What should President Obama say this week to a joint session of Congress about health care reform? Should he repeat another version of his previous “111 health care speeches, interviews, and press conferences in which he’s talked about health care?”Should he send Hillary to Russia to get back the “reset” button? Should he try something else?

Judging by remarks from commentators, if President Obama doesn’t try something else, his message on health care reform won’t persuade. Mark Steyn in The Omnipresent Leader criticizes President Obama: “the more he opens his mouth the more the American people recoil from his ‘reforms.’” And in Obama the Mortal, Charles Krauthammer observes the President’s decline: “The charismatic conjurer of 2008 has shed his magic.” And Peggy Noonan in Coruscating on Thin Ice declares Mr. Obama has lost the trust of the center: “But the great mass of Americans, the big center, will, I strongly suspect, not be listening. Mr. Obama has grown boring. And it's not Solid Boring, which is fine in a president and may be good. It's sort of Faux Eloquent Boring, especially on health care.” Eventually, everyone on board —even movie goers at this White House—knew the Titanic was going down. President Obama cannot afford to do more of the same—he must try something else—when he speaks to Congress.

 How could the President change course—turn the ship of state—and fundamentally reset his health care reform goals? One way is to take some basic assumptions and reverse them. In his books, Cracking Creativity and Thinkertoys, creativity expert, Michael Michalko explains that by reversing assumptions you broaden your thinking, you change perspective, you often see answers to problems that were not obvious before. 

When Alfred Sloan took over General Motors on the verge of bankruptcy, he reversed some assumptions. At that time, Michalko says the assumption was that “you had to buy a car before you drove it.” But by reversing the assumption “to mean you could buy it while driving it,” Sloan pioneered the concept of installment buying for car dealers. Michalko notes, “Many creative thinkers get their most original ideas when they challenge and reverse the obvious.”

Two of the key assumptions President Obama has been clinging to during his health care reform campaign are that reform needs to be comprehensive and that it can be paid for by taking money from Medicare.

But does health care reform need to be comprehensive? Why can’t the White House reverse the assumption? Why can’t Mr. Obama pursue a series of actions? Why can’t he achieve closure through a series of small wins, building a coalition as he goes along, gaining the confidence of the opposition, enhancing his power to persuade? Why not begin with issues like portability of insurance or an authorization permitting the purchase of medical insurance nationwide, issues where he should be able to get a majority of Republicans to join him?

Part of the “power to persuade” is as old as Aristotle; it is the ethos of the speaker. The President’s poll numbers more likely reflect that the President has lost the public trust than that the public doesn’t understand the health care plan. Health care is too important to have a two-tier discriminatory system. The elderly should be cherished as national assets, not given a “blue pill” and told to take one for the Gipper!  Reverse the assumptions: America can spend more and we can keep our promise to provide quality health care to the elderly—does anyone really believe the cash for clunkers program is a better expenditure of taxpayer funds than 5 more years for granny?

Judging by his declining approval numbers during August, a reset should certainly be considered. In fact, in a recent column, It’s Time for Obama to Change Course, blogger Jay Cost at Real Clear Politics argued that the declining poll numbers threaten the President’s “power to persuade.” And if he wants to advance new health care reforms through Congress, then he needs a course correction. His first recommendation for the President is for him to recognize that “the Cheese stands alone,” alone on the mountain top he stands, and he must act accordingly. Even if it is unpopular with those around him; the call is his alone to make. He has to take charge. He has to chart a course.

 If we just focus on this idea for now that the President has to lead even if advisors or supporters are not completely happy, then how might the President change course? What might the President do if he wanted to recapture the center? What would a fundamental shakeup look like?

One suggestion, by Cost, would be for the President to adopt some of his campaign rhetoric. Following up on that suggestion, the President argued as a candidate that sacrifices—yes, sacrifices—would be asked of everyone. Why not reverse the current assumption that Congress, the unions, and trial lawyers are off limits in the health care debate?

Why not begin by asking the political class to lead by example—a time honored tradition in our military—by announcing that there will not be a two-tiered system? That any reform will apply equally to Congress and the President—and if Congress likes its current health care system and wants to keep it, then they must pass similar coverage for all Medicare recipients. 

The unions were among the President’s biggest supporters. If they won’t sacrifice to help him, why should anyone else agree to inferior care or less care than they currently receive? If our private health spending is “too high because our tax rules lead to the wrong kind of insurance,” the President should urge Congress to close the current health-insurance exclusion even if the unions “are particularly vehement in their opposition to any reduction in the tax subsidy.”

Trial lawyers were big supporters of the President. But needless medical procedures ordered merely to inoculate physicians from litigation are a large part of our health care costs. Why can’t punitive damages, designed to punish a plaintiff for misconduct, be awarded to a government owned trust fund to pay for Medicaid rather than being distributed as a windfall to a plaintiff? Congress could set a 20% compensations rate for lawyers pursuing punitive damages in egregious cases, recognizing their contribution to the public interest.

A fundamental shake-up that shows real leadership might help the President gain the confidence of voters, restoring his credibility and “power to persuade,” garnering him a second chance to see health care reform succeed.

When left-wing activists attended Bush functions they shrewdly waited their time before beginning their planned performance: getting attention, throwing the speaker off track, interrupting the speaker merely for the purpose of creating chaos.

But consider the Town Hall protesters; they don’t behave as the Code Pink or anti-war groups did at Bush functions. The Town Hall participants are responding to something that was said by their government representative. The Town Hall meetings are interactive. If Kathleen Sebelius or Senator Arlen Specter say something stupid, disingenuous, or untrue, the crowd shows its disapproval. If a member of the audience says something to Congressman Brian Bard that others agree with, the crowd shows its approval. These are not rent-a-crowd protesters merely acting out just to disrupt. They are citizens who made time to attend. They are voters who feel strongly about the subject. They are constituents who are insisting they be part of the dialog. And the large majority of them were not sent by anybody. They see $9 trillion in debt over the next ten years. They hear arguments for a health care plan that don’t make sense. And they want to understand, and they want to be assured that Congress and the White House won’t make it worse.

Instead of hiding from the folks by retreating to telephone conferences, or cancelling public appearances one day and then slipping in an unscheduled union supported choreographed event the next day, or disparaging constituents, representatives should hold more Town Halls. They should engage in more interactive participation with voters, and they should forget busing in the rent a crowd to artificially “balance” an event.

Representatives have to realize those attending have concerns, concerns felt deeply. And as a member of Congress they do not have much trust in their portfolio with voters; in fact, they rank lower than the neighborhood used car salesman. Politicians should recognize the Town Halls for what they are—the current Town Halls are more like the opposition in the British Parliament responding to a speaker: loud, sometimes raucous, and sincerely serious. The “ruling class” needs to talk to the people in their district, and present their case, and persuade them of their position, if they can.

Democrats should not cavalierly dismiss the Town Hall participants unless they want to be voted out of office because they have lost touch with the pulse of America.

President Obama apparently promised—“YOU WON'T BE WAITING IN ANY LINES'—at Portsmouth, N.H. on July 11, 2009. But by every conceivable metric, we see no reason to be sanguine about his ability to deliver on his promise. We see only a shrinking number of physicians. Reduced physician compensation plans for Medicare in the reform bills (increasing the health-care wedge) and other changes will inevitably make the practice of medicine less attractive to foreign trained doctors who presently immigrate to the U.S.; to foreign trained students graduating from U.S. medical schools that currently remain here to practice medicine; and to college graduates contemplating graduate school. In short, with the contemplated reform, where will the doctors come from if Congress is to keep the President’s promise—no waiting in lines?

How can you avoid delays, rationing, and a less than compassionate government system if you don’t first set a goal to increase the number of physicians? As a practical matter, I believe that any medical reform that fails to first address physician shortages will fail to capture the confidence of a majority of Americans. For example, Deroy Murdock (Government Medicine Kills) reported the following about waits in Canada:

In 2008, the average Canadian waited 17.3 weeks from the time his general practitioner referred him to a specialist until he actually received treatment,” Pacific Research Institute president Sally Pipes, a Canadian native, wrote in the July 2 Investor’s Business Daily. “That’s 86 percent longer than the wait in 1993, when the [Fraser] Institute first started quantifying the problem.

 France claims it long ago achieved much of what today's U.S. health-care overhaul is seeking: It covers everyone, and provides what supporters say is high-quality care. But soaring costs are pushing the system into crisis. The result: As Congress fights over whether America should be more like France, the French government is trying to borrow U.S. tactics.

…

In France, "If you are in medical care for the money, you'd better change jobs," says Marc Lanfranchi, a general practitioner from Nancy, an eastern town. On the other hand, medical school is paid for by the government, and malpractice insurance is much cheaper.

In 2000, the World Health Organization ranked France first in a one-time study of the health-care services of 191 countries. The U.S. placed 37th.

To recruit doctors our military has long had a medical education program. Upon graduation the doctor is required to serve on active duty for a number of years. Why can’t Congress create a program to fund medical school and malpractice insurance for those who commit to accept Medicare, Medicaid and public option patients for a set number of years? Why not a goal to at least double the number of providers, thereby ensuring an increased number of providers who will willingly accept patients covered through government programs?

Thank you for your email regarding your work on Health Care Reform. I have a few thoughts, comments, and questions for you.

1.      I hope your Health Care Reform Bill extends the same medical coverage to our veterans that it does to members of Congress. After all, despite the attacks you sustain from the press corps, our troops overseas are dying or returning with real injuries.  I am sure you would agree that it would be unconscionable for any Congressman to vote for coverage for himself and then to vote to treat veterans differently.

2.      a. In “The Deep Pockets Mirage,” a WA Post editorial dated July 15, 2009, the Post dismissed a tax on the wealthy to fund health care reform as an improbable solution.

[T]here is no case to be made for the House Democratic majority’s proposal to fund health-care legislation through an ad hoc income tax surcharge for top-earning households. . . . There is simply no way to close the gap by taxing a handful of high earners. . . . Pretending that “the rich” alone can fund government, let alone the kind of activist government that the president and Congress envision, is bad policy any way you look at it. 

b. Apparently your bill also doesn’t cover the cost of medical care for un-documented aliens, a cost expected to be significant. Where will the money come from to pay for your reform bill let alone the additional expense for the undocumented? Before passing any health care reform, shouldn’t you know—especially in light of CBO testimony—the total cost for comprehensive reform? 

3.      Please remember that medical care delayed, rationed, or below even minimum standards of health sanitation is care denied. According to a recent report, for example, in Quebec province there is a two to three year wait merely to be assigned a family doctor. Nor is rationed care a viable option. Rationed care that delays treatment until the patient dies is a cruel hoax. Also, high rates of hospital induced infections (as reported throughout Canada) are terrifying. Health Care Reform will be a failure, a dark and dismal failure, if it means Canadian style delays, rationed care, or rampant cases of hospital-induced infections.

4.      Furthermore, where will our doctors come from in the future, since Government run programs historically discourage prospective applicants from entering the field? With government run health care, would you ever consider encouraging a young college graduate to pursue a career in medicine knowing he must spend seven years or more completing medical school, an internship, and a residency only to face a government controlled compensation commission? As noted by the Houston Chronicle, Medicare and Medicaid present less than an encouraging model:

A study last year in the Houston Chronicle found that "only 58 percent of Texas physicians are taking new Medicare cases, and only 38 percent of primary care physicians are doing so." In addition, the study found, "[across] the country, only 600,000 of 1.5 million total physicians are currently willing to treat Medicare patients." If doctors are already reluctant to participate in existing government run plans like Medicare and Medicaid, adding an additional public plan could discourage them even further.

Where are the incentives in your bill to attract young students into the medical profession?

5.      Our friends all agree—we pray your focus is on quality of care, meaning timely and effective treatment, and not access to care, meaning big government commissions restricting care based on artificial tables relating to age, cost, or other bureaucratic vagaries.

Thank you for your service.

We are feeling—almost on a daily basis–the impact of rising energy and food prices (Fortune writes: The next great crisis: America's debt). Can you tell us when fuel will no longer be needed, or how long until research does a work around for drilling oil, since Iran can have nuclear energy but we cannot? How do you know there is another viable option in the short term, meaning within 20 to 30 years?

We look at the exploding federal debt: lower tax revenues; spending for the stimulus bill and GSEs; spending on other programs increasing around 12%, adding $222 billion to the budget (Exploding Debt Threatens America); and the demand by the financial markets for greater yields to finance our debt (US long-term interest rates hit high) and we are less than confident about the future.

Elected representatives in Washington are expanding our debt, increasing our debt service, stressing our creditors—the laughing Chinese students responding to our Treasury Secretary were an ominous sign—as a debtor we are not trusted (Enjoy Stimulus Now, Pay Your $14,000 Share Later: Kevin Hassett)?

You are spending as if the law of economics for individuals has no relevance for a country. You are reportedly borrowing $.46 for every dollar we spend. President Obama says “we are out of money.” Taxpayers will opt to retire, stay at home with their children, cut back their hours, or not expand their business if you punish them for working. Please remember what happened when government passed a tax on luxury boats—the industry almost died, revenues declined, and the bill had to be withdrawn. 

If the financial markets dry up and lenders refuse to accept our dollars, or if our credit worthiness is downgraded (A Wake Up Call, Indeed), or if the cost of all the new programs is as inaccurate as the unemployment estimates—do you have a quick fix to turn it all around? What is the exit strategy (Exploding Debt Threatens America)? When credit markets refuse to lend, do we sell off oil rights beyond 20 miles of the West coast to China and Japan in return for necessary debt financing?

A Heritage Foundation chart in March 2009 visually captures the runaway spending-- this chart is causing us to lose sleep.

Vice President Biden says we will waste money and stimulus checks go out to grandparents dead for 35 years! How do you know government can improve health care by being more involved? Where is the evidence of government success: Katrina; TARP; the stimulus package this year?

When it comes to health care reform we ask that you please “do no harm.” How about first requiring some evidence of a program that works before changing it all and making things worse? England and Canada are not good examples of an acceptable one payer system for Americans. Reports suggest fewer people will want to practice medicine with government mandated care—just at a time when demographics mandate an increase in health providers and specialist.

Please: at a minimum require that any changes apply to all members of Congress and all government employees before adopting changes.

Sincerely,