State Leadership Conference

The 1993 White House attempt to reform the nation's health-care system failed for a key reason: Fear, said Atul Gawande, MD, delivering the keynote address at the 2008 State Leadership Conference, held March 9-12 in Washington, D.C.

Policy-makers were unable to prepare Americans for sweeping change and overcome their fear of losing coverage, said the award-winning author and health-care policy expert, who served on the Clinton administration's health-care reform committee.

"We unveiled it, and it was a huge flop," said Gawande. "We not only lost health-care reform, we ruined it for 15 years."

Gawande, a cancer surgeon, described an experience that exemplifies Americans'continuing fear of change when it comes to health care. Earlier this year, he treated a self-employed carpenter who was required to buy health insurance coverage under a 2006 Massachusetts law. The man hadn't seen a doctor in 15 years, but at his wife's urging went in for a checkup and his doctor found a cancerous tumor in his neck. Even after a successful operation, the man was still upset that he had been required to purchase health insurance, Gawande said.

His patient's reaction points to the role psychology can play in moving the health-care debate forward--in helping understand why people say they want reform, but when confronted with proposals for change, fail to support it.

As experts in understanding what facilitates and inhibits change, psychologists have much to contribute to this dialogue, Gawande indicated.

In 1993, "the insured feared change more than they feared the status quo," he said. Looking forward to the inauguration of a new president, the same reasons that made reform difficult in 1993 could make reform uncertain next year, too. However much costs are rising, and however many people are uninsured, the system isn't yet failing to a point where a clear majority demands reform.

"Our health-care system has eroded badly, but it has not collapsed, so we do nothing," he said.

Yet reform is needed because of its cost in human suffering, and the drain on the nation's resources and ability to compete economically inflicted by the current system, Gawande said. Consider these points:

  • About 28 percent of Americans don't have health insurance for at least part of the year.

  • The uninsured are twice as likely to have an untreated cancer and people without insurance are also twice as likely to be dealing with untreated psychological disorders.

  • Unplanned health-care costs are the top reason for personal bankruptcy filings. Health care increasingly straps businesses with ballooning costs, too, causing the once-great automaker General Motors Corp. to face bankruptcy from the cost of covering workers and retirees.

That lack of coverage takes place in an era of medical advances where treatments are available for 70,000 diagnosable conditions, but there are not enough resources to pay for them, Gawande said.

But there is hope for successful reform and some "huge differences" between 1993 and this time around. For example, today's businesses, faced with rising costs in covering employees, are more willing to back reform efforts and support from organizations such as the American Cancer Society, which argues that coverage for all is crucial to driving cancer rates down.

Faced with that persistent public resistance to supporting big changes, Gawande argued for getting policy alternatives ready, and for facing the fact that there's about a 50 percent chance reform efforts will fail. When it comes time to unveil a plan, Gawande said the public should have a year or two to hear it explained and debated, and its proponents need to be flexible and adaptable as the debate proceeds.

Psychologists can help by engaging in the public debate, and getting people to see past their fear of change and take a chance on a new way of approaching the problem. The most fundamental reform that's needed is severing health insurance from the workplace and allowing everyone to be covered, regardless of their employment status, he said. To start accomplishing that long-term, Gawande said, lawmakers could gradually expand coverage by making Medicare coverage available for anyone born in 1989 and after. State legislatures might also emulate Massachusetts'example and develop their own statewide plans to lessen the ranks of the uninsured.

"Reform is going to be hard," he admitted. "We're all going to have to make changes in the way we do things."