The most recent issue of Health Affairs focuses on “The Politics of Health Care Reform” and features an article by pollster Celinda Lake, president of Lake Research Partners in Washington.
Lake takes the pulse of public opinion by holding focus groups, and then tries to shape a reform plan that mirrors their hopes and fears. Rather than crafting a blueprint for health care reform and then presenting it to the public for discussion, Lake believes that reformers should begin “by exploring voters’ own perceptions and the core values that shape their views on health care…Leaving aside the base voters at opposite ends of the spectrum who were most strongly in favor of or opposed to universal health care,” she and her group “focused on the large clusters of swing voters whose support for health reform was more conditional. Through segmented focus groups and a national telephone survey in 2006, we identified a set of values that drive these swing voters’ perceptions of reform.”
Lake has little patience with old-fashioned reformers: “Advocates for change in health care would like to think that by using a combination of facts and reason, they could persuade Americans that a progressive, universal health care system would be more effective, efficient, and humane than the current system,” she writes. But that’s simply not true, she asserts: “real changes must be enacted in the world of politics and public opinion, where values and perceptions are more important than facts and reason.”
Lake is not alone. I have heard other progressives express their belief that conservatives have “won” the national political debate in recent years because they are so clever at using memorable memes and slogans to appeal to voters’ values and emotions. And Lake is right that slogans don’t appeal to “fact and reason.” Slogans are like television ads or bumper stickers: they’re not designed to provoke thought; the goal is to make the mind click shut like a box.
As Lake goes on to describe the “perceptions” that reformers should
appeal to, it becomes apparent that those perceptions are often simply
For example, she points out, voters really don’t understand what drives
health care spending: “Although their understanding of cost drivers is
usually muddled (far overestimating the importance of malpractice
lawsuits, for example), the desire to get costs under control is the
most powerful impetus for change. Americans believe that choice and
competition help control costs, so including these elements in reform
As Lake knows, malpractice lawsuits are not the main driver behind
rising health care costs. Ever-more expensive medical technology is
pushing prices skyward. She also knows that choice and competition have
not brought health care prices down for the past 50 years, and it’s not
likely that they will in the future. When a rival comes to market with
a new pill, device or procedure it is rarely less expensive than the
treatment it is replacing.
But while acknowledging that Americans are “muddled,” Lake doesn’t seem
inclined to try to open their eyes. Instead, she counsels: use their
confusion to sell them on your plan. That’s why you should never
mention what’s going on in foreign countries: “An American solution is
needed,” Lake explains: “Most Americans are not looking to emulate
Canada or Germany but want a solution that uses American ingenuity to
deliver high-quality, affordable care to all. Many voters believe that
the United States has the ‘best’ health care in the world and are
nervous about changes that might dilute its quality.”
Of course stacks of medical research tell us that we don’t have the
best health care in the world. And if we expand on the system we have
now, we’ll just wind up with a bigger, more expensive mess. Structural
reform is needed. One might want to share that truth with taxpayers.
But explaining that would require appealing to “fact and reason”—which
are prohibited in Lake’s world.
Lake is not interested in explaining reform; her goal is to market
reform. And how do you market a product? By appealing to prejudices,
and playing on the ignorance of your audience. If they think a yellow
box make it a friendlier product, then put it in a yellow box.
But it’s not just the public’s “perceptions” that are important. You
must appeal to American “values.” Here Lake is blunt. “What Americans
want to know is: ‘what’s in it for me?’. “They want to know the bottom
line for themselves and their families: Will this plan make my care
better or worse? Will my costs go up or down? By how much?” After all,
she reminds reformers, “Since more than 90 percent of those who
actually vote still have health coverage, this becomes a comparison of
‘what I have now’ to ‘what I might get.’”
To be fair, Lake says that Americans also care about “responsibility,”
“choice” and “peace of mind.” But she has a disturbing way of assuming
that Lou Dobbs lurks somewhere in the heart of every American. “The
wild card in the health care debate in 2008 is immigration,” Lake
warns. “The continued influx of undocumented immigrants and the federal
government’s failure to manage the immigration system have generated
widespread resentment and frustration. Because voters widely perceive
undocumented immigrants to be a major burden on social services,
including the health care system, their instinctive reactions around
this issue are restrictive and punitive. This presents a dilemma for
advocates and candidates who are serious about achieving affordable
health care for all—knowing that any inclusive proposal will be
attacked as "providing health care benefits for illegal immigrants." In
the current environment, this is potentially a greater vulnerability
than any of the usual attacks on taxes, government control, and so on.”
And this, I have been told, is a reason why reformers should avoid the
phrase “universal healthcare.” It’s too inclusive. It suggests we might
extend healthcare to immigrant children.
Of course, as Niko has pointed out here on Health Beat,
the truth is that illegal immigrants do not present a major burden for
our health care system: “According to a 2006 RAND study, in 2000 health
care for undocumented immigrants between 18 and 64 years old cost
taxpayers about $11 per household—roughly the price of a cheeseburger
in Manhattan.” That’s $11 for an entire year of care. By sharing this
piece of information with the public, we might allay voters’ fears.
Or even better, why not appeal to the public’s more generous emotions?
Yes, most people worry first about themselves and their families, but
most also have enough imagination to fee empathy and to recognize that
“There but for fortune…” Few would want a sick child to go without
healthcare even if her parents had come here illegally.
True political leadership inspires and educates. It makes us feel that we, and the nation, can be better than we are today.
Finally, I can only wonder: what would have happened to civil rights
legislation if, instead of marching, reformers had said “let’s form a
focus group, and find out what the folks sitting on the fence in