The truth about Obamacare.
If, this fall, proponents of health-care reform conduct a postmortem on how President Obama's signature issue went down to defeat—I'm not saying it will, but stick with me here—they will not be far off if they trace it to this summer's "great phrase face-off." From Obama, we got "bending the cost curve," his hope of slowing the rise in health-care spending. From Sarah Palin: "death panels." From Obama: "the status quo on health care...is threatening the financial stability of families, of businesses, and of government." From GOP strategist Frank Luntz and his clients: some bureaucrat will put himself "between you and your doctor, denying you exactly what you need." From Obama: "If you like your health-care plan, you can keep" it. From GOP Sen. Jon Kyl: "Imagine needing a new hip that will make it easier to get around, but just because you're over 75, the government denies you that surgery." Not to mention Republican Rep. Lamar Smith's assertion that the Democrats' bill "contains gaping loopholes that will allow illegal immigrants to receive taxpayer-funded benefits." And then there was that sign greeting President Obama outside an August town-hall meeting in New Hampshire: Obama lies, grandma dies.
Which phrases inspire you to grab a pitchfork, or at least e-mail your congressman: bending the cost curve, or stopping the government from condemning Grandma to death because treating her cancer is too expensive? Exactly.
Anyone who believed that the battle over health-care reform would be waged on facts, logic, reason, and concern for the less fortunate—46 million uninsured—probably also scoffed at Lyndon Johnson's daisy ad. As politicians and strategists (at least the successful ones) have finally learned, appeals to emotion leave appeals to logic in the dust. And no emotion moves people more powerfully than fear. To explain the remarkable traction that death panels and other lies have gotten this summer, however, you need to probe deeper than the emotions-trump-reason truism. The specifics of the exaggerations and misrepresentations that work best speak volumes about fundamental aspects of the American character, about the neuroscience of decision making, and about the extraordinary events of the past 12 months. Yes, I'm sorry to say that AIG is part of this story.
At this time last year, if you had asked people whether the federal government would effectively nationalize AIG and Fannie Mae, and whether the Dow would plummet to 6,627 in March 2009 after reaching 14,093 in October 2007, most would have confidently said no, that will never happen in my lifetime. And yet …c "In a world gone crazy, the impossible—even 'death panels'—suddenly seems possible," says psychologist Drew Westen of Emory University, author of the 2007 book The Political Brain. The idea of death panels gains further credibility, he says, "because many people are vaguely aware that end-of-life care is bankrupting Medicare and that at some point we have to figure out how to deal with that." Its plausibility grows even more when respected figures not known for being kooks or demagogues buy in. On Aug. 12 Charles Grassley, one of the Senate's more respected figures in health care, told an Iowa town-hall meeting that because the House health-care-reform bill includes counseling for end-of-life care, "you have every right to fear. You shouldn't have counseling at the end of life?.?.?.?We should not have a government program that determines if you're going to pull the plug on Grandma."
In fact, what the House bill does is require Medicare to cover appointments for elderly people who want to talk about end-of-life care with their doctor. If you have terminal, untreatable cancer and your heart stops, do you want chest compressions, which will likely break your ribs and cause excruciating pain? If you have a massive stroke and fall into a coma, do you want to be fed through a tube? As things now stand, the elderly have to pay for such consultations out-of-pocket unless they are covered by some Medicare Advantage plans. The House provision does not "compel seniors to submit to a counseling session every five years," as former New York lieutenant governor Betsy McCaughey wrote in the New York Post. But the idea of requiring Medicare to pay for the counseling (saving Grandma money!) morphed into Palin's Facebook post that people "will have to stand in front of Obama's 'death panel' so his bureaucrats can decide, based on a subjective judgement of their 'level of productivity in society' whether they are worthy of health care."
The power of "death panels" as a phrase and a scare tactic also works because Americans are deeply uncomfortable with death. We don't like to think about it or talk about it, says bioethicist Tom Murray, president of the Hastings Center. Only 29 percent of us have a living will. As a result of that discomfort, reminding people of death sends them off the deep end, into the part of the neuronal pool where reason cowers behind existential terror. And we're particularly vulnerable to scaremongering in the atmosphere of dread created by the economic meltdown. When people are already scared about losing their jobs and their homes and paying for health care, it doesn't take a lot to make them afraid of one more thing. We're living with "free-floating anxiety" every day, says psychiatrist Louann Brizendine of the University of California, San Francisco. "The brain is signaling 'danger' right now. Whenever that happens, the brain typically loses its logical reasoning power." Fear is also the most contagious emotion. If Chuck Grassley is worried about death panels, millions of people reason (check that: feel), how can I be sure they're a myth?
Not by availing yourself of the seeming infinitude of information a click or two away. Yes, you can learn that a reference in Mad Men to Fielding beer is an anachronism; the brand didn't exist in 1962. But there is no interest group bent on convincing you that Fielding beer did exist then. In contrast, there is no shortage of groups, politicians, and just plain folks intent on proving that health-care reform will lead to, say, the rationing of medical treatments, and they all seem to have a Web site, blog, and/or Facebook page. Given that people who are sure that the U.S. government faked the moon landings (and that Obama was born in Kenya) can find support for their view online, how surprising is it that you can Google your way to "evidence" of all the evils of Obama-care?
Other health-care lies push the always-reliable hot buttons of sex, homophobia, nativism, and I've-got-mine-so-screw-you. Among them: under health-care reform, you'll have to pay for people's sex-change operations. (No such mandate exists in any of the Senate bills, or in the House bill.) It will cover illegal aliens, or, as a now viral post on a right-wing Web site put it, will cover "some baby making worthless immigrant [so she] can have her 5 brats." (No illegals will be covered. But don't worry: under today's system, some of your insurance premiums do pay for their medical treatment, to the tune of $1 billion a year, because illegals are guaranteed emergency care in every state.) Health-care reform, House Minority Leader John Boehner wrote in an op-ed, "will require Americans to subsidize abortion with their hard-earned tax dollars." (The current prohibition against the use of federal money for elective abortion—not in cases of rape or incest, or where the pregnancy threatens the woman's life or health—remains in place, and the House bill explicitly prohibits using federal money for abortion coverage. But the administration could decide to have a public plan cover abortion, and if the government subsidizes premiums for low-income people enrolled in private plans then, theoretically and indirectly, tax dollars could flow to abortion if the plan covers it.)
The best myths have a kernel of truth, and of all the health-care screeds, the most plausible is that reform will bring tens of millions of the currently uninsured into the system, making it even harder for you to get a doctor's appointment. Indeed, Luntz finds that the consequence of health-care reform that frightens more people (44 percent) than any other is making patients "wait weeks or even months" to get the procedure or treatment you need. ("Socialized medicine" scares 26 percent. "Hillary-care"? 10 percent.) But we're already in the land of waiting weeks for an appointment, thanks to a shortage of primary-care physicians that will only get worse: astonishingly, only 2 percent of medical students are entering primary-care internal medicine, notes the Journal of the American Medical Association. Still, it is a long-established fact of psychology that fear of losing what you have, even if what you have is less than great, always overpowers the hope of getting something better. Sure, Obamacare might keep insurers from denying you coverage for preexisting conditions, offer you a Medicare-like option similar to the plan that millions of seniors love, eliminate insurers' annual and lifetime spending caps, and reduce your premiums. But it just might—who really knows?—take away something you have now. "What scares people is the devil they don't know," says Westen.
Which brings us to outright rationing. In his memo on "10 Rules for Stopping the 'Washington Takeover' of Healthcare," Luntz—and let me say the man is a psychology genius—tells clients to say that "the plan put forward by the Democrats will deny people treatments they need." This has much less plausibility than the longer-waits specter. But it has emerged from confusion over a separate White House initiative: spending $1 billion to compare the effectiveness of different treatments for various diseases. Somehow that has morphed into cost (rather than medical) effectiveness. That is, bureaucrats will decide if it is worth treating you based on some calculation about the value of your life or health.
It's not in any of the bills. But the rationing lie sticks for two reasons. One is that people who should know better keep repeating it. In an editorial on July 31, Investor's Business Daily warned that health-care reform would produce a system like Britain's, where the government decides who gets medical treatment based on whether "your life is considered worth saving People such as scientist Stephen Hawking [who has been paralyzed with Lou Gehrig's disease for decades] wouldn't have a chance in the U.K." But Hawking lives in the U.K., and regularly gets expensive care—because the U.K. doesn't do anything like what the editorial claimed. (Decisions on what drugs and surgeries to pay for are not determined patient by patient, but on whether scientific studies show that they save lives or improve health. What a concept, not paying for stuff that doesn't work.)
The second reason is that the idea of rationing triggers anxiety about the loss of some cherished American ideals, such as freedom of choice about what doctors you can see and what treatments you can get. Although millions of us can't go to doctors outside our insurer's preferred-provider list, and have been denied reimbursement for drugs the doctor prescribes ("Sorry, your plan covers only the generic"), or at minimum have waited for the insurance company to say yes (why do you think the nurse is on the phone with them for 45 minutes?), we still harbor the illusion that no one gets between us and the doctor. "The idea of the dedicated family doctor has been ingrained in the American imagination," says Westen. "We desperately want it, or want it back, and hold it as the ideal of the way things should be." In this case, emotion—hope or nostalgia—rides roughshod over facts. When Luntz polled people on what matters most, No. 1, with 58 percent, was that "decisions about my health care should be between me and my doctor and no one else."
Warning that with health-care reform, "all the health care in this country is eventually going to be run by the government," as GOP Sen. Tom Coburn said on Fox News, is particularly potent. Among the more enduring aspects of the American character are self-reliance, rugged individualism, and just plain ol' being left the hell alone ("Don't tread on me") by government. And we have been told for a quarter century that government is the problem, not the solution—a cesspool of incompetence and unaccountability. As a result, says linguist Geoffrey Nunberg of the University of California, Berkeley, "the phrases 'government takeover' and 'government committees in the operating room' have power. They evoke the government as this inefficient, self-serving, paternalistic entity."
It is a truism of political campaigns that you can't beat somebody with nobody, or something with nothing. It is equally true in propaganda wars. Opponents of Obama's health-care reform have un-leashed all the bogeymen and pushed all the emotional buttons. "All the horror stories are being told by the Republican side," says Nunberg. The Democrats have struggled to make an emotional connection with the public, even though it is possible to do that without lying. Westen suggests the Democrats "should say that, since health insurance is tied to employment, 'the current system takes away your freedom to quit your job.' " Berkeley linguist George Lakoff thinks the White House could win hearts and minds by emphasizing that in the current system, "insurance companies deny you care." And the administration could score extra points by describing people who have been bankrupted or killed by that denial. There is no shortage of examples, from Blue Shield denying high-tech cancer surgery that oncologists said was patients' only hope, to Cigna nixing a liver transplant that was a 17-year-old's only chance of survival. She died. (Wall Street rewards insurers for denying claims; a company with a claims-paid rate of, say, 80 percent is viewed as better run than one with a rate of 85 percent.) "If you told the story of how greedy insurers deny coverage to sick people, you could whip up emotions in favor of reform," says Westen.
Not surprisingly, proponents of health-care reform are somewhere between furious and incredulous that the White House has been so ineffectual at countering the lies. "The White House's philosophy seems to be, don't counterpunch till you're on the ropes," says Westen. "Even now, the president refuses to call out anyone by name who is trying to undo his signature issue." The Obama team has finally realized that it needs to fight back, and this month set up a Web page, Reality Check, to debunk false claims. Memo to administration: the way you know you're a little late on this is when a doctor forwards a chain e-mail to his son, a White House staffer, saying Obama's plan would allow the Feds free access to physicians' bank accounts. The e-mail went viral before the White House could counter the baseless claim. "I don't think anybody anticipated this kind of reaction," says one Democratic congressional staffer.
They should have. Health care stirs powerful emotions, and because the subject is so complicated, people are unable to balance their emotional reactions with rational ones. Moreover, appeals to fear, anger, and hate really gain traction when ignorance is wide and deep. One of this summer's iconic moments was when a man stood up at a town-hall meeting in South Carolina with Rep. Bob Inglis to demand that he "keep your government hands off my Medicare." When some portion of the citizenry is ignorant of the fact that Medicare is run by the government, and lies, damned lies, and misleading statistics flourish, it is little wonder that we find ourselves in a summer of death panels.