In a series of legendary television advertisements that aired in the early 1990s, a fictional middle-class couple known as Harry and Louise helped derail an effort to overhaul the nation’s health care system by stoking fears about how the legislation would affect Americans’ pocketbooks. Those ads sent a message that still resonates today.
In the more recent campaign to overhaul the nation’s health care system, President Obama spoke more often about the benefits of the law to the individual than to society as a whole, according to former Robert Wood Johnson Foundation (RWJF) scholars, now alumni, Julia Lynch and Sarah Gollust. They argue that a stronger moral case on behalf of what became the Affordable Care Act would have created stronger, more lasting support for it and might have blunted some of the ongoing battles that continue today, a year after reform became law.
In a recently released article in the Journal of Health Politics, Policy and Law, Lynch and Gollust assert that a different strategy would have helped Obama broaden and deepen support for the controversial law—and fend off attacks by opponents.
Lynch, Ph.D., recipient of a 2006 Robert Wood Johnson Foundation (RWJF) Investigator Award in Health Policy Research at the University of Pennsylvania and an alumnus of the RWJF Scholars in Health Policy Research program (2003-2005), and Gollust, Ph.D., an RWJF Health & Society Scholar alumnus (2008-2010) at the University of Pennsylvania, base their argument on a survey conducted in 2007 that found that “more than 70 percent of Americans consider health inequalities fundamentally unfair, regardless of the group that is affected by the disparity.”
Lynch and Gollust do not argue against appeals to self-interest. Indeed, they acknowledge that the effort to derail health care reform in the 1990s was successful in part because it made Americans nervous about their personal welfare. Nearly two decades later, Obama framed his campaign to reform health care around issues of personal welfare—and won.
The scholars do argue, however, against overlooking the moral case altogether. They say the Patient Protection and Affordable Care Act of 2010 could have cleared Congress with wider support had proponents employed a communications strategy that placed a heavier emphasis on moral themes. Health care messaging, they argue, does not have to be a zero sum game.
“In contrast to the conventional wisdom posing economic self-interest as the most critical single lever on which to push to generate support for reform, we find that considerations of fairness also shape Americans’ health policy preferences to a surprisingly strong degree,” Lynch and Gollust write.
For the study, Lynch and Gollust drew on data from a nationally representative study conducted in 2007 that used embedded vignettes to elicit attitudes and opinions about inequalities, fairness and health policy.
Making a Moral Case Would Help Obama Build Support for Law, Scholars Say
Had Obama made a stronger moral case for the law, he may have attracted more supporters and drawn criticism from fewer opponents—many of whom are now bent on repealing all or part of the law, Lynch says.
“The underlying sense of unfairness of the current situation wasn’t really effectively mobilized,” Lynch says. “Yes, reform passed. But there are now constant attempts to roll it back and chip away at other government health programs like Medicare and Medicaid.”
Lynch and Gollust acknowledge that Obama, of course, did in some ways appeal to Americans’ sense of fairness during the debate. In his signature speech in 2009 on health care reform, for example, he quoted the late Sen. Edward M. “Ted” Kennedy when he said: “What we face is, above all, a moral issue; at stake are not just the details of policy, but fundamental principles of social justice and the character of our country.”
But the scholars note that the remainder of the speech was framed around appeals to self-interest, which was a reflection of his broader campaign to enact reform.
Changing the frame would attract more supporters, even now, Lynch and Gollust say. As they counter efforts to repeal the law, Obama and his allies would benefit by taking a cue from their opponents and hitting the theme of fairness more strongly: “Their message should be that in a fair society everyone should have access to the health care they need to have the opportunity to pursue a good life. They should argue that it’s unfair to ration care by one’s ability to pay.”
Indeed, opponents are making a strong moral case against the law, they note, arguing that it unfairly forces people to purchase insurance they may not want and requires healthy people to help pay for the sick and injured.
There are no signs, however, that Obama and his allies are heeding that advice and taking a page from their opponents’ playbook, Lynch says.
Lynch, a faculty adviser for the Health & Society Scholars program, and Gollust teamed up to write the paper after discovering a shared interest in public opinion on health policy.
The two scholars are working on subsequent studies that examine public opinion about inequalities that affect certain social groups and that compare beliefs about inequalities in health, education attainment and income.
While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
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