It should have been clear all along that the fate of health reform would depend on the views not of those who don’t have insurance, but of the more than 80 percent of Americans who do. Unless President Obama can persuade them that they have more to gain than to lose from reform, House Democrats from marginal districts and Senate Democrats from red states will be hard to bring along. That argument--that even the health “haves” will benefit from reform--should be at the center of the president’s speech on Wednesday.

As a recent report from the Kaiser Family Foundation makes clear, Mr. Obama has some important facts on his side. Among them:

  • The employer-based health insurance system is under severe pressure. In 2000, 69 percent of firms offered health coverage. By 2008, before the worst of the economic downturn, that figure had fallen to 63 percent.
  • Over the past ten years, while workers’ inflation-adjusted earnings have grown by 5 percent, inflation-adjusted insurance premiums have risen by 80 percent--meaning that workers have to spend a higher share of their income each year just to maintain their current level of coverage. Workers’ premiums for a typical family policy, which stood at $1,619 in 2000, more than doubled to $3,354 by 2008.
  • About one-quarter of the increase in the uninsured since 2000 has come in the heart of the middle-class--families making between twice to four times the poverty rate ($44,000 to $88,000 per year). Ten percent of middle-class adults report that they or a family member lost health insurance because of the current recession.

Up to now, the president has repeated a middle-class message that served him better during his campaign than it has since he took office: If you like what you have now, you can keep it, and nothing in my plan will prevent you from doing that. The debate over the public option has weakened the public’s confidence in that promise. At the same time, the discussion of options for reducing costs and financing coverage for the uninsured has led many members of the middle-class to believe that they will be worse off under reform.

As a result, the president now faces a two-front challenge. First, he must persuade skeptical middle-class voters that his plan will in fact allow them to keep what they have. Second, he must paint a compelling picture of what they stand to lose if we do nothing--higher premiums, reduced benefits, more out-of-pocket cost, and steadily diminishing employer coverage in good times as well as bad.

Behavioral economics supports what political observers have long believed: Fear of loss is a more powerful motive than hope of gain. A man who gained the presidency by mobilizing hope must now go against his grain by appealing to fear as well.