Just days after Barack Obama’s election victory last November, Elaine Kamarck and I published an essay with a somewhat downbeat title--“Change You Can Believe In Needs a Government You Can Trust.” We began this way:

“As Barack Obama takes office in 2009, he will confront a paradox. On the one hand, the American people are demanding action in many areas—to improve the economy, to increase access to health care while restraining costs, and to reduce energy costs and our dependence on oil, among others. On the other hand, people are deeply mistrustful of the federal government as an honest and capable agent for achieving these goals. There is nothing new about this ambivalence, but how the next president deals with it may make the difference between success and failure, measured in sustainable public support as well as legislative accomplishment.”

We went on to trace the history and causes of declining trust in government and to recommend a series of steps—including a government reform agenda and modest, confidence-building domestic policy measures—that the new administration could take to nurture public trust in the federal government as an effective and honorable instrument of national purpose. And we warned that “the new administration cannot afford to assume that because the people grudgingly support a massive rescue plan for the financial sector, they will embrace a major expansion of government in other sectors of our society.”

Nothing that has happened in the ensuing ten months has changed my mind about the importance of trust in government. In October 2008, at the end of the Bush administration, just 17 percent of Americans trusted the federal government to do the right thing all or most of the time. Barack Obama’s inauguration has made remarkably little difference: The latest CBS survey reports that the trust level now stands at 23 percent. By contrast, it stood at 47 percent in 2004, 44 percent in 2000, and 40 percent in 1988. (From the late 1950s through the early 1970s, it averaged more than 60 percent.) 

 The continuing lack of trust has made it far more difficult to persuade the American people to accept a larger role for government in health care. On the eve of the August recess, Democratic leaders decided that to boost the prospects for health reform, they needed an enemy, and they chose insurance companies. While this was a plausible selection, it turned out to have an Achilles’ heel: Government is, at best, no more highly regarded than the insurance industry. While 47 percent of Americans believe that government would do a better job than insurance companies in holding down costs, versus 38 percent who think it would do worse, the question of providing coverage evokes the opposite reaction: Only 36 percent think government would do better, versus 47 percent who think it would do worse. When asked for a summary judgment, 49 percent said that their opinion of the health insurance industry was very or somewhat favorable, while 48 percent said somewhat or very unfavorable—not great numbers, but better than the federal government’s. And its most recent health tracking poll, the Kaiser Family Foundation asked, “Which worries you more: that under a new health reform bill, government agencies would play too big a role in deciding what medical procedures people can or can’t get, [or] that currently, insurance companies play too big a role in deciding what medical procedures people can or can’t get?” By 48 to 38 percent, respondents said they were more worried about the prospective role of government.
 
On Monday, at a town hall meeting hosted by House Majority Leader Steny Hoyer, a man stood up and said, “A woman earlier asked who’s going to keep the health insurance companies honest. I’m concerned who’s going to keep the government honest.” Reluctant as Democrats may be to acknowledge it, this man, far from representing an angry fringe, spoke for at least half the country.

Does this mean that the cause of health reform is lost? Not at all. But success will require a shift, not only of rhetoric, but of many Democrats’ basic assumptions. Mistrust of concentrated power is part of America’s cultural DNA. Most Americans regard government as at best a disagreeable necessity. Even this March, at the low point of the recession and confidence in the future, and at a time when a majority of Americans favored more government control of the economy to stave off disaster, only 40 percent opted for a bigger government providing more services, versus 48 percent who preferred a smaller government providing fewer services. In this context, health reform must be spoken of by its defenders not as a positive good, but rather as medicine needed to arrest a disease—namely, the erosion of wages and the employer-based insurance system—that will eventually damage even the healthy parts of the body.

This is all the more necessary because at present, most Americans are at least moderately satisfied with their own situation. Seventy-three percent describe the affordability of basic medical care for themselves and their families as “manageable” or even “easy”; 69 percent say that their health insurance company pays for all or most of the treatments and medicines they current need; and fully 76 percent say they are very or somewhat confident that if they were to become seriously injured or ill, their insurance would pay for everything they needed to get better. According to the Kaiser Family Foundation, the share of Americans who believe that they or their families would be worse off under reform has risen by 20 percentage points since February. Today, fully 51 percent are more worried about the health reform bill they expect Congress to pass than by the possibility that reform will be delayed beyond this year. On the other hand, only 6 percent believe that the ills currently afflicting the health care system as a whole will get better with no government action, versus 54 percent who say it will get worse.

So as President Obama ponders his forthcoming address to a joint session of Congress, he faces two key tasks. First, he must convince persuadable Americans that they may lose some or all of the health benefits they enjoy now if nothing is done. The persuadable pool includes independents, who believe by a margin of 2 to 1 that government would do a worse job of providing medical coverage than would insurance companies, but who nonetheless think that the system needs fundamental changes.
 
Second, Obama must embrace and defend a legislative approach that does what needs to be done in the least intrusive and worrisome way. In the short term, this may mean minimizing structural reforms while building on existing programs such as Medicaid, S-CHIP, and Medicare—and it certainly sets limits on financing options. Americans believe (albeit by narrow margins) that we can expand coverage without increasing the budget deficit or taxing the middle class. In the long run, both of these beliefs may well be mistaken. In the here and now, whatever emerges from the legislative sausage-factory had better be consistent with them—not because policy reforms always needs broad public support, but because public concern about the deficit has risen sharply since January and because Obama promised repeatedly during the campaign that middle-class taxes would not be raised.

These constraints probably mean settling for something less than full universality—especially if declining public support for Medicare cuts places limits on that program’s financial contribution to reform. The trick will be to put together a package of incremental measures that improve the lives of millions of Americans without worsening the cost spiral and undermining support for further steps down the road.