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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
JAMA Forum

Reframing the Health Policy Discourse

Among the many confounding aspects of recent health policy debates was how much attention focused on the wrong issues. The conversation devolved into a proxy war over the Affordable Care Act instead of dealing with the deep-rooted flaws in our health system. Behavioral psychologists would label this an example of the substitution heuristic: addressing a simpler question in lieu of the actual, more difficult one. As the Senate embarks on its own deliberations, potentially starting with a clean slate, will we have a chance to take on the more fundamental problems around health in the United States?

Dave A. Chokshi, MD, MSc

(Image: NYU Langone Medical Center)

The painful irony is that Americans across the political spectrum are clear about their priorities. In a recent Kaiser Family Foundation poll, 67% of the US public overall said that lowering the amount that individuals pay for health care was a top priority, including 64% of Republicans and 70% of Democrats. About 55% of Republicans and 67% of Democrats agreed that lowering the cost of prescription drugs was an urgent concern.

At the same time, life expectancy in the United States declined in 2015 for the first time in almost 20 years, with enduring health disparities by race and socioeconomic status. The decline in life expectancy is attributable to increased mortality from heart disease, chronic lower respiratory diseases, unintentional injuries, stroke, Alzheimer disease, diabetes, kidney disease, and suicide.

Although clear individual and public health priorities do not necessarily translate into simple solutions, there is considerable consensus on the broad parameters of the way forward. In a recent example, the National Academy of Medicine convened a bipartisan group of experts under the Vital Directions for Health and Health Care initiative. The group’s synthesis report points to 4 policy recommendations: pay for value (eg, support stronger integration of health and social services); empower people (eg, focus on health literacy and shared decision making); activate communities (eg, invest in local public health infrastructure); and connect care (eg, implement real interoperability of health data systems).

What will it take to render this sound, scholarly assessment into actual policy? Much depends on how the ideas are couched in values that resonate with the general public—like a fuel injector for the combustion engine of our political system. The values that become associated with health reform start with how we talk about those ideas.

Language Matters

“Thought is mostly unconscious. Abstract concepts are largely metaphorical,” according to cognitive linguist George Lakoff, PhD, and philosopher Mark Johnson, PhD. What metaphors do people call to mind when they think of improving our health system? We in the health policy community have done no favors with the esoteric language we use to describe key concepts, such as “delivery system reform,” “accountable care organizations,” “social determinants of health,” “medical homes,” and “value-based payment.”

In my own experience with patients and family members, the terms are generally met with bemusement at best—and sometimes even a negative interpretation of what is intended as a positive description. This is borne out in focus groups with patients. In 1 study, the term “value” connoted value in the sense of 99 cent hamburgers. “Medical home,” meanwhile, conjured up images of nursing homes and “places where you go to die.”

The field of finance demonstrates the pernicious effects of jargon at the population level. For instance, John Lanchester, a British journalist who often writes about economics, explains the vote for Brexit in the United Kingdom and opposition to free trade in the United States as consequences of distrust sowed in part by obfuscatory language used by financial professionals. “How much this language divide matters depends on how much we think the gap between insiders and outsiders matters; how much it matters if elites seem cut off from the rest of society; whether the great mass of society has a calm confidence in the judgment of its rulers or feels furious, alienated, ignored and traduced,” writes Lanchester.

Reorienting the Debate

Returning to health care, perhaps there is a chance to reboot the policy debate in the wake of the House’s unexpected passage of the American Health Care Act. Lakoff suggests that the core value around which to reorient the debate is freedom—particularly freeing people from the barriers and costs of poor health. Similarly, affordable coverage that is not necessarily tied to employers unfetters people from ill-suited jobs kept primarily for health insurance benefits—so-called job lock.

The notion of freedom also offers a bipartisan starting point for specific policies. States should be able to pursue bold approaches to lowering health care costs, such as an all-payer global budget approach in Maryland. Both conservatives and liberals would likely cheer a concerted national effort to liberate clinicians from unnecessary administrative tasks, as the American College of Physicians recently called for in a position paper highlighting how paperwork insidiously erodes relationships with patients. And a major investment in the country’s digital health infrastructure could support entrepreneurship while promoting patients’ ownership of their own data.

This is not to minimize threats to health reflected in some of the current administration’s policies, such as draconian proposed cuts to the budgets of the US Centers for Disease Control and Prevention and the Environmental Protection Agency. These also should be viewed through the lens of freedom, because biology and the physical environment can limit a person’s opportunities, and society has an interest in enabling individuals’ freedom to live healthy, productive lives.

As we move beyond a particularly charged moment in health policy, rethinking our discourse may help us find broader coalitions to take on the most challenging shortcomings in our health system.

About the author: Dave A. Chokshi, MD, MSc, is the Chief Population Health Officer of OneCity Health and Senior Assistant Vice President at New York City Health + Hospitals—the largest municipal health system in the United States. He is a primary care internist at Bellevue Hospital and Clinical Associate Professor of Population Health and Medicine at the New York University School of Medicine. Follow him on Twitter at @davechokshi. The views expressed in this post do not necessarily reflect the position of NYC Health + Hospitals nor NYU.
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