Monthly Archives: June 2019

The Critical Role of Trust In Avoiding a “Charge of the Light Brigade”

Posted on by • Posted in Ability, Change Management, Commitment, Duty, Leadership, Leadership Trust, Management, Manager Trust, Transparency, Trust, Truth • Leave a comment

https://www.tlnt.com/the-critical-role-of-trust-in-avoiding-a-charge-of-the-light-brigade/?utm_source=Marketo&utm_medium=Email&utm_campaign=tlntcom-daily-newsletter&utm_content=the-critical-role-of-trust-in-avoiding-a-charge-of-the-light-brigade&mkt_tok=eyJpIjoiWXpGbFlXWTBaalF4WkRReSIsInQiOiJ1TGlrM2FsYTZQZlhkUU5zcnVXa1pwc2dEb253U3hQRUVKcDMxQ2wrZXVyaUJhVnVESmpKd0prNmZzb3pkTUtEZFhZZVlSTXZwd3N6N3ZpWjlNVW9YRVk1UDlFWXRNb3NpSGRqUFBHNjhFRnJzZkZVZWxZMEZUQXpROFVjSEFrUCJ9

The importance of leadership trust increases as the pace of change accelerates. Leaders in hyper-competitive and turbulent business environments need employees to support decisions without a lot of extensive explanation and back and forth discussion. It is not that change management topics like “what’s in it for me” are not important. It is simply a matter that when you need quick action, you may not have time to fully explain why this action is critical.

The need for fast action creates a dilemma for leaders. To move quickly, leaders need employees to accept and believe in their decisions without demanding a lot of discussion and justification. On the other hand, leaders do not want employees to blindly accept leadership decisions if they know these decisions could be leading the company down a path of failure. This issue was famously captured in Tennyson’s poem “The Charge of the Light Brigade” where he described soldiers responding to a questionable order with the stanza “theirs not to make reply, theirs not to reason why, theirs but to do & die.” While this phrase summons up notions of courage and duty, the story it describes is a tragic example of people following leadership orders they knew were foolish. In the case of the Light Brigade, the unwillingness to question the wisdom of their leaders led to 278 needless casualties of which 156 were killed.

Leadership in fast moving world requires asking employees to trust your decisions while ensuring employees are willing to criticize your decisions. To quote General Colin Powell, “Leadership is solving problems. The day soldiers stop bringing you their problems is the day you have stopped leading them.” How can leaders create the sort of trust that strikes this balance between employees accepting decisions but also questioning them? The following are some suggestions based on psychological research studying trust in organizations.

If you do not trust your employees, they will not trust you.

People are good at picking up subtle cues that show whether their co-workers trust their commitment and abilities. If a leader lacks trust and confidence in their employees, then employees will soon lack trust and confidence in that leader. This is a major issue when companies restructure. It is common to assign leaders to “fix” struggling divisions of a company. If these leaders believe existing employees are to blame for the previous problems, then they are almost certain to fail in gaining the trust of those employees when they most need it.

Trust depends on sharing bad news.

Some leaders believe the best way to build employee confidence is to hide bad results and downplay challenges the company is facing. This behavior damages leadership trust. Employees put more trust in leaders who openly share information with them, both good and bad. This goes back to employees trusting leaders who trust them. Leaders who trust employees with sensitive information about company performance are both educating employees on the realities the company is facing and building leadership trust in return. There is a right way to share bad news to avoid undermining confidence. But not sharing bad news at all undermines trust.

Trust comes from you knowing your employees (not just them knowing you).

One often hears leaders attempt to build trust by saying things like, “Anyone who knows me will tell you I am a person of my word.” What these leaders fail to understand is trust, particularly when it comes to providing critical upward feedback, is often more dependent on leaders knowing their employees then employees knowing their leaders. Employees put themselves at risk when they say things that might be viewed as critical of leadership decisions and behaviors. And employees do not want their only interactions with leaders to be centered on them sharing problems. This is captured by something a colleague once told me, “Why would I tell our division president what he is doing wrong if he doesn’t even know what I do. He’d just think of me as that person who complains.”

Building trust with employees depends on getting to know employees. The only way to know your employees is to spend time with them. Short personal interactions have big effects on trust. One way to see the difference between effective and ineffective leadership in this area is to observe executives at company conferences. The ones employees trust are the ones who spend time with employees two or three levels below them. These leaders intentionally start conversations with employees they do not know. Executives employees often mistrust are ones who spend their time in closed conference rooms or fancy dinners talking with other senior executives and people they already know.

Leadership trust comes through manager trust.

Managers play a critical role in building leadership trust. Managers have more time to spend getting to know employees, and as a result they can build far stronger relationships. What is interesting is that how much employees trust their managers depends in part on how much managers trust their own leaders. There is as a “trickle down” effect associated with trust. When leaders build trusting relationships with their managers, their managers are more likely to build trusting relationships with their employees. This is good news for leaders because it means that they can delegate the role of building trust to managers. But the only way to do this is to spend time with their own direct reports. And increasingly companies are adopting organizational structures where executives will have 15 or more people reporting to them. This increases the risk that executives may not spend enough time building trusting relationship with their own reports, which in turn will undermine leadership trust lower within the company.

It is often said that “trust takes years to build but seconds to destroy.” The first part of this statement is not necessarily true. Trust can be built fairly quickly. This is good news for leaders in a fast-moving world where trust needs to be established in a matter of days or weeks. But leadership trust will not come from leaders simply saying, “Trust me.” The only way to build leadership trust is for executives to demonstrate that they trust the employees, communicate with employees in a transparent manner, make time to get to know employees at all levels, and focus on building strong relationship with the people who actually manage the employees. Building leadership trust may not take years, but it does take active time and attention.

 

 

Trump’s health care focus puts GOP on edge

Posted on by • Posted in 2020 Election Issues, ACA, Health Policy, Transparency • Leave a comment

Trump’s health care focus puts GOP on edge

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President Trump has put the issue of health care back on the political front burner, providing ammunition to Democrats and worrying Republicans who think a new battle over ObamaCare will hurt their party in next year’s elections.

Senate Republicans, defending 22 seats next year, thought they had put ObamaCare repeal behind them when they told Trump earlier this year that they have no intention of acting on a health care overhaul before the election.

But Trump threw the issue back at them in an interview with ABC News that aired Sunday, saying his administration will unveil “something terrific” to overhaul the nation’s health care system “in a month.” He argued that action is needed because “ObamaCare has been a disaster.”

Republican lawmakers have little idea of what to expect and say there hasn’t been communication from the administration on the issue.

“All the members of Congress thought it had subsided and hope that it continues to be subsided,” one senior GOP aide said.

“We don’t actually agree with each other on what replacement should be, which means we don’t have a replacement that Republicans can unite around,” added the aide, who called Trump’s remarks a “political gift for Democrats.”

Speaker Nancy Pelosi (D-Calif.), signaling she likely agrees with the GOP aide, released a statement Monday denouncing Trump’s plan and saying Democrats would “fight relentlessly” against it.

“The American people already know exactly what the president’s health care plans mean in their lives: higher costs, worse coverage and the end of lifesaving protections for people with pre-existing conditions,” she said.

Senate Majority Leader Mitch McConnell (R-Ky.) offered a cautious take, stating of Trump in an interview with Fox News that “we’re looking forward to seeing what he’s going to recommend.”

McConnell added that there’s no chance Congress will act on anything Trump proposes until after next year’s election.

“The problem in the Senate and the House is the Democrats control the House. Se we can’t pass what we would like to do,” he said in an interview on “Fox & Friends.”

McConnell has told colleagues he wants to play offense by making the 2020 health care debate about Democrats’ calls for a single payer “Medicare for All” system. Trump’s move makes that more difficult.

“Democrats would much rather say, ‘Republicans are trying to take away ObamaCare and are trying to repeal the law on preexisting conditions’ and not make it about Medicare for All,” the GOP aide said.

Senate Minority Leader Charles Schumer (D-N.Y.) also took a shot at the president, saying Trump had repeatedly promised but failed to provide a “magic health care plan.”

“It never comes out,” Schumer tweeted. “Instead they just keep trying to sabotage your health care and suing to end protections for pre-existing conditions.”

The administration filed a legal brief in May calling for an appeals court to strike down all of ObamaCare. This represented a switch, first revealed in March, days after special counsel Robert Mueller’s report was filed with the Department of Justice, from the administration’s earlier position that only portions of the law should be struck down.

Many Republicans were caught off guard by the administration’s legal brief, which was widely seen in GOP circles as a mistake.

Republicans in the Senate, rather than focusing upon repealing the health care law, have sought to work on bipartisan legislation to lower health care costs.

Senate Health, Education, Labor and Pensions Committee Chairman Lamar Alexander (R-Tenn.) last month introduced a bill with Sen. Patty Murray (Wash.), the ranking Democrat on his committee, to address surprise medical billing and improve transparency for drug pricing.

In a statement last week, he emphasized the bipartisan nature of the proposal.

Separately, Senate Finance Committee Chairman Chuck Grassley (R-Iowa) is working with Sen. Ron Wyden (Ore.), the top-ranking Democrat on his panel, on legislation to cap seniors’ prescription drug expenses under Medicare.

Polls show why Republicans are nervous about ObamaCare.

A Wall Street Journal-NBC News poll published earlier this month showed that 24 percent of respondents nationwide think health care should be the federal government’s top priority, and Democrats lead Republicans on the issue by 8 points.

Democrats also won back the House majority last fall largely by talking about health care and the GOP’s failed effort to repeal ObamaCare.

“It’s been a loser of an issue for them,” said John Weaver, a GOP strategist who previously worked for former Ohio Gov. John Kasich (R) and the late Sen. John McCain (R-Ariz.). “In the last cycle it was one of the main causes for them losing the House.”

Some Republicans on Capitol Hill are skeptical about whether the White House will come out with a detailed health care plan and suspect that Trump’s latest comments may be more motivated by the desire to signal to his conservative base that he hasn’t given up on repealing ObamaCare.  

“The president and congressional Republicans have two fundamentally different political views on health care — not substantive views but political views. The president thinks any health care reform, repeal and replace, is a win and goes into his column and helps him and the Republicans,” said Vin Weber, a Republican strategist.

Weber said the GOP’s best strategy going into 2020 is “attacking the Democrats for being too far to the left, and the Democrats are giving them ammunition.”

McConnell in April said the key to GOP success in 2020 is to make the election “a referendum on socialism,” while Weaver on Monday said Republicans would like Trump to simply focus on the economy.

“You think he would be focused on the economy,” Weaver said. “Republicans have no credibility when it comes to health care.”

He called Trump’s renewed health care push “politically irresponsible.”

 

Efforts to save new moms clash with GOP’s Medicaid cuts

Posted on by • Posted in 2020 Election Issues, Block Grants, Health Policy, Maternal Mortality, Medicaid, Safety-Net Providers, Underinsured, Uninsured, Vulnerable Populations, Womens Health • Leave a comment

https://www.politico.com/story/2019/06/14/new-moms-clash-gop-medicaid-cuts-1364564

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The push to address the soaring U.S. maternal morality rate is colliding with a broader, more ideological public health imperative: Republican-led efforts to scale back Medicaid.

The safety net program pays for half of all births in the nation. Democrats and many public health experts see it as a natural vessel for slowing the death toll of pregnant women and new mothers, by extending care in the crucial year following childbirth.

But concern over the potentially staggering cost has already quashed efforts in states such as Texas and left liberals in Congress glum over the prospects for a nationwide legislative fix.

“Medicaid represents the best of America and the administration’s effort to gut it would be a massive step backwards on confronting America’s maternal mortality crisis,” Sen. Elizabeth Warren (D-Mass.) wrote in an email.

The dynamic mirrors the federal response to the opioid epidemic, in which Republicans and the Trump administration support making addiction services more available while simultaneously working to shrink Medicaid, the largest single payer of behavioral and maternal health care.

Research has shown the risk of death after childbirth persists for a full year, from such factors as heart disease, stroke, infections and severe bleeding. Black and Native American women are about three times more likely to die from a pregnancy-related cause as white women, according to the Centers for Disease Control and Prevention.

Warren, along with fellow 2020 Democratic presidential contenders Sens. Bernie Sanders, Cory Booker and Amy Klobuchar, back extending Medicaid’s current requirement to cover new mothers from 60 days to one year after childbirth. Democratic proposals in the Senate from Dick Durbin of Illinois, and in the House, from Reps. Robin Kelly of Illinois and Ayanna Pressley of Massachusetts would do that along with provide states grants to improve hospital deliver practices, among other things.

But the efforts aren’t yielding GOP buy-in across the country, as conservative lawmakers keen on shrinking the program press for narrower fixes, such as increased data collection on deaths and a national standard of best medical practices. Proposals to enhance Medicaid coverage to address maternal mortality haven’t attracted a single Republican co-sponsor in Congress, with both sides at loggerheads on whether to grow or shrink the entitlement program.

“All mothers must have access to adequate care before and after delivery, and we should provide states with the tools and flexibility they need to ensure coverage of their most vulnerable populations,” Sen. John Cornyn (R-Texas) told POLITICO.

A Republican aide said GOP lawmakers are focused on getting a better picture of how many pregnant and postpartum women actually need coverage before exploring how to expand access to care. “That is a laborious process to undertake as we have to talk to both the states, stakeholders, and CMS to discern what coverage gaps exist. And we need to know the role other sources of coverage play as well,” the aide said.

Democrats say the prospect of expanding Medicaid benefits scares Republicans in an era of pitched partisan battles over health policy.

“Following the ACA and repeal Obamacare debates, health care, especially Medicaid experience, has become a hot issue — not quite a third rail but definitely hot and our GOP counterparts are a little squeamish,” a Democratic aide working on the issue said.

President Donald Trump last year signed a maternal care measure that directed millions of dollars in new spending to help states collect data on maternal mortality, but has been mum on extending Medicaid coverage to new mothers. His administration will weigh whether to allow Missouri to use its Medicaid programs to offer extended coverage to mothers struggling with addiction — but not the broader Medicaid population.

Meanwhile, the administration is aggressively pursuing an overhaul of Medicaid, finalizing proposals to allow states to apply for block grants that cap program spending and approving requests to condition benefits on work. The administration’s separate efforts to overturn Obamacare would also jeopardize federal subsidies that low-income mothers use to purchase coverage.

The focus on maternal mortality is driven by rising trend lines showing about 700 women die each year due to pregnancy related conditions a rate that’s more than doubled over the last three decades. About a third of the fatalities occur between one week and one year postpartum, according to a recent CDC report, putting the U.S. behind other developed countries for maternal health. And 60 percent of maternal deaths are preventable, with African American women and other minorities disproportionately affected.

Researchers studying the pattern say that extending Medicaid coverage would provide comprehensive benefits for chronic health conditions like heart disease, which accounts for a quarter of maternal deaths.

“The postpartum period is such a period of vulnerability,” said Houston physician Lisa Hollier, immediate past president of American College of Obstetricians and Gynecologists and chair of Texas’s Maternal Mortality and Morbidity task force. “The transition time [from pregnancy to full recovery] is one when we see unmet health needs.”

Obamacare helped boost coverage for new mothers. The uninsured rate for women who reported giving birth in the past year fell to 11.3 percent in 2016 from 19.2 percent in 2013 according to a study in Health Affairs.

The gains in states that expanded their Medicaid programs under Obamacare were especially pronounced, with the uninsured rate among new mothers falling 56 percent compared with 29 percent in non-expansion states.

But the Republican-led push to dial back Medicaid expansion has put a spotlight on controlling spending across the entire program.

Some states are exploring alternatives. Missouri’s Department of Social Services this month intends to ask the Trump administration for a waiver that would allow it to offer Medicaid coverage to postpartum women struggling with substance abuse for one year after they give birth. The move would cover about 1,500 of the 24,000 women in the state whose benefits lapse 60 days after childbirth.

The state’s Republican-controlled legislature endorsed the idea last year after killing a broader expansion of Medicaid benefits to postpartum women.

In Texas, where 382 women died within a year of giving birth between 2012 and 2015, Republican Gov. Greg Abbott this week downplayed the state’s maternal mortality rate on Twitter and said that the state was already doing enough to deal with the issue.

Last month, legislators opted to develop postpartum care services within an existing state program geared towards family planning, which will cost about $56 million over five years, instead of extending Medicaid for 12 months, which carried a five-year price tag of nearly $1 billion in state and federal funds.

Kay Ghahremani, the state’s Medicaid director disputes the cost analysis, saying it would actually save money in the long run by promoting wellness and averting potential emergencies.

“It’s the most important thing we can do for maternal health in this state,” said Ghahremani, now president of the Texas Association of Community Health Plans. “We don’t want to see a single mom die from things that are avoidable.”

 

Trump admin opens door to fundamental changes in healthcare benefits

Posted on by • Posted in 2020 Election Issues, Defined Benefit Contribution Option, Employee Benefits, Health Reimbursement Accounts (HRA), Limited Delivery Networks, Out-of-Network • Leave a comment

https://www.healthcaredive.com/news/trump-admin-opens-door-to-fundamental-changes-in-healthcare-benefits/556927/

The Trump administration has opened the door to altering how healthcare benefits are provided to millions of American employees. A new rule, set to go into effect next year, will allow employers to provide workers with funds to shop for coverage on their own, an option that could dramatically upend employer-sponsored coverage.

Instead of working with an insurer and allowing employees to pick from a few insurance options, employers will be able to funnel money into a standalone tax-exempt HRA (health reimbursement account) and employees could use those funds to shop for coverage on their own, either on the Affordable Care Act marketplaces or off.

“Long term, this added flexibility may reshape a significant number of employer coverage offerings and result in sizable shifts from employer to individual coverage,” Chad Brooker, an associate principal at Avalere who consults on healthcare reform and the impacts on business strategy, said in a statement.

White House officials said the change provides more flexibility to employers and gives workers greater choice when choosing coverage. The White House expects 800,000 employers to choose this defined benefit contribution option, which is expected to affect 11 million employees and their families.

The American Benefits Council cheered the move.

“We commend the Administration for taking what we believe is an important step toward greater flexibility in health care coverage,” the employer group’s president, James Klein, said in a statement.

But others voiced their concerns about potential costs and access issues.

Paul Fronstin of the Washington, D.C.-based Employee Benefit Research Institute said it may be overwhelming for some employees used to relying on their employers to do the bulk of the shopping for them or going to bat for them when an issue with the insurance carrier arises.

“Some people are going to like that and some people are going to hate it,” Fronstin told Healthcare Dive.

Positives of the idea are that it could lessen job lock, when an employee is somewhat stuck in a job because they don’t want to, or can’t afford to lose benefits, including health insurance.

With the unemployment rate near a historic low, Fronstin doesn’t expect large employers to switch immediately. However, when the next recession hits, “I think the future of health benefits gets put to the test,” he said.

But others say the idea that it solves job lock is overplayed.

The options on the ACA exchange, particularly in St. Louis, may come as a shock to employees who are used to robust networks, Kevin Guss, vice president of private client benefit services for St. Louis-based benefits consulting firm J.W. Terrill, told Healthcare Dive.

There are few providers selling individuals plans, out-of-pocket maximums are far higher and many have very limited networks with little out-of-network availability, he said.

“You can save money if you pursue this path, but buyer beware,” Guss said.

 

 

 

The drug pricing debate is stuck in the past

Posted on by • Posted in 2020 Election Issues, ACA, Biologics, Biosimilars, Competition, Food and Drug Administration (FDA), Gene Therapy, Generic Drugs, Generic Entry, Health Policy, High Drug Prices, High Prices, Highly Specialized Drugs, Limited Competition, Out of Pocket Expenses, Patent Protections, Precision Medicine, Preexisting Conditions • Leave a comment

https://www.axios.com/drug-pricing-debate-stuck-in-past-10ba315e-0ddf-4013-8c5a-f8ee89c2f530.html

Illustration of falling pills and coins

There’s a scientific and economic revolution happening in medicine, and the political debate over drug prices isn’t keeping up. Not only are policymakers struggling to agree on solutions, they’re mostly talking about yesterday’s problems.

Why it matters: Medical innovation is already hurtling toward a new era of highly specialized drugs — some are even tailor-made for each individual patient. They may be more effective than anything we’ve seen before, and also more expensive. But the drug-pricing debate is more focused on decades-old parts of the system.

The big picture: “We haven’t really contemplated how we’re going to absorb some of these things,” Food and Drug Administration Scott Gottlieb said. “These are good problems to have…but they are policy challenges.”

Where it stands: Congress is mainly squabbling over proposals to reduce prices by boosting competition — by making it easier to start developing generics, or by changing patent protections that help pharmaceutical companies keep their rivals at bay.

Yes, but: Those regulatory tools were designed for a world in which pharmaceutical companies develop relatively simple drugs and try to market them to a big group of people. But science is rapidly moving away from that world.

  • Gene therapy, for example, is the new wave in cancer treatment. It helps patients’ own immune systems fight off cancer — which means each dose is custom-made for each patient. It’s a highly promising approach, but treatment can come with a price tag north of $1 million once all is said and done.
  • The old dichotomy of a brand-name pill followed by a generic version of that pill doesn’t really hold up for custom-made drugs.
  • So tools that try to promote competition simply may not work as well. “I don’t think they’re solutions for gene therapies because I think you’re ultimately going to have to figure out ways to capitalize those costs,” Gottlieb said.

Even without being custom-made, many new drugs are still trying to treat smaller groups of patients — like people with the same specific genetic mutation.

  • “Generic entry might not prove to be as successful for addressing this problem as it has historically been, and I think it’s because we fundamentally have shifted into these other types of products where competition is just more challenging,” Vanderbilt’s Stacie Dusetzina said.

Most of these new drugs belong to a class known as biologics. They’re more complex than the drugs we’re used to, and therefore have the potential to be more precise in the way they interact with your body.

  • “The way drugs are produced and made now is quite different from the way they were produced and made in the early ‘80s, and that’s both because…you have a lot of these drugs being made for small populations, and for biologics the science is so much more complicated,” said Rachel Sachs, a professor at Washington University.
  • Biologics don’t have traditional generic versions; the equivalent are products known as “biosimilars.”
  • The Affordable Care Act created a pathway for the FDA to approve biosimilars, but that market has been slow to take off, and at least in the early going, biosimilars often don’t offer the same steep discounts as traditional generics.

Promoting competition isn’t the only idea in the world, but more muscular price controls are much more controversial.

  • Most of these new, complex drugs are administered at a doctor’s office, not picked up from a pharmacy. The Trump administration has proposed tying Medicare’s payments for that class of drugs to the lower prices that other countries pay, and Democrats support direct Medicare price negotiations.

The bottom line: “One version of ten years from now will have very limited competition in certain types of markets, either because the market has eroded it to be that way or because the drugs that are coming out will by definition have limited competition,” said Rena Conti, a professor at Boston University.

 

 

 

On the Doorstep With a Plea: Will You Support Medicare for All?

Posted on by • Posted in 2020 Election Issues, Employer-Based Health Insurance, Grass Roots Support, Health Insurance Coverage Adequacy, Health Insurance Industry, Health Policy, High Deductible Health Plans, High Premiums, Human Rights, Labor Union, Out of Pocket Expenses, Preexisting Conditions, Public Option, Single Payer Health System • Leave a comment

Art Miller listened patiently as the stranger on his doorstep tried to sell him on the Medicare for All Act of 2019, the single-payer health care bill that has sharply divided Democrats in Congress and on the presidential campaign trail.

The visitor, Steven Meier, was a volunteer canvasser who wanted Mr. Miller to call his congresswoman, Abby Finkenauer, the young Democrat who took a Republican’s seat last year in this closely divided district — and press her to embrace Medicare for all. Beyond congressional politics, there was the familiar role that Iowa plays as the first state to weigh in on the fight for the Democratic presidential nomination.

“I want to know how my grandkids are going to pay for it, O.K.?” Mr. Miller, 71, mused, peering at the flier that Mr. Meier had handed him.

It was a fairly typical encounter for Mr. Meier, 39, who with hundreds of volunteers around the country is working with National Nurses United, the country’s largest nurses’ union, to build grass-roots support for the single-payer bill, a long shot on Capitol Hill and a disruptive force in the party. House Democrats have declared this Saturday and Sunday to be “a weekend of action on health care” — but they are split over whether to embrace extreme change or something closer to the status quo.

A single-payer health care system would more or less scrap private health insurance, including employer-sponsored coverage, for a system like Canada’s in which the government pays for everyone’s health care with tax dollars. Democrats not ready for that big a step are falling back on a “public option,” an alternative in which anyone could buy into Medicare or another public program, or stick with private insurance — a position once a considered firmly on the party’s left wing.

Lawmakers like Ms. Finkenauer, mindful of the delicate political balance in their districts, fear the “socialism” epithet that President Trump and his party are attaching to Medicare for all. On Friday, Mr. Trump called the House bill “socialist health care” that would “crush American workers with higher taxes, long wait times and far worse care.” But even Ms. Finkenauer, who beat the incumbent Republican in November by 16,900 votes, has been pulled left by the debate, embracing the public option, which could not get through Congress when the Affordable Care Act passed in 2010.

“In a divided Congress, I’m focused on what we can do to bring immediate relief to Iowans,” she said in an email.

The nurses’ union and a number of other progressive groups want nothing less than a government system that pays for everyone’s health care, seizing on the issue’s prominence and a round of Medicare for all hearings in the House with canvassing in the districts of many of the 123 House Democrats who have not thrown their support behind a single-payer system.

“Hearings are a moment for us to have a national stage for this campaign,” Jasmine Ruddy, the lead organizer for the nurse union’s Medicare for all campaign, told several dozen new volunteers on a training call last month. “It’s up to us to take advantage of the momentum we already see happening and turn it into political power.”

But building support for a single-payer health care system has been slow going. On Wednesday, the chairman of the Ways and Means Committee, Representative Richard E. Neal of Massachusetts, convening the House’s third Medicare for all hearing, said it was about “exploring ideas.”

Republicans warned darkly of sky-high tax increases, doctor shortages and long waits for care. Representative Kevin Brady of Texas, the senior Republican on the committee, said his constituents were “frightened” about their private coverage being “ripped out from under them.”

The nurses’ union campaign began just after Democrats won the House in November, when the union and several other groups held a strategy call with Representative Pramila Jayapal, Democrat of Washington, the chief author of the Medicare for All Act, and Senator Bernie Sanders of Vermont, who pushed Medicare for all into the mainstream during his 2016 presidential campaign.

“Rather than try to convince people it’s the right system,” Ms. Ruddy said, “our strategy is to reach the people who are already convinced that health care is a human right, to bring them in and actually make them feel the action they are taking matters.”

In Dubuque, Mr. Meier and his partner, Briana Moss, have knocked on 250 doors and gathered about 50 signatures over the past few months. About 20 volunteers, including a retired nurse and several college students, are also involved. Nationwide, canvassers have knocked on 20,000 doors and collected 14,000 signatures since February.

On a Saturday afternoon, Mr. Miller, a Vietnam veteran, told Mr. Meier about his positive experience with government health care through the Department of Veterans Affairs, saying, “I’ve seen how it can work.”

A few houses down, a woman who owns a cleaning service and would give only her first name, Sharon, and her party affiliation, Republican, said that if the bill covered abortions, “I won’t go for that.”

She added that she would be happy to stop paying $170 a month for supplemental insurance to cover what Medicare does not, but she did not want to see people who do not work receive free care. From the garage, her husband hollered that he agreed. Conceding defeat, Mr. Meier and Ms. Moss moved along.

Both Sanders supporters, they took on the cause in part because Ms. Moss has Type 1 diabetes and has struggled on and off to stay insured, though now she has Medicaid under the Affordable Care Act’s expansion of the program. Ms. Moss, 30, went to see Ms. Finkenauer in her district office this year and asked if she supported a government system that eliminated insurance. Ms. Finkenauer, she said, stated her preference for a public option.

“That’s simply a compromise that leaves the insurance companies still in the game,” said Mr. Meier, who recently started working at John Deere building backhoes and will soon have employer-based coverage after being uninsured for his entire adult life.

The Jayapal and Sanders bills would both expand traditional Medicare to cover all Americans, and change the structure of the program to cover more services and eliminate most deductibles and co-payments. There would effectively be no private health insurance, because the new system would cover almost everything; Mr. Sanders has said private coverage could be sold for extras like cosmetic surgery.

While polling does show that Medicare for all has broad public support, that drops once people learn it would involve raising taxes or eliminating private insurance. That finding bewilders Mr. Meier, given many of the conversations he has on people’s front steps.

Those conversations keep coming. Rick Plowman 66, complained bitterly about how despite having Medicare, he had to pay nearly $500 for inhalers to treat his chronic obstructive pulmonary disease. Still, he was skeptical.

“I just don’t know what it’s going to look like down the road,” Mr. Plowman said. “Even Social Security for kids, you know? Even for you guys?”

“I’m willing to start making that sacrifice right now,” Mr. Meier pushed back. Mr. Plowman signed the petition.

At a white bungalow around the corner, Mr. Meier found — finally — that he was preaching to the choir with Bobby Daniels, 50, and his wife, Andrea, 46. Mr. Daniels, a forklift operator from Waterloo, said their coverage came with a $3,000 deductible and he would “most definitely” support Medicare for all. Ray Edwards, 36, an uninsured barber, also heartily signed on.

At the final stop of the day, Mr. Meier and Ms. Moss encountered Jeremy Shade, 36, a registered Republican who promptly told them his sister lived in Canada and had spent “hours and hours in the hospital, waiting for care” under that country’s single-payer system.

“I get that concern, and it’s something I’m worried about, too,” Mr. Meier said as Mr. Shade’s dog barked. “Would you be interested in maybe just calling Abby Finkenauer and saying, ‘Hey, what are we doing about the health care problem in this country?’”

“My wife would,” Mr. Shade said, explaining that she was a Democrat. “I’m real wary about it.”

Two hours of hot canvassing amid swarms of gnats had yielded six petition signatures and a few pledges to call Ms. Finkenauer. Mr. Meier was determined to end on a positive note. “I really think health care could be the issue that could get people to stop being so on one side or the other,” he said, a point that Mr. Shade accepted, shaking his hand before retreating inside.