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Dear colleague,

This month, FrameWorks Institute dedicates our newsletter to one issue: healthcare.
Since its founding a decade ago, FrameWorks has pursued a multi-method research agenda designed to generate a more productive conversation about healthcare reform. Links to the research can be found in the sidebar to the left. The following interview with Frameworks President Susan Nall Bales compares communications strategies that health care reformers have employed with the findings from FrameWorks' extensive research and practice in framing healthcare reform.
We hope you will find this interview interesting and informative.
Reflections on the Healthcare Reform Debate: an Interview with FrameWorks President Susan Nall Bales
Public Structures Q: You have said that the public conversation has not shifted since the early 1990s, when health care reform was last at the top of the public agenda.   Can you explain?
 
I remember going to a public discussion at the outset of the development of the Clinton healthcare plan, and it was a debate between progressive and conservative public opinion experts. The moderator asked each of them, What will be your major communication strategy? 
 
I remember vividly the ads that the conservative expert described. The visual employed by those ads was a long line outside of a US Post Office, where the "US Post Office" title was switched out, and it became "Government's Healthcare".  He said, 'All I'm going to do is talk about how you're going to have to wait in line to get access to government-controlled healthcare.' That ad is what has essentially been playing since then, and what is playing now. The problem has been that progressive healthcare reform advocates have not come up with productive ways to deflect that message.
 
What conservatives did was to suck the issue of healthcare into the issue of government, and then apply to healthcare all the entailments that come with government: corruption, bureaucracy,waste, fraud, and abuse. It's a classic framing strategy.  The strategy of progressives, by contrast, has centered on two mantras also used during the Clinton healthcare debate. One was, "healthcare is a right not a privilege". The problem with that, as Frameworks research has demonstrated, is that those who believe that assertion are already on board. But it is not a persuasive argument for anyone who isn't already a believer.
 
The other strategy has been, "cover the uninsured," which sets up an "us verses them" mindset. The individual stories that advocates have been encouraged to tell inadvertently direct people to think about individuals' choices, mistakes and responsibility for themselves. This, in turn, obscures "systems" thinking. FrameWorks Institute's research found that generating a clearer understanding of how and where the system is broken, and what can be done to reform it, is key to successful reframing efforts.   
 
So what are the stories that health care reformers should be telling? 
 
We should be telling stories about the system as a whole - as a grid, if you will, and looking at where it breaks down, where people fall out of this system. That's very different from a story that focuses on an individual who lost her insurance when she switched jobs - that kind of story tends to cue feelings of sympathy, but leaves people without any new information about how the system functions and what, exactly, is broken and needs repair. There are other opportunities that have been underexplored that could be very powerful to American thinking.  For example, some advocates have told stories about the percentage of bankruptcies that are directly traceable to healthcare costs.  These kinds of stories help people understand that the problem is undermining the ability of people to contribute to their communities, and of communities and the economy as a whole to stay solvent.  When you tell the individual story, you can only see clearly the idiosyncrasies of the individual's story. We need to widen the lens to show the broader context.
 
As Aldo Leopold observed, it all depends upon whether you look at the world as commodity, or as community. Progressives have inadvertently chosen to commodify healthcare, and community thinking has been sidelined.  As a result, all of the considerations that come with consumerist thinking - how much of it am I going to get; are you going to make it harder for me to get what I've had?  - dominate the discourse. These concerns are symptoms of consumerist thinking. So the administration and progressive advocates have been pushed into playing the Consumer game  - which, at the end of the day, becomes about reassuring people that they will be able to get theirs.
It is not, unfortunately, about making people more fully appreciative of and articulate about the contribution of infrastructure to the country's posterity, and our collective responsibility in managing that infrastructure.
 
President Obama is widely recognized as a masterful framer of social issues.  What happened?
 
The communications strength of this President has been both his respect for ordinary people and for their ability to think at a high level about public issues, and his willingness to engage them, and educate them at that level.Certainly we saw that in his major speech on race. He and his staff knew that race was going to be an issue they had to deal with very carefully.  I don't think they believed that healthcare posed the same magnitude of peril.
 
It is indeed true that people know the system is troubled. But as we have seen in our research, "change" is very threatening to Americans on this particular issue.  FrameWorks' research showed that people needed a step-by-step plan that inserted "accountability" at every point because they were nervous about the role of government, and they needed to be reassured that this plan would move in the right direction.
 
So how would you "reboot" the public conversation?
 
The vista that policy leaders see when they talk about "healthcare reform" - the need for it, its ultimate impact, and the way that it could be brought about  - is invisible to the American public.  Instead, the American public is caught up in a conversation that is about me, my healthcare, and my fear of losing it.
 
When you're in that kind of situation, there are two things you need to do to reframe:  one is to re-explain what this is about- why reform is necessary, what it connects to in the larger scheme of things, and how it resonates with American values.  There has been very little of that.  It is as if Healthcare Reform were a value in itself. Frameworks research would suggest that what needs to be done is to connect healthcare reform to long term goals, such as the future prosperity of society, our ability as an ingenious country to reform systems, or our ability to build the system that was never fully built in the first place, and to explain our collective responsibility in managing that infrastructure.
 
We need to move away from the idea of health care as a vending machine, in which my responsibility is reduced to choice and cost, to a concept that is more along the lines of a highway system.  I want that system maintained so that I can use it - and so that others can too, and I understand that it needs to be designed to work for everyone.  While I might not need to get to Visalia, I certainly understand that others may need to do so, and I understand that the system's reliability and functionality depend on its ability to get everyone where they need to go.  That is the frame change we need on health care reform.

Because, at the end of the day, the debate is not going to be won with a slogan; it's going to be won by the group that is able to cue up the most robust and concrete vision of how people want to see their society. Right now healthcare reform resisters are winning the day in part because it's about freedom, and individual choice, and consumerism.  We need to change that.