In July 1988, Congress passed a bill capping older people's out-of-pocket costs for catastrophic health care at $2,000. Opinion polls showed that the majority of older Americans supported it. Yet a year and a half later, a humiliated Congress repealed the bill in reaction to a fierce wave of protest from older Americans over the higher Medicare premiums needed to defray the cost of the cap.

Last year, supporters of the Clinton health care reform bill, buoyed by an initial wave of public support, suffered an even worse defeat, one that hurt the administration's political fortunes and also failed to win badly needed reforms of the health care system.

What is it about health care reform that causes our political leaders to stumble so badly? Why does the public seem so supportive at some stages of the reform process while at others public support vanishes and even turns against the reformers?

Dozens of explanations have been advanced for the fall of the Clinton health care reform plan. But I believe that at bottom, like the catastrophic care bill, it fell victim to a massive failure of public deliberation -- a lack of dialogue that seduced leadership into misreading the public and caused the public to mistrust the leadership. A similar failure threatens the debates about crime, immigration, welfare reform, education reform, racial politics, and other urgent social issues.

 

Dialogue of the Deaf

For some years now, the nation's leadership class and the public have been carrying out a bizarre dialogue of the deaf. Leaders have little trouble conversing with each other. Their dialogue amongst themselves is robust and constant, finding expression in countless conferences, workshops, meetings, and forums. But when it comes to engaging the public, the lack of genuine dialogue is lacking. Leaders have no trouble talking to the public. Mechanisms of top-down communication --TV appearances, punditry, advertising, spin-doctoring, so-called "public education" -- abound. What is missing is any real give-and-take between leaders and the public. The public and the leadership class simply do not seem able to converse with one another in a fashion that makes productive public deliberation -- the life-blood of democracy -- possible.  Clinton's health care reform plan was not shaped by discussion with citizens about rising health care costs and what to do about them -- the public's main focus of concern. Rather, it was the product of experts and leaders alone. Technical experts designed it, special interests argued it, political leaders sold it, journalists kibitzed it, advertising attacked it. The public served merely as confused spectators, never directly engaging the Clinton reforms, good or bad, right or wrong, and never understanding the specifics of the plan and its implications for their lives.  The opponents of the Clinton plan found it pathetically easy to raise fears about reforms the public did not understand. To fill the vacuum left by the public's lack of knowledge and deliberation, opponents conjured up a nightmare: the prospect of ever more  impersonal "cattle car" care, regulated by the federal government, with higher out-of-pocket costs for medical care, higher taxes, less choice, lower wages, and increased unemployment.

From the point of view of organized interests -- the insurance industry, the pharmaceutical companies, the trade unions, the business corporations, the medical profession -- there may have been a debate. From the point of view of warring factions in Congress, there may have been a debate. From the point of view of the administration, its friends and opponents, there may have been a debate. But from the point of view of the public, there never was an opportunity to deliberate between alternative choices and to engage the Clinton plan in all its virtues and shortcomings. As far as the public is concerned, the great health care debate of 1994 never took place.

From the point of view of organized interests -- the insurance industry, the pharmaceutical companies, the trade unions, the business corporations, the medical profession -- there may have been a debate. From the point of view of warring factions in Congress, there may have been a debate. From the point of view of the administration, its friends and opponents, there may have been a debate. But from the point of view of the public, there never was an opportunity to deliberate between alternative choices and to engage the Clinton plan in all its virtues and shortcomings. As far as the public is concerned, the great health care debate of 1994 never took place.

 

Unrealistic Expectations

To understand why the public ultimately rejected the Clinton health care plan without ever having seriously deliberated, one must grasp the mindset of the public when the president formally presented his plan in September 1993. Concern with rising health care costs had been growing for years, and people had long been trading horror stories about outrageous hospital bills and insurance companies taking away coverage just when it was most direly needed. The public was mindful that many Americans had no health insurance whatever, and a majority felt this was morally wrong. The appeal of health insurance that can never be taken away and of achieving universal coverage while simultaneously controlling health care costs was enormous. The president's speech heightened expectations that were already unrealistically high and set the stage for the letdown that followed. Several weeks after the speech, polls showed a margin of almost two to one approval of the plan (57 percent to 31 percent). But the following July, approval had slowly melted down to minority status (37 percent). Six public preconceptions about health care --some of them contradictory -- were responsible both for the initial positive public response to the plan and for the subsequent disillusionment.

1. By margins of more than three to one (margins that had held for more than 50 years), Americans had come to believe that health care is a right and that it is the government's responsibility to honor it.

2. Again by overwhelming margins, Americans expressed high levels of satisfaction with the quality of the medical care they and their families were receiving and their access to it.

3. A majority nevertheless felt that rising costs were undermining the medical system, creating a crisis.

4. The public placed the blame for rising costs squarely on "greed" and "waste" in the health care system: hospitals, lawyers, physicians, and drug companies. Since it blamed greed and waste for the rising costs, the public understandably rejected calls for sacrifice and change of behavior on its own part. That perspective put it on a collision course with most experts. Experts see the two main causes of rising costs less in terms of greed and waste and more in terms of an aging population (the main consumers of health care) and the explosive costs of new medical technologies. These are problems whose solution necessarily entails some sacrifice on the part of the public ~ either helping to pay for the higher costs or forgoing some services, or both.

5. Americans were unrealistic about solutions. They assumed it was possible to reform health care mainly by cracking down on waste and greed, and then use the savings to add health care benefits at no extra cost.

6. Finally, during the early 1990s, Americans felt the need for reform with particular urgency because of the recession. Fears of losing jobs spilled over into concern about losing health insurance, making health care the number one or number two public priority according to polls.

Thus, when the public listened to the president announce his plan, they did so with high hopes and unrealistic expectations. They expected government to exercise its responsibility to ensure high-quality health care for all Americans, to make sure people would not lose their health insurance if they lost their job, to control or reduce costs so that insurance premiums did not keep rising, to protect quality and access, to encourage the miracles of modern technology, and to do it all by wringing waste and greed out of the system, not by raising taxes, except, perhaps, for some modest sin taxes on tobacco or alcohol.

The president's address reinforced these views, but left people short on specifics. The week after the president's address, polls found, not surprisingly, that only 21 percent of Americans felt they knew a lot about the plan. But as time passed, strangely, fewer people felt they knew a lot about it: in October, 17 percent, in November, only 13 percent. By August 1994 a Harris poll showed that fewer than one in five Americans felt well informed about the debate in general (13 percent) or about how various reform proposals would help them and their family (15 percent).

What little people did learn about the plan had shaken their assumptions and planted a worrisome seed. In response to an October 1993 Washington Post poll, more people suspected that the plan would worsen their health care than improve it (34 percent as against 19 percent). It did not prove difficult for the plants opponents to nourish the seeds of doubt.

 

Why the Failed Dialogue?

The main purpose of public deliberation is for people to come to grips with reality. This has not yet happened to health care. Americans continue to believe that when it comes to health care, they can have it all -- quality and convenience and high-tech medicine and lower costs. Polling data show that most Americans do not understand the extent to which their own habits and demands contribute to health care cost escalation. They do not realize the extent to which an aging population, scientific advances, and the existence of a cost system that systematically hides the total costs of health care from consumers are driving health care costs. They do not understand what sacrifices and benefits each health care choice entails, or the need to make sacrifices.

When serious public deliberation is absent, the public is said to be in a state of "raw opinion." As people deliberate an issue, they begin to feel more knowledgeable, their opinions grow firmer and less volatile, their views become more coherent and less contradictory, and, above all, wishful thinking is replaced with more realistic choice making. The surest sign that people have reached genuine deliberative judgment is when they are fully cognizant of the consequences of their opinions and take responsibility for them.

It is sobering to realize that for all the debate about health care reform, public deliberation on the subject is still in an early stage, having progressed very little beyond the raw opinion stage.

Public realism -- the willingness to abandon wishful thinking in the interest of solving the nation's problems -- is the end product of serious deliberation; deliberation, in turn, is the product of dialogue. What accounts for the spectacular failure of dialogue on health care and so many other important issues?

I believe the fault lies with leadership, including both inappropriate leadership attitudes and inappropriate leadership skills. Inappropriate attitudes are more fundamental. If the attitudes change, the skills will follow.

The inappropriate attitudes are part of a phenomenon that Kettering Foundation President David Mathews calls a "culture of professionalism" -- a growing gap between professionals and public that is rapidly creating new, invidious social class distinctions between elites and the general public. Anthropologist Clifford Geertz has noted in his own profession a "me-anthropologist-you-native" outlook that unwittingly and automatically converts the subject of study into an object of study, depersonalizing the relationship in the process. Today, professionals in all fields -- "me-journalist-you-Joe-six-pack," "me-surgeon-you-brokenhip-in-room-360" -- have the same outlook. They take for granted that a certain distance separates them from their subjects, thus creating an invisible barrier between them. Leaders see themselves as elites who do things for "the people." The people, placed in the role of those for whom things are done, grow passive and unrealistically demanding, abdicating their responsibility for their own lives. The relationship between leaders and citizens inevitably deteriorates, with citizens constantly nagging at government about their rights, while government officials, tiring of incessant public demands, respond by growing more secretive, more cunning, and more manipulative.

Not surprisingly, the professional's view of communication with the public is a one-way, top-down affair. The goal is to elevate public awareness of an issue by imparting some tiny fraction of their own expertise. Ignoring the lifetime of prejudices, convictions, personal experience, and preconceptions people bring to public issues, they wrongly assume that the public is a tabula rasa on which one can write whatever message one wishes to convey. More often than not, however, people react to leadership messages in ways that diverge wildly from the intentions of those conducting the public's so-called "education."

Policymakers do not communicate that way among themselves. With each other they engage in dialogue, gain mutual understanding, grasp pros and cons as well as likely consequences. Often the process goes on for years. But when it comes to communicating with the public, the emphasis is no longer on the give and take of dialogue, the probing of choices, mutual understanding, and taking whatever time is necessary to understand consequences. It is not unusual to hear leaders speak blithely of the need for "education campaigns," one-way monologues that expect the public to grasp virtually overnight what they themselves took years to digest. The public's voice is heard only in opinion polls and talk radio and in the distorted representations of special interests.

Relying unduly on opinion polls, leaders never develop the skills that come with genuine public dialogue. In the initial stages of dialogue, people rarely express themselves clearly. They need to vent their frustrations before they face reality. Frustration about unreasonable hospital bills may first emerge as ranting and raving about greed. Only after they have vented their frustration are people ready to settle down into rigorous deliberation.

In opinion polls, people say "yes" to proposals to which they haven't given an iota of thought, simply out of a sense of urgency that something be done.  They do not literally mean what they say. But the public's cranky sounding-off is translated into numbers in an opinion poll, giving the appearance of being "scientific," and political leaders who would never be misled in a real conversation swallow the results. Worse yet, they act on them.

To engage the public in dialogue, leaders must move beyond reacting to opinion polls. They must learn how to engage a worried citizenry in serious discussion on how to allocate limited resources. And they must discuss these matters with the public as equals, not as superior professionals condescending to impart information to an ignorant public. The dialogue must be genuine. The leadership has to be willing to listen and to change in fundamental ways as well as the public.

 

A Strategy for Public Dialogue

Merely announcing, as the Clinton administration did, that a public debate will take place on health care does not make it so. For a genuine debate to happen, a strategy must be devised to deal with the public's wishful thinking and with leadership's blind spots. Such a strategy will have two elements, one that focuses on the substance and sequence of health care reforms, the other on managing the public deliberation process.

Because a nation's health care system must ultimately reflect its deepest values, the American people must play a key role in shaping theirs. Perhaps as a nation we really are willing to consume a far larger proportion of our GDP on our health care systems than other nations are on theirs. Maybe we are willing to sacrifice other good things to try to save the lives of "preemies" and to follow every possible technological lead at public expense. But we won't know what we truly value until and unless we confront the reality that pursuing these objectives means abandoning others that may be of equal or greater importance to our society. All the hard choices, however, can't be dumped on the public at once. What choices is the public prepared to deliberate and in what sequence?

In the aftermath of the Clinton plan's defeat, a number of reform ideas are floating around Congress. One is to reform insurance to make it easier for people to carry their health insurance from job to job and harder for insurance companies to blackball people with so-called preexisting conditions. Another is to encourage states to experiment more freely with various reform packages. Another is to start to curb some of the legal excesses that cause physicians to practice costly defensive medicine.

The public embraces all these reforms. All are more complex and expensive than many of their proponents admit. And most arouse special interest opposition. Nevertheless, some of these limited reforms are likely to be enacted since none demands sacrifice on the part of the public or major changes in behavior, and so do not presuppose the need for further public deliberation. We can therefore expect this Congress or the next to pass an incremental health care bill embracing at least some of these changes.

More fundamental changes must wait on public and leadership willingness to enter into more serious deliberations. Where public deliberation is urgently needed in the future is on the consequences of the fact that the American people demand more medical care than they are willing to pay for. This demand places immense strains on the health care system. As Americans age and as technology expands, the desire of people to take full advantage of the benefits that modern health care offers grows ever stronger. The question is how best to accommodate this desire without sacrificing competing public needs.

The central issue in health care reform is how to manage the growing supply of health care benefits created by technology in the face of insatiable public demand. Which aspects of health care should fall under the rules of the market where people get only what they pay for, and which should fall under the rules of entitlement where people receive health care benefits as a matter of right whether or not they can pay for them? I believe we can best make ourselves ready to confront these fundamentals by debating the dilemmas of health care reform in a sequence proposed by two research organizations that have been studying the public's relation to health care.

 

The Public Agenda-Kettering Plan

Research by the Public Agenda and Kettering Foundations indicates that the public has not yet confronted three major health care reform dilemmas, each increasing in difficulty.

The first is how to retain and improve the health care benefits of those who now have health insurance, extend some of these benefits to those who now lack insurance coverage, and at the same time keep public costs under control and preserve the vitality and competitiveness of the economy. The dilemma is how to balance the desire for expanded insurance coverage, now provided by employers and government, without placing a crushing burden on those who foot the bill either employers or taxpayers.

The second dilemma, a more painful one emotionally, concerns the desire to curb the growth of health care costs and at the same time continue to enjoy the benefits of advancing technology. Medical experts are accustomed to heated debates over new technologies whether, for example, to use a clot-dissolving drug that is marginally more effective for some patients but costs in excess of $2,000 a dose, ten times more than existing treatments. But average Americans are not ready yet to wrestle with these kinds of decisions.

The third dilemma, the one Americans are least ready to confront, is the conflict between reducing costs and doing everything possible to save lives. Americans are ill-equipped, both mentally and psychologically, to participate in decisions that involve rationing in life and death decisions for example, the recent surgery in a Philadelphia hospital that separated Siamese twins, one, as expected, dying immediately, the other given a 1 percent chance to live, at a cost to taxpayers of hundreds of thousands of dollars.

A successful deliberative process on all three of these dilemmas, considered in sequence, will take at least three to five years and will call for real leadership skill. It should not be assumed that the outcome, if successful, will be confined to laws and government regulations. Individual and private sector decision making will be decisive. When average citizens are obliged to make life and death decisions for their loved ones routinely under circumstances charged with anxiety and feelings of incompetence and helplessness, the private sector rather than government, and the medical profession rather than individuals must assume most of the responsibility. But the public must participate in these and other wrenching decisions as consumers, employees, and citizens. And the government must play an important role in those aspects of health care deemed to be rights that cannot be decided solely on the basis of ability to pay.

 

The Deliberative Process

In my book, Coming to Public Judgment, I describe seven steps through which public deliberation on any complex issue must proceed to be successful. Where does public discussion of health care reform fall in terms of these seven steps?

Americans first began to be aware of the problem of swelling health care costs during the mid-1970s (step # 1); they began to feel the urgency of the situation during the recession of the early 1 990s (step #2); and they began to react by paying heed to proposals for reforming the health care system during the presidential election of 1992 (step #3). President Clinton's 1993 proposal to guarantee health insurance that can never be taken away helped move the public into the fourth stage, resistance: the public began to confront its own wishful thinking, preparing the way to acknowledge that attacking waste and greed alone is not the panacea that will magically solve the problem of guaranteeing quality medical care while controlling costs.

Today, the public remains stalled at the stage of resistance (step #4). In every important area of health care that requires citizens to make sacrifices or accept real change, the public has been unable to take the fifth step, "choicework," where people, having overcome their wishful thinking, deliberate realistic policy choices and wrestle with their pros and cons.

Needless to say, the public is far from reaching the two final stages of deliberation in which people reach tentative conclusions (step #6), largely cognitive in character, about the appropriate policy choices, and the final step, judgment (step #7), where they add strong elements of emotional and moral conviction to their cognitive conclusions.

To engage the public in successful deliberation, leaders must abandon the failed top-down model of communication. The techniques on which professionals have relied for so long the lawyer-like debates that take place in Congress, the "packages" of policy-wonk information whose consequences for the public are not clearly spelled out, the media-based campaigns of public education that fail to take into account the public's need to reconcile conflicting values do not advance serious public deliberation.

If the nation's leadership can reach out to the public, transcending the divide caused by its own "expertise," and if it can acquire the skills needed to engage the public in a genuine dialogue on health care reform, it may in the process find ways to bridge the larger disconnect that extends beyond health care to so many issues distressing the nation. If we are able to resolve our health care dilemmas and learn to engage in fruitful public dialogue at the same time, our democratic process will be the winner.