Friday, June 27, 2008

Session 5: Ethical Questions in the Reform of Health and Medical Care: The Significance of the American Political Tradition

Andrew Busch, Ph.D., Claremont McKenna College

Lawrence Jacobs, Ph.D., University of Minnesota

CHAIRMAN PELLEGRINO: This morning we return to a consideration of some of the ethical issues again associated with the various proposals that are coming forth on the question of medical and health care. As I explained to our two guests, we do not have long introductions. So I'll merely introduce them by name and their location.

The title today is "Ethical Questions in the Reform of Health Care," this time looking at it from the point of view of the American political tradition. And our first speaker is Andrew Busch , Dr. Andrew Busch of Claremont College . Dr. Busch ?

PROF. BUSCH: Well, thank you very much. It's a real pleasure to be here. It's a real honor and privilege to be here, and thank you for inviting me.

Obviously health care and health care reform has had American policymakers befuddled for some time, and even public opinion is very ambivalent because Prof. Jacobs points out in one of his articles that's included in the booklet of materials, there are a variety of other polls that I could cite that show this, but suffice it to say, that Americans are ambivalent about this issue.

And so I think it's important for us to really give a serious consideration of what you might call "first principles," that is, how does this issue of health care relate to some fundamental principles of American politics and how that can perhaps guide us as we think about these issues going forward and provide maybe a more solid footing for thinking about some of these issues.

So what I'm going to do actually is think about this first in terms of the Declaration of Independence. And rather than include any essay of mine in the booklet, I just asked that a copy of the Declaration of Independence be inserted. We're all familiar with it. But I think it's always useful to take a fresh look at it and a look with an eye particularly to this issue of health care, and I think it's always a good place to start because I think the Declaration represents in a lot of ways the touchstone and perhaps the best, most concise summary of the fundamental political principles of the American republic.

So what are these fundamental principles that you can glean from the Declaration of Independence? There are really four main ones, I think, and maybe some subsidiary ones as well, but four main ones.

The first one is — and you can really see each, a clause or a phrase in the Declaration that relates to each of these. The first is equality. "We hold these truths to be self-evident that all men are created equal." Now it's fairly clear that the founders did not mean certain things by this. They did not mean this as a call necessarily to enforce material equality because obviously people aren't born materially equal or equal in wealth. And they pretty clearly did not mean that they thought that people were naturally equal in every respect in terms of propensity to hard work or intelligence or ambition or any of those things. So those things are not meant, but they did mean something pretty clear by this, and it's related to the second notion, which is that we have natural rights.

The very next clause, in fact, in the Declaration, that they're endowed, that is that all men are endowed by their creator with certain unalienable rights, that among these are life, liberty, and the pursuit of happiness. So these are people's natural rights.

Well, what is a natural right? In the view of the founders, it's a right that people have by the mere fact of being born a human being. There are rights more specifically if you look to the Lockean tradition that people have in what you might call the state of nature, before there was any government at all. Right? What sort of rights would people have if there weren't any government yet at all? And they identify these as being life, liberty. Locke says property — at the time of the Revolution, most formulations of this property — though Jefferson folded that into the concept of the pursuit of happiness. Maybe you have freedom of conscience in the state of nature. Nobody can tell you what to think. You can live your life more or less as you would like with certain rules, certain limits, according to the laws of nature as Locke would have it, and you have the right to acquire property through your own labor. These are things that you have even if there is no government. So these are the key natural rights.

The third key principle that you can glean from the Declaration of Independence has to do with the purpose of government. And that is in the very next sentence it says that to secure these rights — that is these inalienable natural rights — governments are instituted among men. So in the view of the Declaration, and I think the founders more generally, the purpose of government is to protect natural rights.

And this is related to Locke 's view and the view of others of people forming a sort of social contract, that people form governments for a particular purpose. In the state of nature, they might have a lot of rights, but these aren't always secure because people can come along and try to take your life. They can try to take your property. They can try to tell you what to do and boss you around. And there's no common judge. And so when every man is a judge in his own case, you wind up with a lot of problems.

And so people give up some of their natural rights, their right to be judged in their own case. They create a common authority. They give that power to the common authority, but only on the condition that the common authority uses its power to protect the rest of their natural rights and it actually succeeds in making those rights more secure than they would be in the state of nature.

Finally, the fourth point is consent of the governed. Right? The second clause of that sentence says that governments derive their just powers from the consent of the governed. This principle also flows from the notion of equality, that, in fact, you might be able to put a yoke on a pair of oxen and try to make them pull your plow around and so on. But when you're dealing with human beings who have equal and natural rights, you can't govern them without their consent precisely because they are equals.

There are some corollaries that are important that flow from these principles. One of them is when we're talking about natural rights, generally the founders are talking about individual liberty. They're not talking about collective rights. They're not talking about group rights. They're talking about individual liberty and individual responsibility that comes with that, and consequently you could say that there's a distinctly American notion of human dignity which is that human dignity is very much connected to the fact that people are free and that they have responsibility for the conduct of their own lives.

It is this liberty and responsibility that give people their dignity, not necessarily whatever material condition they find themselves in at that particular moment.

Limited government is pretty clearly a corollary of this. If the purpose of government is to protect natural rights, to protect life, liberty, and the pursuit of happiness, then it also isn't to do many other things. Right? The purpose of government is not in this view and the view of the Declaration or the founders in general to try to perfect society, to try to perfect individuals, to try to eliminate all social inequalities or things of that sort.

It's a distinctly non-utopian notion of the purpose of government which leads in the direction of a limited government that leads a large private sphere and a large sphere for civil society.

Another corollary is that, again, because of the principle of equality, government can use coercion. That's what governments do. They pass laws, and they try to make you obey them. Government can extract resources from society through taxes if there's consent. But it can only do these things for the common good, not for some individual's private gain.

Again, because people are equal, those who are in government or those who have access to the levers of government do not have a right to force other people to pay for their own private gain. There has to be some common purpose and some common benefit to the actions of government.

And, finally, the principle of natural equality or equality of natural rights in the state of nature also leads to a kind of political corollary of equality under the law, that once you do have government you have to have the rule of law and there has to be equality under the law.

These principles and corollaries produced a particular Constitutional structure, and it has at least a couple of major parts. One of them is that the Constitution does empower the federal government in certain respects. It creates a federal government that is more powerful than under the Articles of Confederation to be sure. And it empowers the federal government to conduct certain specified business, not, it should be pointed out, to do anything that it feels like, but to conduct a certain specified business delineated by the enumeration of powers for the common good.

At the same time, the Constitution aims very strongly to protect rights given that that is considered to be the first and foremost purpose of government. It does this explicitly through the Bill of Rights and also several provisions within the Constitution itself, but also it does this implicitly through the structure of government, particularly by trying to prevent an over-concentration of power both horizontally and vertically.

The horizontal version of this is what we would call "separation of powers," the fact that the federal government is divided between the three branches, none of which are considered to be supreme and which have the ability to check each other in certain ways. The vertical version of this is federalism, the fact that power is divided between the federal government and the state governments.

Now obviously these principles, these corollaries in the Constitutional provisions and structures that flowed out of them are subject to all sorts of debate. While Americans may generally agree in the principle of limited government, just exactly how limited is a matter of debate and there's no easy answer to that. But I think it's fair to say that in general these are, certainly if you start with the Declaration of Independence and the Constitution, the key principles of American politics.

So how does this translate to health care reform? Well, I think the place to start is by thinking about where health care and health care policy fits within the universe of the things the government does.

And the place to start there is by recognizing that at least within the framework of the Declaration of Independence or the founders' conception of natural rights, health care is not a natural right. Certainly government provision of health care is not a natural right for the obvious reason that natural rights are things that people enjoy in the state of nature before there's a government. And so by definition, government provision of health care cannot be considered a natural right in those terms.

It may be the consequence of this is, when you think about the issue, that health care and health care reform might be very important issues. They might be areas where there ought to be policy departures either incremental or radical. It may be an area where greater public attention should be focused or a greater priority should be placed than is currently the case. But it cannot be considered something that should be approached with a kind of single-minded zealousness that supersedes the other fundamental principles of American government. It has to be balanced with fundamental principles or values.

To put this another way, I think Americans want a solution to or solutions to the problems that they see in health care, but that doesn't mean that they necessarily want a solution that would do violence to fundamental principles of American political life. And so the question is, you know, how do some of these particular principles relate to health care? And there are a number of them, I think, that do.

For example, the principle of individual rights or individual choice can be related to a variety of health care issues. For example, whether or not to impose an individual insurance mandate on people: Is this consistent with individual rights or not? Perhaps or perhaps not. It depends on how you think about that issue. But certainly it has implications for individual rights that need to be taken into account.

At the biggest level, of course, there's the question of how you finance this through taxation that might impact people's property rights. And at the lowest level, the more sort of fine-grained level of health care reform, it would relate to all sorts of questions like, are people going to have a choice of health care provider? Are they going to have a choice of insurance companies? Are they going to have a choice of benefits plans? And I would argue that a health care reform that, all other things being equal, a health care reform that protects, that does a better job of protecting individual rights and individual choice is more in keeping with fundamental American principles than one that doesn't.

In a related vein, individual responsibility comes into play. Certainly, I think — I wasn't here yesterday. But having looked through the materials, I suspect that was discussed yesterday at some length.

This is also related to the question of an insurance mandate. It's related to the question of whether you allow insurance, health insurance, rates to change depending on people's health care choices and their personal behavior. And at the biggest level, there's the question of whether you make people more dependent on government or whether they retain greater responsibility for themselves.

Again, I guess I would argue that a health care reform that protects individual responsibility or that promotes it would be more in keeping with fundamental American principles than one that reduces people's individual responsibility in some important way.

I think that the principle of equality under the law comes into play, not because I think the founders would consider it a violation of equality under the law for some people to have insurance and other people not to on the face of it, but because I do think there is a certain arbitrary quality in the tax treatment of insurance with tax benefits going to employer-based insurance but not other insurance. I think that does raise a question of equality under the law that has to be grappled with.

There is, of course, a very big question of what the aggregate government cost is going to be and the aggregate level of government control is going to be, and this relates to the principle of limited government. Obviously, this is an issue that's going to come into play if you think seriously about a single-payer program. There are a variety of other health care reforms that might bring this issue into play in a major way. And what we do with the existing health care entitlements, Medicaid and Medicare, relates to this issue as well. How do you provide the services that you want to provide without completely obliterating the principle of limited government?

By one estimate by 2050, if there's no change made, Medicare alone will take a considerably greater proportion of the gross domestic product than Medicare or Medicaid and Social Security combined do today. So that raises a real question about whether the United States can remain a society that's committed in any significant way to the principle of limited government and a significant private sphere in civil society.

The principle of federalism comes into play, I think, in many of these issues in terms of how much leeway states are given to tailor health programs for their own particular needs and how much ability they have to experiment with different approaches. This would apply either to new programs or how to reform Medicaid which, as you know, is a program that states are deeply invested in and have a major role in.

There's an issue that has to do with consent of the governed, I would argue, and that is that if the nation is considering some sort of major health care reform, I would argue that the principle of consent of the governed would dictate that such a policy needs to be at least somewhat reversible. It needs to be designed in such a way that you can imagine a way to step back from it. Otherwise, you have consent of the governed in this moment, but then every future generation is completely locked in or for all practical purposes is locked in.

In fact, I have to recall back in 1993 and 1994 when President Clinton was proposing his health care reform plan and he would always insert a phrase in his speeches promoting his plan that his hope was to produce a health care program that would give a right to health care that could never be taken away. And he meant this to be reassuring, but I actually found it rather chilling because what it meant to me was, no matter how inefficient this program may prove to be in practice, no matter how regimented it may become, no matter how expensive it may become, even if it becomes catastrophically unsustainable financially, even if it becomes a complete disaster in every respect, you could never get rid of it.

And I think we have to keep in mind that, no matter how hard we try, it's very possible that any health care reform is not going to go as expected and that it's going to be important for future generations to be able to back out of it in some way.

This would argue for either a more free-market approach, which is politically easier certainly to undo — government programs are much harder to undo than the lack thereof as we've seen over the last 70 years — or it might argue for an increased government role, but in an incremental way rather than a really gigantic way that would be much harder to back out of somehow if it doesn't work very well.

And I think any health care reform has to plausibly be connected to the common good. That is, there has to be a plausible argument that can be made that there is a national benefit to this reform, whatever it is, and that it's not simply sacrificing 85 percent for the private benefit of 15 percent because then it becomes more questionable about whether it really is the use of public power for the common good rather than just the private good of some Americans.

And I think there are a couple of — these are more substantive. I think there are a couple of process points that are related to American principles that are key as well. One of them is that clearly any health care reform plan needs to be approved through an open process with full public input. I think there were a lot of reasons that the Clinton health care reform did not wind up passing. One of them was because people calculated that it was not compatible with the principle of limited government. But part of it was because many Americans concluded that it was not compatible with the expectation of a policy being developed through an open process with full public input.

Also, I think this is something that isn't considered as often, but I think ought to be. Whatever health care reform is adopted, I think if one is adopted, it needs to be implemented in a way that remains under the control of Congress rather than Congress delegating vast quantities of regulatory power to executive branch agencies. I think this is important for reasons of consent of the governed and accountability, public accountability, and I think it's important because of separation of powers.

I think over the past century, we have gotten increasingly accustomed to Congress literally surrendering large parts of its law-making authority to executive branch agencies in ways that I think are detrimental to the fundamental principle of separation of powers. And so to whatever extent any new program could avoid that, I would think that it would be more consistent with key American principles.

I would just conclude by saying that, you know, obviously health care is a very, very important issue. It affects every American, and it has to be thought of in its own right. But it can't just be thought of in its own right. It has to be thought of in terms of the broader stakes, and the broader stakes include the character of the American republic.

I think you could argue that we've developed a model in America of a free society that is unique and distinct from the social democratic or democratic socialist models of Europe with a greater emphasis on individual liberty and responsibility. As I mentioned, a greater notion of human dignity is actually related to people's responsibility for themselves, a greater respect for property rights, and perhaps a greater emphasis on opportunity than on guaranteed economic results. And I think that America has for the most part benefited from this model, and I think the world has benefited from there being a major nation in the world that offers this alternative model of a free society, and I think any time we're talking about a major health care reform or a reform this significant size of a segment of the economy in a society, there is a danger that, in fact, that uniqueness could be lost if we get it wrong. And I think that the more that we take into account these fundamental principles, the more likely it is that we will be able to avoid that and retain our distinct and unique model of a free society.

Thank you.

(Applause.)

CHAIRMAN PELLEGRINO: Thank you very much, Dr. Busch . Our next speaker is Lawrence Jacobs, the University of Minnesota .

PROF. JACOBS: Magically, my presentation is going to appear on the screen at any moment. I know that. Trusting that that is going to happen at any moment — yes? Do I have to hit something? Thank you very much.

Well, first, I want to thank you for the invitation to appear with you, and I want to praise your efforts and for the development of this commission's work.

In really thinking hard about, and searching for, and investigating and publicly deliberating about our identity as a nation, and the social union that holds us together as more than just individuals, I spend a lot of time going to conferences and reviewing papers and various publications, and these questions are often considered to be soft or kind of not really hard-headed.

A lot of the work that I see at least in the academic world and the kind of policy analysis world tends to focus on researching important but often narrow questions or trying to address more technocratic issues about how to better perfect or adjust already-existing programs. To step back and really ask larger questions about our shared values as a country and some of the ethical underpinnings of it is too often neglected, and I want to praise this commission's work and its evolution in addressing that.

Now I am not an ethicist. I'm not a philosopher. And so my focus and professional background is as a social scientist who studies public opinion, public values. For many years, twenty years, I've been doing research on health policy in politics, and that's the background I come to you with today. And I tend to be someone who finds data to be important. I'm guided by it, and it leads me often to areas of the gray between more kind of essentialistic principles.

Now as I was listening to my colleague talk about America 's values, this is certainly an important element of American society. But I think the values that we find in America are quite pluralistic, and I'm going to provide some evidence of that briefly just by way of kind of sparking some discussion. But I think those values are long-standing. They're pluralistic, and they're dynamic. There's change over time in relation to changing circumstances and conditions in the country.

There is most definitely a Lockean tradition of limited government and respect and adulation of individual rights and liberty. America stands out in a whole variety of different kinds of survey measures with regards to our support for a private-enterprise system, our belief in rewarding work and accomplishment, and there's a lot of evidence of supporting this. I'm glad to share some of those.

But there's also another tradition in America that you could describe as a kind of civic republicanism — with a small "r" — or a kind of communitarian tradition. You see it discussed in the tremendous debate around the Constitution. I was delighted to see the Declaration of Independence. If you go back to that period, the Declaration and then the Federalist Papers which we all talk about were a very important part of a debate.

There was another side of that debate, and it tends not to get as much attention and is sometimes referred to as the Anti-Federalist or you kind of go into the writings of Alexis de Tocqueville, the famous French thinker who came to America, and he marvels at this complexity of America's moral bearings and culture.

Now I want to lay out a few themes and walk through some data that I think might illustrate some of these themes. And the basic point I would make is, if you're searching for a moral compass, don't think of it as one final resting point. I would say there are moral compasses and that they are dynamic, as I said before.

Some of the multiple and competing strains in American public thought resonate and emanate from the specific policy issues. There are variations across different issues and certainly in health care, public beliefs, and also the policy debate. Public thinking does not go on as if it were public with some kind of cloistered jury. It's a very dynamic sort of process.

Now let me kind of walk through what I see as some of the main strains and bring in some of these issues in public thinking today, and then hopefully this will be a kind of a prod to a certain kind of discussion.

This is one of my favorite movies. "We've got a problem." And we don't agree about a whole lot in health care, but I think we're pretty close to a negative consensus that what we have is not doing very well. Now people will disagree on the degree of that breakdown, but there's pretty wide agreement. And, indeed, we see this in terms of public opinion data. You'll notice that top line, the big blue one. That represents the percent of Americans who say that the health care system needs fundamental change or needs to be completely rebuilt.

Now I was recently at a transportation seminar that Congressman Oberstar who chairs the Transportation Committee in Congress and, you know, they're looking at transportation, and they were showing numbers that were about half this, and they were very impressed with that and talking to us. "Well, this is very impressive, Congressman, but let me tell you what's going on in health care." These numbers and this level of concern about the health care system is unlike anything I've seen in any other policy issue, and I work pretty broadly.

And what's quite striking is some variation here, but it's within a pretty narrow band and it's pretty consistent. And I suspect if we went back before 1991 when this series begins, we could stretch it back a bit further.

And then the other, the lower line, is a series of questions that shows about 70 percent or so of Americans saying that the health care system has major problems or is in a state of crisis. The main point here is this is a remarkable degree of agreement that our health care system, to the extent that it is a system, is not working.

Now having said that, often there's a kind of ergo moment when people roll our their proposal. And I want to urge you not to equate the negative consensus with any thought of a positive consensus. My view is that we don't have a positive consensus. And, indeed, the deep agreement we have that the system is broken has become an invitation to stalemate and some very bitter polarization with very strong kinds of deeply principled views on what the right direction is.

I want to lay out four different reasons for being cautious in moving forward and thinking about how to proceed in dealing with this negative consensus. One is that there is a deep public ambivalence about what to do, and I'm going to show you a couple of different ways to think about this. I could give you some other ways.

And often, by the way, you'll see the set of numbers I'm going to show you here in a second presented separately depending on which side of the divide you're on. If you're promoting kind of a maximal individual choice model, there's one set of numbers people use. If you're promoting a single-payer sort of model, there's another set of numbers. I'm going to try to be as honest as humanly possible and present you both sets of numbers. There's obviously other numbers.

But here's the main point. When you ask Americans and try to tap their evaluations of the health care system — How is the country doing overall? How are other Americans doing? — you tend to find about over seven out of ten Americans expressing real concern about the nature of coverage and the cost of the system to other Americans of how the system is doing. When we turn and ask about what's your personal, your personal experience or the experience of your own family with regard to coverage or cost, you find that the level of concern drops by at least half.

And when we go over to quality, you'll notice right away that the level of dissatisfaction with quality is substantially lower than it is for coverage and cost. But even here, you see this bifurcation and a deep unhappiness with how the system is doing and a much different evaluation on how things are for individual Americans and their families.

In this case, we've got only 15 percent of Americans saying that they're dissatisfied with the quality that they and their family receive for health care from their doctors and providers. That's quite a statement. But there's a split identity, and this gets tied up quite often in some of the debates and discussions.

There's another important element of this kind of public ambivalence. In my view, there are two strains, and it falls from this Lockean tradition and from this more communitarian civic or public tradition that has really in some ways defined American culture.

We find consistently that when you ask about concrete government programs that address individual threats to citizens, there is substantial public support. You might think of this as a kind of operational liberalism; that is, in terms of the operation of our society and specific government programs to address what are seen as real problems facing individuals, there is an open embrace of government.

And here is just a couple of examples. Questions that ask Americans about their attitudes towards national health insurance financed by tax money that would pay for most health care services, we find consistently over 50 percent of Americans favoring that.

Here's another kind of conundrum. Most of us who study health care will tell you that the costs are high and probably unsustainable moving into the future if their current rate of increase continues. And yet Americans have a very different attitude towards it and there are some that would say, "Well, this just reflects the fact that Americans, their knowledge and their expertise, is not very good and we shouldn't be even looking to the general public for these sorts of issues.”

I think there's another issue, which is that the lexicon, the language that we use, tend to be quite different. When we talk about costs, we mean usually system costs. When Americans think about cost, they mean price and they mean household budgets. And so we find over six out of ten Americans saying that they think other Americans spend too much on health care and that the government spends too little.

Now I have a whole presentation on this whole idea, and I've got to tell you it's really hard to explain where Americans are coming from when they think government is spending too little, too little given the budget situations that we face. But there it is.

So we've got this one element that looks very much like support for a fairly liberal view. On the other hand, this Lockean tradition is very much alive. And there's consistent suspicion and opposition to direct massive government involvement. And there's a lot of different ways to talk about this. But maybe the simplest way is this nice, what we call “balanced brain” question that gives Americans a choice between maintaining the current system based mostly on private health insurance or adopting a government-run system. And what we find is that the current private health insurance system is favored pretty consistently by majorities or pluralities notable.

Now even among reform supporters, this ambivalence about the role of government is evident, and this is often forgotten. One series of questions asked Americans, "Do you prefer a government-run, tax-supported universal health insurance?" And we find that about 56 percent said yes. So then we followed it up and we asked that 56 percent, that is the reformers, “what if,” and we gave them a series of possibilities: “What if this reform that brought in national health insurance would limit your access to some medical treatments that are currently covered?” Well, among that 56 percent, you now have 64 percent saying they would oppose it. And you bring in the possibility that your choice of doctors might be limited — 49 percent are opposed — or that there might be waiting lists for some non-emergency treatments — 40 percent oppose it — or that there might be an increase in health insurance premiums or taxes, and again you see an increase in substantial opposition and concern about that.

These are all issues in which people have strong debates about whether they would happen, the degree to which they would happen. They are clearly an important element of the debate. And the only point I would make here is that when you begin to probe, even among those who are most inclined to support government reform, that there's a good deal of this uneasiness with government and the dislocation that could result from fairly comprehensive reform.

Okay. So that's one element of what I think is an important discussion about American public thinking and it's this deep public ambivalence.

I want to bring in another element, and it builds on this point that I made about being careful not think of the public as a cloistered jury that's going to come out with a verdict and then policymakers somehow are going to fall on their knees and thank the gods for showing the direction. It doesn't work that way, of course, and anyone here from Washington is not going to be surprised by this.

There are lots of different ways to measure the polarization of Washington . This is just one measure, and it simply shows the difference between the political parties in the House of Representatives and in the Senate in Washington . And the main point here is you can see that in the 1930s into the 1950s, the kind of Eisenhower era and then even into the 1960s, the early 1970s, there was a good deal of bipartisanship. Now some of this was a kind of conservative coalition that came together on certain issues. On the other side, there was a kind of a tradition of moderate Republicans like Jacob Javits who helped to build the Medicare system and then others.

But the point is, there was a pretty large — maybe a third of the House and the Senate, maybe a bit more or a bit less that crossed the aisles. Wilbur Mills , Democrat from Arkansas who was chair of the Ways and Means Committee, pushed through some pretty significant tax-cut legislation. In any case, you get the point.

But what I want to focus on is what we see more recently as you move towards the right. This is our recent era, and you can see that we are at or above the historic levels that we've been able to track going back in American history in terms of the polarization in Washington . So when you look at the proportion of votes on the floor of the House and the Senate where 90 percent of Democrats line up against 90 percent of Republicans or you look at this sort of very nice measure of the distance between the parties, we are more divided in Congress today than perhaps in any point in American history.

Now does that affect the debate? Yes, it does. And I'm going to show you why in a second.

Now one of the big favorite stalking horses is media. The media is why we're so divided. It really poisons the environment. And we went and analyzed media coverage — we do this pretty regularly — tracking the nature of press coverage and the issues that are picked up. And one of the themes that really comes out in our research is that the media largely represents, reflects, the policy issues that are being discussed in Washington and policy circles more broadly, not surprising, but also the tone and tenor of that discussion.

So when you see a high-level of polarization as we're seeing in our era, it's reflected in press coverage and it varies over time, and we've seen actually going back to the 1970s that the focus on conflict and political strategy and kind of insider got-you sort of coverage on health policy issues, on really detailed policy issues, has increased over time. Now having said that, the media also amplifies that disagreement and that conflict, but it's a combination of both.

And I want to show you just a little snapshot of — and I know it's going to be hard to read, but I'll describe it to you — a little snapshot of how this sort of interaction of policy, highly polarized policy debates, public thinking, and media coverage come together.

Now the top line with the box — and I'm going near-sighted, so I apologize for those of you who can't quite see this. But the line at the very top — and this is during the Clinton health reform era. I think we could find this during other periods, but it shows you the period between January of 1993 when the Clinton Administration is sworn in and inaugurated through September of 1994 when the Clinton health plan was basically pulled off the table.

Now that top line with the box represents public support for President Clinton 's health reform plan. And you can see that in September 1993, it was about 60 percent support for President Clinton 's plan, and then it drops to 40 percent. And at that point in July, it was about 60 percent who opposed the President's plan, so it was kind of a flip.

Now what's going on during this period? Well, you know the story well about the tremendous battles that went on in Congress. The President, this is one of his top items — perhaps the only issue after the budget and the economic stimulus plan — and he never got a vote in Congress the acrimony was so large.

The thing I want to focus us on is how the press covered this. Now you'll see the other dark line that's got the triangle, and it's the one that kind of rises over the course of this period between January of '93 and September of 1994. That reflects the proportion of attention by the press — in this case, Associated Press, so it's pretty melba-toast-like — the focus of the press on the political story, the political bickering, the strategy focus, the gamesmanship of the policy discussion. It's fairly — it's often subordinate, but it's below 40 percent, at times even around 20 percent of the press coverage through 1993. Beginning though in late 1993 and into 1994, it accelerates to the point where it's the dominant, clearly the dominant, way in which the press is covering the debate on the Clinton plan.

Now what's interesting is you back up and you look at what's going on in 1993 in the spring and even into the fall of 1993, and there was a discussion for this brief period about the national consequences and the national issues, the national values tied up in health reform. And it's during this period and particularly just following peaks in press coverage about these more national collective considerations that we saw support for the President's plan increase.

Now I don't want to get into the strategies, and I frankly don't care about who's to blame and who's not. The point I want to just make here and use this as an illustration is to show the way in which public thinking is endogenous to the larger public debate and the press coverage and the larger information environment, that the public is very much informed and impacted by the discussion and the nature of the discussion.

When it's highly polarized and there is deep disagreement, the public gets uncertain and its sense of risk skyrockets and its support for any reform, whether it's Bill Clinton's health reform or frankly President Bush's Social Security reform, it plummets. And I think that's about as close to an iron rule of public opinion as we can get, and I can give you a lot of citations to support that.

Okay. We've had a long history of — I know the staff has been putting together some of that history on health insurance over the last century or more. Depending how you look at it, we're about at Cycle 8 thinking that we're now going into another one.

And I want to just kind of highlight — and hopefully this will feed into some of your thinking — some of the implications of this multiplicity of public views, and I'm just wrapping up.

When you look at proposals for tax credits, consumer-choice models, they certainly convey concern. I think the public generally sees that, but they are very vulnerable to Democratic counterattacks that these proposals do not address the larger systemic problems and dissatisfaction which I referred to earlier and that they do not lower the price that the consumer feels, and, you know, this is predictable. This is kind of Attack Politics 101. You don't need to pay anyone a lot of money to come up with that.

Now when Democrats come forward to expand health insurance, expand the role of government, regulating insurers, or taking other steps, they will get credit for trying to do something about the price and trying to do something about the frustration with the health care system. But they are quite vulnerable to kind of the Lockean counterattack; namely, that this is more big government, that it's going to increase uncertainty, dislocation, and will risk the personal health care that Americans value so highly.

Now it's interesting when we go back to 1965 with Medicare Reform which is thought of by some as a golden era, perhaps by others as something quite different. But at that moment when Lyndon Johnson has just gotten a massive landslide victory and a mandate, only 46 percent supported Medicare when posed against a private health insurance model.

And I would say one of the key lessons here is that we focus too much on the public as the oracle for the direction we go and that we need, as a policy community, to really identify those basic principles and the basic approach for moving forward.

This is all by way of saying the work you're doing is very important and that I hope it will feed into the discussion I think we're heading into. Public opinion cannot unify a highly divided, polarized set of policymakers and policy analysts. That is something that the policy analysts and the policymakers need to do for themselves.

(Applause.)

CHAIRMAN PELLEGRINO: Thank you very much. Two excellent presentations, clear and to the point, and we appreciate it. Our plan is to — I think we can take a break now and return for Peter Lawler who will open the discussion, and then both of our speakers will serve as a panel responding to and working with Peter . So let's take a break until five minutes after 10:00 . We have an earlier adjournment than we usually have because of plane arrangements, so taking promptitude will be appreciated by everyone. Thank you.