain control of a debate that was threatening to spin out of control, reenergizing his presidency in the process; to declare, and take ownership of, his own plan; to reunify a divided Democratic party; and to allay widespread public fears that have weakened support for reform in recent months.

In many respects, Obama’s speech met these challenges; in others, it represents only the first phase of a work still very much in progress. The president’s forceful eloquence came as a welcome contrast to the recent appearance of passivity and drift. He made a strong case for a more civil and fact-based debate— further underscored by impolite behavior from some Republicans in attendance. Anecdotal evidence suggests that many moderate Democrats will find it easier to rally around the president’s approach than to reconcile themselves to the bills the House and Senate committees have thus far produced.

It is in the area of public persuasion that most of the work remains. On the one hand, an early CNN poll suggests that the speech was well received and had moved a substantial portion of the public in the president’s direction, in part because more than seventy percent of those who heard or watched the speech felt that he had clearly stated his goals and plans for health care. (As CNN pointed out, the audience skewed heavily toward Democrats, and the positive effects of Bill Clinton’s equally well received 1993 health care speech turned out to be short-lived.)

On the other hand, it seems likely that three major areas of public doubt remain. First, one wonders whether older and retired Americans were entirely reassured by the president’s declaration that “Reducing the waste and inefficiency in Medicare . . . will pay for most of this program.” The government’s programmatic and fiscal knife is rarely sharp enough to cleanly separate fat from muscle.

Second, in response to the rising tide of public concern about the budget deficit, the president promised that the plan will not add to the imbalance, now or in the future. But at first glance, the funding sources he announced do not appear enough to fully finance the ten-year, $900 billion dollar price tag he endorsed (the White House may clarify this in coming days), and one suspects that increasingly deficit-conscious citizens sensed a gap between expansive promises and the revenues thus far dedicated to them. Recent analyses suggest, moreover, that plans that are deficit-neutral during their early years can fall farther and farther out of balance as time passes. Indeed, this is bound to happen unless health expenses grow no faster than the revenue sources dedicated to them—an equilibrium we are a long way from achieving.

Finally, modern behavioral economics confirms what centuries of political observers have claimed: fear of loss is a more powerful motive than is hope of gain. Today, substantial majorities of Americans are reasonably satisfied with the scope of their employer-provided insurance coverage and the benefits they receive from it, and they regard the costs as high but bearable. The president can and should do more to convince them that the status quo is unsustainable. The facts are on his side. In recent years, the percentage of employers offering health insurance has declined, and workers’ premiums have doubled even as wages have stagnated. High levels of unemployment are likely to persist for years to come, weakening workers’ bargaining power in the face of relentless pressure to cut costs, which is bound to affect health benefits as well as wages. To persuade wavering Americans that change is necessary, the president must convince them that to stand pat is to risk losing what they have.