By Kim Krisberg
We're talking about it all wrong. Health reform, that is. We (reformers) think we're answering the questions that will change opponents' minds, when there's no answer that will ever satisfy. My head hurts just thinking about it (though a giant, energy-efficient light bulb flickered on over my head after I thought about it a bit.)
In essence, how do we talk about public health values? That was one of the main -- and I think most interesting -- topics at the American Public Health Association's Midyear Meeting in Chicago in late June, which focused exclusively on "Implementing Health Reform: A Public Health Approach." The three-day gathering, which welcomed more than 600 public health practitioners, zeroed in on the public health and prevention provisions of the health reform law, especially its landmark investment in prevention via the $15 billion Prevention and Public Health Fund, money from which has already begun flowing to states to boost community health efforts and target the root causes of poor health and disease. (These root causes are commonly known in public health circles as the social determinants of health, i.e. the social and environmental factors that determine a person's risk for disease.) For many in public health, the prevention fund is acknowledgment that good health happens both inside and outside the doctor's office.
The meeting was an impressively interactive event, where attendees discussed ways to ensure that health reform results in both access to affordable health insurance and better health outcomes, an indicator of success that is consistently and unfortunately missing from our national debate. (For more on the Prevention and Public Health Fund with specifics on where the money is going, check out this report from Trust for America's Health). In fact, some positive outcomes have already materialized. For example, meeting speaker Caya Lewis, chief of staff at the Centers for Medicare and Medicaid, reported that more than 5 million Medicare beneficiaries have taken advantage of free preventive services because of cost-sharing changes authorized under health reform -- a full accounting from CMS is here.
But back to language. How can public health practitioners help protect this new prevention fund and its support of community health efforts? How can they make their case?
Celinda Lake had some answers. Lake, president of Lake Research Partners, addressed the meeting's opening session with a presentation on the "Public Health Context for Reform." The good news, she said, is that polling shows that the public overwhelmingly supports community prevention, even though they're not entirely sure what that entails. When taxes get mentioned, support starts to wane, though it's still above the 50 percent mark. Lake noted that people prefer to talk about prevention in a context that involves both community prevention and individual responsibility. Here's the exact recommendation from her PowerPoint presentation, which struck me as a powerful call to action: "Frame the overall goal (of community prevention) as making good, healthy choices easier. We can bridge the values of individual responsibility and collective action by framing this as a matter of individual choice that the community can play a role in making easier."
And in a time when suspicion of government seems so high, that makes such perfect sense. People want the government to invest wisely, but they don't necessarily want it to reach too deeply into their personal decision-making. So, framing the prevention discussion around ways to make healthy choices easy, accessible and affordable would strike a good balance and tip a nod to individual responsibility. But is it enough to tip the scales in favor of public health?
Well, today's public is a tough crowd. Even with all the facts on the table, the debate over health reform rages on.
"We believe deep down that the facts will set us free and that data will win the day," said Lawrence Wallack, dean of the College of Urban and Public Affairs at Portland State University and a speaker at the midyear meeting's closing session. Unfortunately, facts matter much less than we'd like to believe.
For example, Wallack said, health reformers have taken on the issue of controlling costs -- and for opponents of reform, there can be no better discussion. Confused? Here's the catch: Reformers think they'll find an answer that will finally satisfy opponents, when the only answer that will satisfy them won't even solve our health care problems. And so "reformers are trapped in their own question," Wallack said.
Opponents, on the other hand, are occupied with entirely different questions, like what role government should have in our lives and whether the new law will impede our freedoms. And in an argument of costs vs. freedom, freedom wins, Wallack said. (This is when my invisible, energy-efficient light bulb switched on. Of course! Why are reformers framing their side of the debate to elicit a logical response, when opponents are framing their side to elicit an emotional response? We're not even playing on the same field. And even though many people will respond positively to the data-driven argument, the emotional argument will always be louder and attract more attention.) As Wallack said, the debate "pits fear and resentment against hope and trust."
America, Wallack said, has two languages: First is the language of rugged individualism and open markets, and second is the language of community, of shared responsibility and social solidarity. And while the language of community may be America's second language, it's the first language of public health. So, where do we go from here?
First, Wallack said we need to start making big picture arguments about what kind of country we are and what kind of values guides us. The real issue is how do we define fairness? It's about what words mean, not what words we say. Brilliant!
"This is about who we are as a people," Wallack said. "Each of us needs to speak our values so that others understand that our well-being is rooted in the community that we all create together."
Check out APHA's YouTube channel for video coverage of this great speech and many more from June's midyear meeting.
Kim Krisberg is a freelance reporter living in Austin, Texas, and has been writing about public health for almost a decade. While her education is in journalism, her heart is in public health.
I read a discussion today about how American politics takes two approaches to making laws: proclamations or policies. The proclamation camp views law as a moral statement of what is best (think Prohibition or Emancipation). The policy camp views law as a means to shape society to be a better place (think traffic laws). I think one problem that often arises in public health discussions is that the Proclamation camp thinks simply stating a moral imperative will fix things while a great many public health experts are in the Policy camp (and the evidence is generally also there, that making legal changes benefits people in a way overarching moral statements don't) for good reason. But this article is also right on the button - public health advocates need to use sweeping moral change language too to captivate rather than getting into the policy details that create immediate, gut level disapproval in so many.