Health Care

“The administration lost the communications war with disastrous consequences that played out on Election Day 2010.” That is former Pennsylvania Governor Ed Rendell, but it could have been any number of pundits or political figures who argue that the Obama administration didn’t effectively sell health care reform in 2009 and 2010. John Sides has already used this space to show that some of the major scholarly works on Presidential messaging or framing are skeptical about the power of bully pulpit, a point Ezra Klein has made in The New Yorker as well. Looking specifically at health care, I’ve argued that the stability in the words that Americans use to describe their views on health care reform means that it is unlikely different messages would have demonstrably changed public opinion. On Monday, I also tracked public opinion on health care reform across a variety of demographic sub-groups and found a level of sub-group stability that makes it harder still to contend that politicians’ changing messages were a central driver of public opinion. Here, I want to use Americans’ words about health care reform to reinforce that point. If anything, health care reform might be a good example of the limits of elected officials’ capacity to reshape public opinion through framing.

In surveys conducted by the Pew Research Center and by the Kaiser Family Foundation, respondents were asked to explain in their own words why they supported or opposed health care reform four times between the debate’s beginning in the summer of 2009 and the 2010 mid-term elections. I took a set of commonly occurring words in those responses and then considered which words were most likely to be used by supporters or opponents of health care reform. Below, I plot these differences (on the y-axis) by a measure tapping how commonly and consistently the words are used overall (the words’ frequencies divided by their standard deviations, on the x-axis). The words in red that are closer to the top are those used disproportionately by supporters, while those in blue indicate the language of opponents. In all four surveys, the single word most associated with opposing health care reform is “don’t,” typically followed by “cost” (in 3 of the 4 surveys). Terms like “pay,” “run,” “money,” and “control” were some of the other words most consistently associated with voicing opposition.

Among supporters, the most common words were “health” and “care,” followed by words like “help,” “afford,” “access,” and “children.” From the point of view of partisan messaging, though, what is striking is the stability of the words used both by supporters and opponents. In July of 2009, the Tea Party was just starting to capture headlines and President Obama still enjoyed something of a honeymoon in the eyes of the public. A bipartisan group of Senators was meeting to discuss health care reform. But even then, before the “death panels,” the town hall meetings, the September Presidential address, the legislative wrangling, and so much else, supporters and opponents had largely found the language that they would maintain throughout the debate. Above all, citizens opposed to health care reform were worried about its cost and about an increased government role in health care, while supporters saw the issue as one of expanding access and assistance to children and other groups.

My understanding of the individual mandate, like that of Harvard economist Gregory Mankiw, is that it is functionally equivalent to a tax on those who don’t have insurance. One reason its advocates might have framed the policy as an individual mandate is to avoid being seen as raising taxes, making the individual mandate itself a framing device. In that light, consider the words that Americans opposed to health care reform used to express their opposition. In July of 2009, the word that ranked 9th among the vocabulary of health care reform opponents was “tax.” In November of 2009, “tax” jumped to 7th, before moving to 8th in May of 2010 and 10th in October of 2010. What’s more, “cost” was consistently either the second- or third-ranked word among opponents throughout this period. So even before a bill had been drafted, opponents were concerned about what health care reform would mean for government costs and for federal taxes. The increased salience of the individual mandate did little to assuage those concerns. While health care reform is taken to be an example of the importance of framing, it might just be an example of the limits of framing instead.