Few of us could have predicted (or were ready for) the firestorm of opposition that provisions in the stimulus bill related to electronic health information or comparative effectiveness research created a few weeks ago.

Oh, we might have thought that privacy issues related to electronic health records (EHRs) might be of concern. Or the fact that electronic health information systems or comparative effectiveness research were not as “job creating” as money for road building (even though they are predicted to create 200,000 or more jobs). But did we anticipate adequately that these two provisions would be so commingled, misunderstood, or hysterically misrepresented in the media as they were?

The tactics used to attempt to defeat these two provisions are instructive, because they will be used in much greater measure when the real health reform legislation becomes public. In President Barack Obama’s February 28 video address, he acknowledged the coming opposition. I offer a few suggestions for how to fight back, and I hope you will contribute your comments as well.

Tactics That Almost Worked: Lies, Repetition, And Speed

Outright Lies. It may have started with the reemergence of an annoying critic of the Clinton health reform plan, Betsy McCaughey, and an editorial she wrote for Bloomberg News titled “Ruin your Health with the Obama Stimulus Plan”. McCaughey, a former lieutenant governor of New York and an adjunct senior fellow at the Hudson Institute, had misrepresented health reform before. In a widely panned article in the New Republic  in 1995, which was eventually repudiated by that publication, she made claims about the Clinton health reform bill that were simply untrue. Her claim to fame was the fact that she had combed through every word of that very long piece of legislation, something almost no one else had done quite that thoroughly.

But, as Ezra Klein points out in his blog posting titled “Lies, Damn Lies and Betsy McCaughey”, “McCaughey, it turned out, isn’t a very good reader.” She misrepresented and misinterpreted key elements of the Clinton plan, but she ended up a media queen, and her accusations were repeated and asserted as facts, over and over again, by the right wing.

This recent controversy was fed by yet another inaccurate article by McCaughey for Bloomberg News a few weeks ago. Among other inaccuracies, she claimed that the National Coordinator of Health Information was a new bureaucracy. (It is not. Former President George W. Bush initiated it in 2004.) That electronic health information would force doctors to do what the federal government thinks is appropriate and effective. (The stimulus bill does no such thing. ) That the Federal Council for Comparative Effectiveness Research would slow the development of new technologies and treatments. (Not. )

McCaughey claimed that information generated by comparative effectiveness research would dictate to Medicare a new cost effectiveness standard. (The Stimulus Bill avoids using the terminology of cost effectiveness and an earlier statement released by the Senate Finance Committee stated that comparative effectiveness information should not be used for coverage decisions in Medicare.) And that the elderly would bear the brunt because Medicare pays for treatments deemed safe and effective. (Medicare pays for treatments that are reasonable and necessary. The Food and Drug Administration [FDA] deals with safety and effectiveness.) And the list of inaccuracies goes on.

Repetition And Speed. The lies are not what is so interesting about this latest dust-up. What is instructive and interesting is the way in which this misinformation made its way so rapidly through the body politic and into the blogosphere, much like radioactive dye that is used in PET scanning to highlight heart disease. McCaughey’s comments were almost instantly picked up by Rush Limbaugh, Fox News, the Drudge Report, the Wall Street Journal, and local radio talk show hosts around the country (such as Ronn Owens at KGO in SF).

The misrepresentations were then echoed but not refuted very effectively by either David Axelrod or David Gregory on NBC’s Meet the Press  and in the New York Times, which also repeated the claims:

But critics say the legislation could put the government in the middle of the doctor-patient relationship. Bureaucrats “will monitor treatments to make sure your doctor is doing what the federal government deems appropriate and cost-effective,” Betsy McCaughey, a former lieutenant governor of New York, wrote on Bloomberg.com. Rush Limbaugh broadcast the charges to millions who listen to his radio talk show.

By providing links to McCaughey and Limbaugh, the Times attributed credibility to their claims, in a style very common among journalists today. Make a statement, provide a quote, make another statement, provide another quote. Voila. You are being fair and balanced. Analysis or critical deconstruction be damned.

The Attempt To Fight Back

By the time these claims that comparative effectiveness research and health information technology (IT) would destroy American health care as we know it had circulated on blogs, radio, and some cable TV, too many people had bought into it to really refute it effectively, although several entities did try. The Washington Monthly’s “Political Animal” blog  issued a strong rebuttal. Keith Olbermann of MSNBC’s Countdown program did a serious rant on the subject, outing McCaughey for taking money from pharmaceutical manufacturers, whose interests were to destroy the legislative language.

Media Matters exposed the Wall Street Journal’s treatment of the subject, in which they picked up the McCaughey lies verbatim. I myself phoned into the Ronn Owens radio program and made a valiant attempt to set the record straight (to no avail, I might add), and I blogged on Huffington Post about it, attempting, with a bit of irony, to defuse the most offensive of the attacks.

But the combined efforts of a few lefty blogs and one lefty cable TV show most likely did not persuade the Americans who were first hit by McCaughey and Limbaugh. The flood of e-mail and calls to legislators surprised even the Republicans. And had the Democratic staff not understood exactly where this was coming from, and had the speed with which the legislation passed been slowed down, there is no telling what might have happened to the funding for health IT or comparative effectiveness research. As Billy Tauzin, the head of Pharmaceutical Research and Manufacturers of America (PhRMA), was quoted in the Los Angeles Times’ article, “I hope it is a clear warning. There are a lot of beehives out there. You don’t just go around punching them.” ( (By the way, I have absolutely no idea what he is talking about, unless he is characterizing Republicans as a bunch of angry bees just waiting to sting us all to death!)

Preparing For The Next Round

Who won this round? Obviously the Democrats did. And policy folks like myself who believe that comparative effectiveness research and electronic medical records are way past due for implementation in American health care. But we weren’t nearly swift enough or strategic enough to stop the flood of abuse these two programs took in a very short timeframe. We will need more than the blogs and Keith Olbermann next time to fight back. Next time the strategy will be to slow things down long enough to kill the program with a thousand cuts.

There are several ways that lies and repetition can be countered. One is to be the first to set the agenda. Another is to find credible spokespeople to communicate that agenda. And still another is to anticipate the opposition and organize a way to refute it quickly.

During the Obama campaign for the presidency, the campaign made a valiant and sophisticated effort to set the agenda and refute the lies being circulated.  There was infiltration of Google search pages and a Web site called “Fight the Smears” that actively fought back against every ridiculous attack and lie, although in some quarters, it was “don’t confuse me with the facts,” and the lies continued to circulate.

There was also a blog team that I worked with that anticipated the attacks on Obama’s health care plan, and we posted on hundreds of blogs in battleground states, providing supporters with ammunition to fight back. We also wrote letters to the editor and opinion pieces, and we commented on hundreds of articles that misrepresented Obama’s health care program.

Our work was made much easier by John McCain’s own health reform ideas, because we were able to set the agenda early on as to the tax implications of his proposals and the dangers they posed for ordinary Americans. Senator McCain never recovered the momentum on health reform and almost stopped talking about it by the end of the campaign.

During the Clinton health reform period, not enough consultation was done with communications experts about how to set the agenda and refute the attacks. “Harry and Louise” took over, and the rest of the game was playing catch-up. This time it is not impossible to anticipate what the major attacks will be. Whatever Obama and the Democrats propose will be called “socialism” or “government takeover”. Ironically, the same voices calling for nationalization of the banks and the credit industry today will lead the way with little obvious sense of their own contradictions. Pointing out those contradictions in advance can help to serve as an “inoculation” against the power of their arguments.

The president is clearly the most effective communicator in his administration, and his willingness to set the agenda, anticipate the attacks, and create a structure (war room? Web site? new blog team? effective surrogates?) to carry his message will be absolutely critical to the passage of any health reform legislation. It is very easy to scare people with lies. It is much, much harder to educate them with facts. But effective persuasion does not depend entirely on facts. It also depends on credibility, honesty, simplicity, repetition, and organization. Obama and his team are masters of all of these techniques, and as they analyze what almost happened with health IT and comparative effectiveness research, they can raise the volume and get ahead of the inevitable tsunami to come.