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Defining the (carefully crafted) terms of healthcare reform

There’s no reform bill to debate yet, but both sides know that shaping the debate early is crucial to victory.

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"This is not a rational process. It's a propaganda process. It's a campaign to inflame emotions and trigger psychological responses with particular words and labels, not to explain the pros and cons of how a particular system will advantage some and disadvantage others."

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In 1993, the insurance industry played on Americans' emotions with a series of TV ads that drummed up fear of change. They featured a suburban couple, Harry and Louise, who worried that the complicated plan with its government bureaucrats would get between them and their doctor and limit choice. "Government-run healthcare. There's got to be a better way," the ad concluded.

"‘New' scares people. ‘New' is not something you want to do in healthcare," says Richard Kirsch, national campaign manager for Health Care for America NOW, who published an article in 2003 making the case for a new strategy to frame the policy debate.

In response, organizations working for reform have sought to get their message before the public quickly enough to influence the debate.

"One of the things we have tried to do in our work for advocates is understand how to talk about change in healthcare, while assuring people that there isn't too much change and that it won't take away things that they care about," says David Mermin, a partner at Lake Research Partners, a public opinion research firm.

"It's been a gradual accumulation of understanding of what works and what doesn't in moving people to a place where they're not only supportive but robust in their support for major change in healthcare," he adds.

Some early conclusions: "public" is a more benign word than "government"; "option" is a less-threatening word than "plan." Hence the key messaging term, "public option."

The Clinton-era call for "universal healthcare" evoked images of a big government program that gives something away. "It sounds like they're paying for something for somebody else," Mr. Mermin says.

The new message – "quality, affordable healthcare" – signals that people will pay something. "It's not welfare," he adds. "That is an American value that everyone is doing their part."

The term "quality" also signals that the new plan is not a discount product. "People don't want their healthcare to be cheap. It's not a discount product. That's a key message to put ‘quality' and ‘affordable' together," adds Mr. Kirsch, a veteran of the Clinton healthcare wars.

The Democrats' messaging meisters are convinced they can beat the GOP on all but one point: illegal immigration. None of the plans in the works on Capitol Hill includes coverage for illegal workers, but conservative commentators, including CNN's Lou Dobbs and former Sen. Fred Thompson (R), recently made the case that those in the country illegally would gain access to a government-run health plan.

Undocumented workers and their families are already gaining access to emergency rooms, says Professor Jamieson. There's no indicator that they will be more costly to the government with access to insurance.

But Jamieson says Democrats have got to get immigration "off the table, because it is an issue that derails the debate."

As Congress heads into a debate on overhauling a system that accounts for 18 percent of US gross domestic product ($2.5 trillion a year), the importance of controlling the message heard by the American public could hardly be greater.

"It is the reality of American politics that defining an issue or a policy is as important as the policy itself," says Julian Zelizer, a congressional historian at Princeton University in New Jersey. "Every time we have a major debate, it's clear that [whoever] frames the debate has a better chance of winning."