Framing Health Care Reform for Public Understanding and Support

The Perspective: Strategic Frame Analysis (SFA)

• Pays attention to the public’s deeply held worldviews and widely held assumptions.

• Studies those assumptions to determine their impact on policy preferences.

• Taps into decades of scholarly research on how people think and communicate.

• Suggests ways to help people reconsider issues by changing the way issues are framed.

What Are Frames?

Big ideas -- shared and durable cultural models -- that people use to make sense of their world. These organizing principles are ‘triggered’ by familiar and highly charged vehicles as symbols, pictures, metaphors, and messengers – the grammar of storytelling. One evoked, frames provide the reasoning necessary to process information and to solve problems.

PAT IS A WEASEL

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If Pat is a Weasel,

• And I loan money to Pat, will I ever see it again?

• And I confide a secret to Pat, will s/he keep it?

• And I ask Pat to do something important for me over the weekend, can I count on him/her to do it on time?

• And s/he dated your son, daughter, brother, sister or mother, would you be happy?

What Research Suggests About How People Process Information

• People are not blank slates • People use mental shortcuts to make sense of the world • Incoming information provides cues that connect to the pictures in our heads • People get most information about public affairs from the news media, which creates a framework of expectation, or dominant frame • Over time, we develop habits of thought and expectation and configure incoming information to conform to this frame

The Questions We Ask

• How does the public think about health care and the larger context of the health care system? • Are there dominant frames that are automatically relied upon to make sense of unfamiliar situations or policies?

• How do these frames affect policy preferences?

• How can the problems affecting health care be reframed to evoke a different way of thinking, one that makes appropriate policy choices salient and sensible?

Where and How We Look for Answers

Methods • Open-ended interviews • Ethnographic studies • Focus groups • Media effects experiments • Media content analysis • Survey research Disciplines • Mass communications • Political science and political psychology • Cognitive sciences (linguistics and anthropology) • Sociology and social movements

Are you satisfied with current child care arrangements?

The Cognitive Perspective

83% say yes Issue Visible Attitude Hidden Reasoning What are they thinking?

Issue Visible Attitude

Model B Implication 1 Model A Implication 2 Implication 3 Implication 4 Implication 5 Implication 6 Model C Implication 7 Implication 8 Implication 9

The Challenge of Reframing

• When communications is inadequate, people default to the “pictures in their heads” • When communications is effective, people can see an issue from a different perspective

Different Kinds of Stories Set up Different Policy Solutions

EPISODIC FRAMES • Individuals • Events • Psychological • Private • Appeal to consumers • Better information • Fix the person THEMATIC FRAMES • Issues • Trends • Political/environmtl • Public • Appeal to citizens • Better Policies • Fix the Condition

Reframing Tobacco

Smoking: Old Frame Choice/freedom Individuals Drug addiction (personal vice) Responsibility of parents Bad behavior (teens’) Vital industry Protection (Just say no) Smoking: ReFrame Defective Product Big Tobacco Manipulation of drug addiction Responsibility of government Big $ in politics/corruption Deviant industry Protection from advertising

CHANGE BEHAVIOR CHANGE PUBLIC POLICIES

Therefore…

• Persuasive communications cannot depend on simply putting information in front of people • It must change the lens through which they see the information • If the facts don’t fit the frame, it’s the facts that are rejected, not the frame • Awareness is not the (only) goal; if the frames don’t work, your issue will fall off the public agenda anyway

Applying Strategic Frame Analysis to Health Care

The Research Base

Completed • Meta analysis of existing public opinion • 19 focus Groups in 3 states: NH, CA, AZ • 50 cognitive elicitations in 2 states: NH, CA (engaged citizens + influentials) • Framing analysis of news and advocates’ materials • Content analysis of selected media • 1 public opinion survey in AZ Projected • 2 statewide public opinion surveys (CA, NH) • Development of a simplified model for the health care system • 4 focus groups (NH) • 18 related focus groups on race and health care

1.

5 Observations Toward A Situation Analysis

The problem is not about health, it’s about cost.

It’s about catastrophic, not preventive situations.

Health care is an expensive product, not a system.

This heightens individualistic reasoning.

Everyone has a story; everyone affected.

Access is reinterpreted as cost.

Insecurity about affordability drives people to prioritize “me and my family’s protections.” There are reasons to dismiss the appeal to health: USA = best health care in world; NH = healthy state.

• “I went without insurance for a year and I can remember stepping on a knife and thinking, ‘Oh my God, I'm going to have to go to the vet to get him to stitch me up.’” NH woman, focus groups. • “I think, essentially, it’s an affordability problem. Health care and health insurance coverage has become unaffordably expensive and for some that results in their having no coverage at all and there’s a lot of discussion about the problem of the uninsured, but there’s also tremendous pressure in the uninsured population to pay more and more for their coverage and so the way I see it is that we are essentially heading into a crisis of affordability for both health coverage and healthcare generally.” NH man, elicitations.

• “We have more people out of work that just can't afford it. They are either living on unemployment, or they are living on their savings, or they move back home, or families are moving out of California trying to find a cheaper place to live. California is just not conducive to low cost health insurance.” San Jose man, focus groups.

Reasoning in the Cost Frame

• If cost is the problem, covering the uninsured is not the solution.

• If cost is the problem, expanding eligibility will drive up costs.

• If health care is a precious and rare commodity, expanding demand without expanding supply (doctors) will drive up costs.

• If health care is a limited commodity, anything you give to others must be taken from me.

• If cost is the problem, the uninsured are people who have been priced out of the system or who are too cheap to pay, so lower the cost and they can repurchase – or choose not to do so.

5 Observations Toward A Situation Analysis

2. The operating model most available to most people is a consumer model in which health care is a commodity to be purchased by consumers, and the health care system is perceived as a private relationship between insured and provider

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• • • • The consumer model makes sense of all aspects of the problem: price, choice, vendor, quality, etc. Health care is a private good and there is no role for the uninsured who are, by definition, non-consumers.

The consumer model splits the constituency for reform between those who perceive the problem in different ways: quality, cost, or access . The negative power of the consumer model makes people fear they will lose ground if reforms are implemented; they are wary of anything that might take away their current coverage.

My mind. My body. My spirit. My health.

Insurance Co

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Insurance Co

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Systems View vs. Consumer View

Consequences of the “Consumer Good” Model of Health Insurance:

• • • • • What is Hidden?

A “Big Picture” understanding of the system The Uninsured Alternatives to the current situation The moral dimension of the problem The role of Government • • • What is Advantaged?

Promotes insecurity Promotes passivity Co-opts Responsibility

• • • • • •

3.

5 Observations Toward A Situation Analysis

Current reform appeals (e.g. cover the uninsured, expand to parents of CHIP children, etc.) cause Americans to default to a “them vs. us” zero-sum frame, and quickly evoke rhetoric and images from welfare and immigration debates (AZ and CA) and images of undeserving poor in NH.

For some Americans, primarily liberals, appeals to justice are effective (core base of 30% in AZ).

For a broader audience, it is unlikely that the rights frame will advance health care reform beyond a less tattered safety net.

Many Americans believe that adequate services for the poor already exist and that no one is really refused care.

Focusing on The Uninsured draws attention away from the system as a whole.

Discussion defaults to which group most deserving.

When threatened with insecurity, or limited product, people worry about negative consequences to their own coverage.

Us vs. Them

“We work to have private insurance and then people who get state Medicaid sometimes have better insurance coverage than we do and we work hard for our insurance…I'm not denying…but sometimes it feels like we're being punished because we work.” Ethnic woman, Phoenix focus groups “It's generation after generation that knows how to work the system, and they don't work,” Latina, Riverside CA focus groups “Free generally enables people to stay on welfare and get everything paid for that you and I work our butts off to enjoy.” Riverside man, CA focus groups “I'm sorry but I've been working and you're getting a state subsidy and I'm the one that is paying for you to do that. My standard of living is going down slowly, slowly, slowly because of having to increase these costs…I end up paying for it and I feel kind of cheated because wait a minute. I contribute to society. I do these things. I'm doing something and giving back and yet I'm not getting anything in return for it.” Asian American woman, Fresno, CA focus groups

What’s Fair?

“If you are going to extend it to adults, it shouldn't be just the parents of kids…“It should be to all adults.” “But if you are going to extend that, you need to extend it to anybody who doesn't have insurance.” “Otherwise it's a penalty to people who don't have children.” NH focus group conversation

Reframing “Responsibility”

•Consumer Stance – Responsibility for

Me

•Altruistic Stance – Responsibility for

Them

•Manager Stance – Responsibility for

It/Us

5 Observations Toward A Situation Analysis

• •

4. People are much more likely to favor reforms when they are framed as addressing situations that any person believes s/he could experience than when they are addressed to group identity.

Foregrounds the value of fairness without creating zero-sum considerations between groups or individuals. Can identify with many situations in which they might lose ground.

“Is it the minimum wage workers that can't afford the insurance, or is it because their companies won't give them enough hours to qualify for insurance?” “A part time person is going to make enough just to cover the insurance for the month.” “They hire you part-time because they don't want to pay your health insurance.” “But they don't pay you that much extra in salary to make up for it.” “For God's sakes, it's so much money…If I were to go back into the workforce, most places would only hire me part time.”– NH focus group conversation “In New England, there’s a lot of smaller operators, like there’s 15 employed people in a place working and they ought to be able to pay so much a month and carry on. At least get some insurance.” “The farmer can’t afford to pay them enough to insure them because the insurance would cost him so much it would put him in bankruptcy. And I don’t think that’s right.” -- NH elicitations

5 Observations

• • • •

Toward A Situation Analysis

5. Size of the reform and the responsible party need careful consideration or reforms will be rejected.

Big reforms elicit fear or losing ground; little reforms don’t address scope of problem.

People believe that government is less effective than business in solving problems.

Look to business to validate government reforms (not “socialized medicine”).

Reforms that feature small business in the package are highly favored.

Health Care Reform

• Crisis requires extensive overhaul of the system, but • People are extremely nervous about wholesale change, because • They do not trust the government and its politicians to do the right thing, thus • There is support for a stepped, “moving in the right direction” approach that incorporates a broad range of proposals but implements them gradually

Needs Change, but not complete overhaul.

The AZ statewide survey • 54% say “there are some good things in our health care system, but fundamental changes are needed to make it work better • 23% believe “the health care system has so much wrong with it that we need to completely rebuild it” • 19% agree that “on the whole, the healthcare system works pretty well and only minor changes are necessary to make it work better”

Reframing Health Care Reform

Preliminary Recommendations

Preliminary Recommendations 1. Step by Step 2. Situations, not Groups 3. Explain how the system works 4. Vary the messengers 5. Government as referee 6. Prime policies with values

1. Develop and advance a step-by-step plan

• Without a blueprint, people are unlikely to support incremental reform • With only a blueprint, people are likely to think change is too big and they will lose ground • Address cost and quality as well as access • Reform system for long-term (no band aids) • Transparency imperative • Multi-sector buy-in required (biz and docs) • Opportunity for philanthropy to play strong role

1. Example: Step by Step

“Ultimately, our nation needs to achieve fundamental reform in a health care system that has deep potholes all along the road of life: from first job to retirement….But we can fix the system in incremental fashion, by taking small but meaningful steps to expand coverage and promote fundamental improvements the health status of all Californians. Obviously we need a plan, but let’s not let the perfect be the enemy of the good.”

2. Explain lack of insurance in terms of situations, not groups

• First job, divorced, downsized, self employed, small business, part-time job, early retirement, specific industry, etc.

• Places the system is broken • Don’t talk disparities, victims or groups • Avoid zero sum, them v. us, personal experience – all default to insecurity

3. Vary the messengers associated with reform

• Business inoculates against socialized medicine • Profile industries or job classifications where benefits are lacking • Doctors inoculate against Harry and Louise • Reject victims as spokespersons • Try to avoid the usual suspects

4. WANTED: a simplifying model that connects citizens in the health care system and benefits from full participation.

What’s a simplifying model?

• A vivid analogy or mechanism that captures the essence of a scientific concept, and • has a high capacity for spreading through a population In the absence of the perfect: “We know that 6.7 million Californians find themselves shut out of the system. That’s close to one in every five Californians – the equivalent, amazingly, of the combined populations of our three largest cities (Los Angeles, San Diego and San Jose), with most of San Francisco thrown in as well. Put another way, this is like having a north-south freeway system designed for all Californians that dead ends above L.A. - leaving everything below it completely off the map! This affects all of us, because the health care system only works well when we all share the benefits and costs.”

5. Example: Government as Referee

“Government needs to call upon thoughtful interests in the society to come up with a plan for fixing the system for the long-term. That means bringing expertise and involved parties to the table, setting out a plan, phasing in needed repairs, and setting up a system of monitoring and accountability so that things don’t get too far out of hand again.”

6. Prime policies with values

• Unframed policies default to cost • Align reform with state and national values: Practical Management, Prevention, etc.

• Explain urgency as getting ahead of problem • Stress a reasonable approach, consensus building • Avoid partisanship (Just Politics) • Where salient, use the Rights Frame (places of worship) • Focus public education efforts teaching how the system works and where it doesn’t work

Convincing Reasons for Reforms 1-10 point scale, AZ Survey

• PLAN. “There’s no one fix that will address all the problems in the health insurance system. What is important is that we put a long-term plan in place and begin to take necessary steps toward improving health care.” 8.0

• PREVENTION. “Quality health insurance that includes check-ups, immunizations, well baby care, pre-natal care and other preventive care pays for itself in the long run by preventing problems before they happen or become serious. By expanding health insurance coverage, health care reform will pay for itself and result in healthier communities.” 7.8

• PLACES NOT PEOPLE. “There are lots of situations that result in people being uninsured – small businesses that do not offer health insurance, insurance companies that reject coverage due to pre-existing conditions, young adults that are too old to be on their parents’ coverage but cannot afford their own, early retirement, divorce…We need health care reform that means people in any of these situations no longer have to worry about health insurance.” 7.5

“I think it’s a very hard situation. It’s a very expensive situation. And everybody gets – I know the insurances are high, the premiums, I don’t know…I really don’t know how you’d ever try to solve it so it could be/ everybody could get insurance, I really don’t know. It’s a hard situation.” NH elicitations informant

Current Motivation Assumptions • Crisis • Problems • Uncontrollable threat • Worry • Sympathy • What’s in it for me Better Motivations for Engagement • System break-down • Solutions • Man-made problem • Plan • Efficacy • Right thing to do

Thanks to our Funders

• California Wellness Foundation • The California Endowment • Endowment for Health (NH) • Healthy New Hampshire Foundation • St. Luke’s Health Initiatives www.frameworksinstitute.org