Framing Health Care Reform for Public Understanding and Support

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Framing Health Care Reform for
Public Understanding and Support
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The Perspective Strategic Frame Analysis (SFA)

• Pays attention to the publics 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.

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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.

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• 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?

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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

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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?

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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

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The Cognitive Perspective
Are you satisfied with current child care
arrangements?
83 say yes
Issue
Visible Attitude
Hidden Reasoning
What are they thinking?
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Visible Attitude
Issue
Implication 1
Model A
Implication 2
Implication 3
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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

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Different Kinds of StoriesSet 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

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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
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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 dont fit the frame, its the facts
  that are rejected, not the frame
• Awareness is not the (only) goal if the frames
  dont work, your issue will fall off the public
  agenda anyway

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Applying Strategic Frame Analysis to Health Care
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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

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5 ObservationsToward A Situation Analysis

• The problem is not about health, its about cost.
• Its 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 familys protections.
• There are reasons to dismiss the appeal to
  health
• USA best health care in world NH healthy
  state.

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• 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, its 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 theres a lot of discussion about the
  problem of the uninsured, but theres 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.

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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.

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5 ObservationsToward 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
  .
• 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.

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My mind. My body. My spirit. My health.
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Insurance Co.
Insurance Co.
Systems View vs. Consumer View
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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

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5 ObservationsToward A Situation Analysis

• 3. 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.

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• 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 insuranceI'm not denyingbut
  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 costsI 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

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• Whats Fair?
• If you are going to extend it to adults, it
  shouldn't be just the parents of kidsIt 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

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Reframing Responsibility

• Consumer Stance Responsibility for Me
• Altruistic Stance Responsibility for Them
• Manager Stance Responsibility for It/Us

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5 ObservationsToward 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.

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• 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 moneyIf I were
  to go back into the workforce, most places would
  only hire me part time. NH focus group
  conversation
• In New England, theres a lot of smaller
  operators, like theres 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 cant afford to pay them enough to
  insure them because the insurance would cost him
  so much it would put him in bankruptcy. And I
  dont think thats right. -- NH elicitations

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5 ObservationsToward 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 dont 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.

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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

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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

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Reframing Health Care Reform

• Preliminary Recommendations

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Preliminary Recommendations

• Step by Step
• Situations, not Groups
• Explain how the system works
• Vary the messengers
• Government as referee
• Prime policies with values

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Develop and advance astep-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

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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 lets not let the perfect be the enemy
  of the good.

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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
• Dont talk disparities, victims or groups
• Avoid zero sum, them v. us, personal experience
  all default to insecurity

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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

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

• Whats 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. Thats 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.

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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 dont get too
  far out of hand again.

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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 doesnt work

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Convincing Reasons for Reforms1-10 point scale,
AZ Survey

• PLAN. Theres 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,
  divorceWe need health care reform that means
  people in any of these situations no longer have
  to worry about health insurance. 7.5

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I think its a very hard situation. Its a very
expensive situation. And everybody gets I know
the insurances are high, the premiums, I dont
knowI really dont know how youd ever try to
solve it so it could be/ everybody could get
insurance, I really dont know. Its a hard
situation. NH elicitations informant

• Current Motivation Assumptions
• Crisis
• Problems
• Uncontrollable threat
• Worry
• Sympathy
• Whats in it for me

• Better Motivations for Engagement
• System break-down
• Solutions
• Man-made problem
• Plan
• Efficacy
• Right thing to do

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Thanks to our Funders

• California Wellness Foundation
• The California Endowment
• Endowment for Health (NH)
• Healthy New Hampshire Foundation
• St. Lukes Health Initiatives

www.frameworksinstitute.org