John Kingdon (2011) writes that political communities tend to congregate around exciting ideas. They avoid boring subjects. This prompts policy advocates to “sell” their ideas to both policy makers and to the public. Regardless of political affiliation it is interesting to follow how well the Obama administration has “sold” the Affordable Care Act (ACA) to the public. The graph below, from the Henry J Kaiser Foundation, demonstrates the significant struggle that exists between those that support and those that oppose this legislation. Over the past several years, the public has generally viewed this law as ‘unfavorable’.
It is interesting to note that there was a more favorable public opinion when this bill was signed in 2010. One could suppose that this was because the ACA was exciting. It was new and it was revolutionary in our time. As the excitement faded, the focus became more on the difficult intricacies of the legislation. And public opinion waned.
Excitement for the public does not always have to be positive. The enormity of health care spending has the public involved out of concern, even fear. The switch from a fee-for-service payment based model to an outcomes based system provokes a lot of attention. But how will real change occur?
Jeffery Leibman, of Results for America and The Hamilton Project, asserts that the evidence is what must drive sustainable change (Leibman, 2013). Mr. Leibman writes that tackling problems should be data- driven and outcome based (2013). Ideally, this would enable the health care system to stop spending money on ineffective programs. With the United States spending a disproportionate amount of their gross domestic product, relative to individual’s health status, this would seem like a straight forward proposition.
The question remains as to whether the public would support these initatives?
As with the ACA, gaining public support for any policy development is critical. Although legislation may be passed without consensus, (i.e. the ACA) implementation and sustainability are deeply affected by the public. In a study conducted by the Harvard School of Public Health, researchers found that the American public was unlikely to favor being told which treatments were allowed based on their effectiveness (Botta, Blendon & Benson, 2014). Cost-effectiveness research (CER) has become a popular way to curb out of control spending using the best evidence available. CER agencies have been developed in the United Kingdom, Italy, Germany and Australia (Botta, Blendon & Benson, 2014).
This leads me to question whether a firm foundation of evidence can really drive effective change?
Consider the evidence surrounding palliative care services (coalitionccc.org, 2015):
- Cost neutral or cost- saving.
- Improved patient satisfaction.
- Improved quality of life scores.
- Increased life expectancy.
An article in US News and World Report (Moeller, 2013) labeled palliative care “an enormous game changer”. The evidence is strong and public awareness is growing; yet a bill recently introduced in the House of Representatives (H.R. 1666) designed to provide funding, education and research for palliative care died in committee (congress.gov).
Kurt Lewin theorized that change occurs in a ‘unfreeze, change, refreeze’ format. The American health care system has to ‘unfreeze’ old models and ideals to arrive at any real change. That change must then be ‘frozen’ into our lives, habits and way of thinking. It appears that in many ways our system is frozen in world where evidence does not quickly translate into practice.
What a great opportunity for the DNP to help build a system of effectiveness and quality for our patients!
Botta, M.D., Blendon, R. J. and Benson, J. M. (2014). Cost-effectiveness decision making and US public opinion. Jama Internal Medicine, 174(1), 141-143. doi: 10.1001/jamainternmed.2013.11332.
Coalition for Compassionate Care of California. (2015). Value snapshot- Home based palliative care. Retrieved from http://coalitionccc.org/wp-content/uploads/2014/12/snapshot_home-based_palliative_care.pdf
Congress.gov. (n.d.) H.R. 1666- Patient centered quality care for life act. Retrieved from https://www.congress.gov/bill/113th-congress/house-bill/1666
Kingdon, J. (2010). Agendas, Alternatives, and Public Policies, Update Edition (2nd ed.). London: Longman Publishing Group.
Liebman, J. B. (2013). Building on recent advances in evidence-based policymaking. Results for America and The Hamilton Project.
Moeller, P. (2013). What you need to know about palliative care. US News and World Report.
Nursing theories. (2013). Change Theory, Kurt Lewin. Retrieved from http://currentnursing.com/nursing_theory/change_theory.html