Health Care's Public Perception Malady

For many years, it was hard to know whether the oft-told story of the elderly woman who walks up to her congressman, wags a finger in his face, and says, "Tell Washington to keep its hands off my Medicare!" was actually apocryphal. But today, this episode is being re-enacted over and over again, at town meetings and in coffee shops where politicians go to practice their phrenological arts, passing their fingers over the ever-changing bumps on the public's collective pate. One recent example came in a Washington Post article, in which Rep. Bob Inglis, a Republican from South Carolina, related that an elderly constituent gave him this very instruction. The depressing punch line, however, was this: "I had to politely explain that, 'Actually, sir, your health care is being provided by the government,'" Inglis recalled. "But he wasn't having any of it."

This anecdote is coming from a Republican almost guaranteed to vote against whatever health-care reform bill emerges from Congress. What matters is that even after Inglis explained that Medicare is indeed a government program, his constituent "wasn't having any of it."

Inglis is hardly the only one to have this experience. President Barack Obama himself, in his travels promoting reform, has had to deal again and again with some voter who has come to believe that health reform contains a secret plan to euthanize the elderly. "I have been told there is a clause in there," said a phone caller at one of Obama's events, "that everyone that's Medicare age will be visited and told to decide how they wish to die."

Where could she have gotten that idea? Oh yeah -- from half the conservatives with access to microphones. They have taken an innocuous provision in which Medicare will reimburse doctors for counseling patients on end-of-life care and living wills and used it as the justification for telling people a number of different scare stories, each one a more brazen falsehood than the last.

In some tellings, government bureaucrats will visit the elderly to force them to choose their manner of death. In another, their doctors will be required to "tell them how to end their life sooner" (this one is being popularized by Betsy McCaughey, as despicable a merchant of lies as has ever slithered through our public debate). One GOP member of Congress after another has simply dispensed with all the complexity and said that the Democratic health plan will cause seniors to be "put to death by their government" or some variation thereof. (As usual, Jon Stewart gave the most cogent summary of the conservative strategy. Parodying GOP arguments, he said, "The small-business exemption limit may be unworkably -- ah, fuck it, YOU'RE ALL GONNA DIE!")

Why would anyone believe such a thing? After decades of being told that the federal government is a sinister, rapacious beast with nothing but evil intents, the idea that a complex bill might contain a Soylent Green provision isn't too far a stretch. Nonetheless, it remains entirely possible that before long, health reform will no longer be a debate but will become an actual policy, one that will succeed or fail on its own merits. As both sides have understood (the Republicans more so than the Democrats, however), this battle is so critical because the stakes go to the heart of each party's approach to the role of government.

Both parties hope that the successful implementation of their favored policies will lead to a broader acceptance of their ideology. Republicans want to privatize government services not only as an end in itself but to show people that the private sector works better than government. In the same way, Democrats advocate for effective government services not only to solve an immediate problem but to demonstrate that government can in fact do some things very well.

Unfortunately, the successful implementation of a government program doesn't necessarily convince people that government can successfully implement programs. Antipathy toward government even among many who receive both Medicare and Social Security -- two of the most successful government programs in history -- is remarkably strong. In fact, by some measures, the elderly have the most skeptical views of government. For instance, in the latest version of the Pew values survey, 64 percent of those over 65 -- who are either on Medicare and Social Security or know that they will be soon -- said that "when something is run by the government, it is usually inefficient and wasteful" (see page 34 here). That compares to only 43 percent of those age 18 to 29.

A conservative might argue that the elderly's antagonism toward government comes from their experience with it. But both Medicare and Social Security are hugely popular among their recipients. Think about the cognitive dissonance involved: I'm very happy with my Medicare coverage, and I couldn't live without my Social Security, but don't get that damn government too involved in health care!

Forty-four years after its passage, the success of Medicare -- just to review, a big-government program that has provided health care to tens of millions of seniors who would not have otherwise had it, does so more efficiently than private insurance, has seen costs grow at a slower rate than private insurance, and is smashingly popular with its recipients -- has not seemed to fundamentally alter the public's receptiveness to anti-government arguments. Ditto for Social Security. Ditto for the Veterans Administration, which is the only truly socialized health-care system in America, and one that is considered by many health-care experts to provide the best health care in the country.

How do we account for this? It's true that some people are just idiots and will believe almost anything they're told. But more than that, it shows the enduring power of ideological rhetoric. When something is repeated often enough, and with enough conviction, lots of people will end up believing it, no matter the facts.

Unfortunately, to the members of Congress now wondering whether a nay or an aye on health-care reform carries the greater political risk, all opinions are equally valid. The informed constituent who supports reform to rein in insurance-company abuses and move toward universal coverage has no greater sway than the constituent who opposes it because his cousin told him that his buddy said that he heard a talk-radio host say that Obamacare means we'll all have to donate our kidneys to terrorists.

For all their fear-mongering against government health insurance, no Republican would be politically foolish enough to advocate dismantling Medicare. If Obama's reform is passed, no matter how successful it turns out to be, conservatives will continue to insist, each and every day and as loud as they can, that government can't get anything right. As for the public, even as they take advantage of their government health care and pensions, drive on their government roads, play in their government parks, surf the Internet their government created, feel protected by their government police and fire departments, and generally enjoy the benefits of government's efforts, a healthy portion of them will continue to believe that their government might just be trying to kill them.

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