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.

Kevin Lamarque/Reuters
President Barack Obama met with governors to discuss healthcare at the White House on June 24.

The final details of healthcare reform have yet to emerge from the committee rooms and caucuses on Capitol Hill, but the battle to shape public opinion is already fully scripted and well under way.

The "messaging wars" are, in many respects, just as important as those taking place now in congressional committees. Democratic activists say that President Clinton's bid for healthcare reform in 1994 and - for those with longer memories – President Truman's failed 1946 plan toppled on fear, not policy.

Those administrations were outflanked rhetorically long before bills got near a vote. But this time both sides are keenly aware that the words they use now could play a decisive role in what happens to the policy to come.

So they are rolling out a new battery of poll-tested phrases to tilt the terms of the debate to their own advantage. Is it a "government takeover" or a "public option"? Is it "universal coverage" or "quality, affordable healthcare for all"?

"These are very carefully selected linguistic choices," says Kathleen Hall Jamieson, a professor of communication and director of the Annenberg Public Policy Center at the University of Pennsylvania. "There is a linguistic set of choices under every policy decision, and when you frame it poorly, you're going to lose the argument."

So far, the biggest flash point in the debate has been the prospect of a government-sponsored insurance plan to compete with those of private insurers. President Obama says it's needed to ensure affordable coverage for all Americans and to restore the nation's fiscal health. GOP critics say it's a slippery slope to an all-government, single-payer plan that will ration care.

But while the policy wonks work out the legislative language, messaging gurus and pollsters are working out what to name it.

The big messaging breakthrough for Democrats was to dump any reference to a "government-run healthcare plan" in favor of a "public option." Instead of "universal coverage," which signals a big government program, the new message is "quality, affordable healthcare for all."

For its part, the GOP is trying to humanize its messaging.

Don't talk about "healthcare systems," said pollster Frank Luntz in a leaked memo, confirmed by a spokesman, on the language of healthcare for GOP lawmakers. Personalize the impact of a government "takeover" on individual healthcare decisions.

"Nothing will anger Americans more than the chance they will be denied the healthcare they need for whatever reason," he wrote.

That phrasing is ubiquitous in GOP floor speeches, although some lawmakers or their aides deny that a pollster is behind it.

Previous attempts at healthcare reform – in 1994 and 1946 – underestimated the power of the opposition to define the message before the policy took shape. The American Medical Association sank the Truman plan by dubbing it "socialized medicine," and the insurance industry ran ads suggesting that the Clinton plan would limit choice.

There was no pushback. It's an error that Obama-era reformers say they will not repeat.

"At the national level, there was no messaging, no public discussion for months as we waited for a bill to come out, and it allowed the opposition to define the issue," says Robert Chittendon, executive director and cofounder of the Herdon Alliance, a coalition to promote healthcare reform.

"By the time we got around to getting a bill, we had an argument we couldn't refute," he says. It's a war of words - poll-tested, dial-tested, scrubbed, and polled again. The target is voter emotions.

"We're getting the spin before the substance," says Brooks Jackson, director of, a project of the Annenberg Public Policy Center.

"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."

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."

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