Saturday, May 8, 2010

The Lost Battle: How the Democrats Failed to Gain Public Support for Health Reform – Peter Banks

During the State of the Union address in January, President Obama detailed the difficult task of undertaking health care reform when he stated, “I didn't choose to tackle this issue [health care] to get some legislative victory under my belt. And by now, it should be fairly obvious that I didn't take on health care because it was good politics (1)." President Obama’s words proved to be prescient, and even with the passage of the “Patient Protection and Affordable Care Act” in March, the health care debate continues to this day. Although politicians performed many of these debates in front of cameras, the discussions occurring within the general population promised to have the greater affect on the implementation and the success of health reform. It was within these discussions the Democrats failure to effectively present health reform to the American public was most apparent.

The Democrats inability to secure popular support of health reform forced them to expend great amounts of political capital and may, in all likelihood, cost them seats in the upcoming election. By ignoring the importance of the effective use of branding, the power of marketing, and the significance of reactance, the Democrats failed to gain support for health reform within the general public. This failure in understanding how best to obtain support for reform jeopardized the forward progress gained by the passage of the bill and cultivated a situation in which the American public rejected a piece of legislation that intended to create a healthier United States.

Branding Health

By failing to effectively brand reform legislation, the Democrats missed an opportunity to create a connection with the public and the possible support gained from such a connection. Establishing a brand identity is the central task in the development and long-term conceptualization of any marketing plan (2). Addressing this issue, The Hastings Center, a non-partisan research institution dedicated to bioethics and the public interest, asked eleven authors to explore the foundational principles of health reform. Two of these principles, health and fairness, were used extensively as brands by Democrats during the public debate on health reform legislation (3, 4). Although both political parties accepted the value of a healthier nation and more access to coverage, the vagueness of these brands failed to provide the Democrats with the necessary selling points when presenting health reform to America. This vagueness can be seen in Erika Blacksher’s paper on Health, when she described the brand of Health as, “rarely identified, defined, or defended in explicit terms (3).” The use of these ineffective brands created a weak foundation for the Democrats, preventing them from effectively presenting the positive aspects of the bill to the American public. Instead of gaining support from the public through clear and concise branding, the Democrats allowed health reform to be shaped by outside forces that turned opinion against the legislation.

In the last months leading up to the critical votes on health care reform, the Democrats lack of strategic brands was recognized and an attempt to install new points of focus was made. One brand that was introduced was President Barack Obama. During the presidential campaign, then Senator Obama, effectively utilized brands such as “Change We Can Believe In” and “Yes We Can” to win the presidency (5). His slogans fulfilled two important goals of branding; strategically eliciting a particular set of beneficial associations in the mind of the voters and laying a foundation for instant recognition regarding the underlying promises made by his campaign (2). Originally, President Obama distanced himself from health reform legislation, claiming to have learned from the criticisms leveled at President Clinton’s attempt at health reform in 1995 (6). Although his foray into the health reform debate galvanized the Democrats, and secured passage of the legislation, the brand of President Obama was introduced too late in the political process to effectively garner public support. Much of the public’s frustration and distrust of the reform process was simply shifted to President Obama, driving his approval ratings down and tarnishing the widely popular brand of the President himself (7). Another more visual brand introduced by the Democrats was the personal story. Many Democrats, as well as the President, used stories of people whose livelihood had been destroyed, or diminished, because of health care costs as reasons for the need for health reform (8). Although these stories provided relatable talking points that were used to better inform the public, they failed as brands. Brands are value propositions that provide a solution to a problem (2). Anecdotes of bankruptcy from health care bills and rejected coverage due to preexisting conditions raised awareness about the need for reform, but their use as brands ultimately failed because they were unable to change the public’s high level of skepticism about whether the changes made by the bill would actually improve the overall health care system (9). The increased use of President Obama and personalized stories in the months leading up to the vote on health reform displayed the Democrats awareness of the need for more effective brands. Unfortunately, these brands failed to provide the relationship with the public the Democrats hoped to create and continued the trend of unsuccessful branding in the health reform campaign.

Marketing Reform to the American Public

When selling a product to a consumer, private companies will spend countless hours, and even more money, on how to best market their product to the general public. The focus of this research is to identify the needs and the wants of the target audience and to use that information to engineer a specific promise, or promises, which fulfills the desires of the targeted group (10). One promise widely circulated by the Democrats was better access to health care. While this promise surely resonated within the approximately 45 million citizens who were uninsured at the time, it failed to provide an effective promise to those who already had health insurance (11). This lack of enthusiasm about one of the main promises offered by the Democrats can be seen in a recent Kaiser poll that asked people how health care reform might affect them personally. Overall, the nation was divided nearly into thirds between who thought they would be better off (35%), worse off (32%), and not affected (28%); with little change over the last couple of months during the final push towards passage (12). For a promise to be valuable it must address the wants, the needs, and the aspirations of the audience (13). By choosing access to coverage as the major promise of the campaign, the Democrats failed to offer a compelling concept for reform to the roughly 68% of American voters who rate their health insurance as “good” or “excellent” (14). A promise that proved to be more effective was controlling costs. Although the bill was widely criticized for flirting with a one billion dollar price tag, ballooning health insurance premiums provided the Democrats with a small toehold in the cost debate. Many Americans were personally experiencing the rise in health care costs, with one half of people interviewed in a Kaiser poll saying that the amount they paid for insurance increased in the last year (15). The Democrats were able to use the promise of controlling premiums as an effective message, but it was a promise recognized too late in the reform conversation. When presenting health reform to the public, the Democrats produced an uneven record of identifying the wants and the desires of the American people. This mixed success in providing promises to the public must change if the Democrats hope to gain support as the bill moves forward.

In order to provide better promises, the Democrats needed to discover the core values of the audience they were targeting (10). Once those core values were ascertained, they could be used to frame the health reform debate. Former Senator Tom Daschle described the target audience of health reform when he stated, “Many people who have insurance now are satisfied with it and are wary of change (16).” While the Democrats introduced a historical piece of legislation that trumpeted change in a broken health care system, they faced a nation whose major core value was a freedom to not change (9). As discussed above, the Hastings Center examined some of the core principles of health reform and one of them was liberty, a word synonymous with freedom. In the past, the core value of liberty was pushed by those who opposed government involvement and structural change, with the looming threat of “socialism” hanging over any political debate (17). Knowing this, the Democrats needed to establish an ethical and political justification for health reform that depended on reconciling liberty and equity (17). By not creating this connection, the Democrats failed to position health reform as on the side of liberty and freedom. This failure allowed the accusations of socialism, and the fear of losing freedom, to dominate the public discussion of health reform. The Democrats inability to convince the public that health reform strengthened widely held core values created a situation where people rejected the legislation not out of disagreement, but out of fear of losing freedoms that were not endangered.

Ignoring the Importance of Reactance

By underestimating the level of public negative reactance regarding health reform legislation, the Democrats left themselves in a defensive position that forced them to expend political capital and to lose constituent support. First introduced by Jack Brehm, Reactance Theory suggested that individuals become more psychologically aroused when their perceived behavioral freedoms are threatened or reduced (18). The Democrats originally tried to frame health reform legislation around the individualized concept of personal health (19). What the Democrats failed to realize was that there were many other aspects of the reform debate that had the potential to incite a passionate negative response. Specific issues found in the bill, such as the initial suggestion of a public option and the false specter of federally funded death panels, led to a public misinterpretation of personally divisive issues that raised reactance (20). Instead of being able to define the initial debate by highlighting positive aspects of the legislation, the Democrats were forced to react to a swell of negative opinions created by the perceived threat to public freedoms. This failure to prepare for reactance defined the debate on health reform and severely hindered the Democrats hope of gaining needed ground level support during the beginning stages of the heath reform campaign.

Along with failing to recognize the significant role reactance would play in the public debate regarding health reform, the Democrats were unsuccessful at managing the level of negative pushback once it was identified as an issue. The Democrats inability to effectively brand, or frame, the health reform discussion was a key reason why they were unable to limit negative reactance. A consequence of this failure was source derogation, where reactance to the behavior modification is followed by aggression or hostility aimed at the threatening agent (21). This aggression was openly displayed during the summer of 2009 when many members of Congress were bombarded with accusations, and challenges, at town hall meetings held across the country (22). The Democrats faced a difficult situation of trying to use low controlling language, while explaining a broad sweeping piece of legislation that impacted a large proportion of the general population. In order to find a balance, and manage negative reactance, the Democrats needed to better inform the public about the legislation. Unfortunately, the polls presented an engaged, but somewhat ill informed, public. When asked in a recent Kaiser poll about the affect health reform would have on their insurance, four in ten people currently believed that if health care reform passed most people who currently received health insurance coverage through their employers would have to change their existing coverage arrangements (12). This was up from three in ten people in January (11). Along with being for the most part incorrect, this misconception displayed the Democrats failure to present even the most basic elements of their bill. The mishandling of the management of reactance by the Democrats created serious doubts about the future success of the bill. Needing to present a well-crafted message that controlled negative feelings, while also inspiring confidence in the new legislation, the Democrats failed to effectively inform their constituents of the actual impact health reform would have on the individual lives of the public.

Passing health reform legislation was a monumental achievement by both the President and the Congress. The skillful political maneuvering needed to pass such a large and complicated bill was something many citizens of the United States would not be able to comprehend and the Democratic Party should be commended for their accomplishment. Unfortunately, the Democrats failure to secure public support for health reform may eventually doom the legislation. By overlooking the importance of branding, the effectiveness of marketing theories, and the strength of reactance, the Democrats created a situation in which the public actively demonstrated their reluctance for health reform before and after the passage of the bill. In order for health reform legislation to succeed, the public must embrace the demand for change in a broken health care system and the Democratic Party must take the lead in this campaign. The Democrats failed to secure this backing during the time leading up to the passage of the bill, but there is still time to positively frame the health reform discussion. Although the legislative process of health reform is over, the success of the legislation will be judged by its effectiveness moving forward.

Moving Forward on Health Reform: The Need for Continuing Engagement

During remarks made to the joint session of Congress on September 2009, President Obama outlined the vision of health reform when he stated that the bill would, “provide more security and stability to those who have health insurance. It will provide insurance for those who don't. And it will slow the growth of health care costs for our families, our businesses, and our government (23)”. These common goals provided a solid foundation for the campaign on health reform legislation, but the Democrats inability to effectively market these ideals to the American people created a disconnect between health reform and the public. The Republicans jumped on this impasse using branding, social marketing, and negative reactance to create public unrest and mistrust of the health reform legislation being offered by the Democrats. Allowing the Republicans to control the conversation about health reform was a mistake by the Democrats, with possible implications ranging from failure of the bill moving forward to losing control of both the House and the Senate. In order for the Democrats to avoid these very real possibilities, they must not back away from the legislation, and they must fortify health reform with a strong campaign supporting the positive aspects of the bill.

Changing the Obamacare Brand

With the Democrats initially struggling to find effective brands to offer the American public, the Republicans were able to frame the debate on health reform. Visual cues such, as the “2,700 page document,” provided striking parallels to the recent “too big to fail” banking collapse, while verbal cures, such as “socialism” and “Obamacare,” connected health reform to an overbearing government bureaucracy. Instead of using branding as a tool to sell the target audience on health reform, the Republicans utilized these brands, specifically Obamacare, as a cautionary warning (24). The Democrats must rebrand health reform in order to ensure the success of the legislation and they can begin by adopting Obamacare as their own. With only 17% of the public approving of the job Congress is currently doing, President Obama remains the most popular, and central, figure in the health reform discussion (7). Keating Holland, CNN’s polling director, illustrated these feelings when he said, "The Democrats have another advantage - most Americans trust Barack Obama more than the GOP on health care. That gives the president an opportunity - and seven months - to make the affirmative case for the health care bill (25)." The President and the Democrats should begin using the term Obamacare whenever possible, diluting the original message, while also creating a rallying cry for the success of reform. Although financial reform and immigration are touted as the next political fights, the President and the Democrats must not shrink away from publicizing the initial accomplishments produced by the health reform legislation. Brands have social and individual dimensions (26). By framing Obamacare as the protector of a public that is being overcharged (individual) and underserved (social) by outside influences, instead of the original frame of increased government involvement, the Democrats can secure a strong brand in the health reform discussion.

The Market to Choose

The Republicans were able to turn public opinion against health care reform by claiming that the legislation jeopardized an important core value – freedom. Representative John Boehner, Minority Leader of the Republican Party, expressed this threat, while also impressively rephrasing a promise the Obama campaign had effectively used during the Presidential election, when he stated, “Look at this bill. Do you really believe that if you like the health plan that you have, that you can keep it? No, you can’t (27).” The facts of this statement can be called into question, but the concept of losing the freedom to remain in a chosen health plan resonated across America (28). In response, the Democrats need to challenge the loss of freedom promised by the Republicans and also build a new foundation of core values in which health reform can regain a stronger position in the public mindset (26). While personal stories about individuals acquiring insurance for the first time will play well in the media, the Democrats must also push stories about people keeping their insurance because of a decrease in their premiums. By allowing the public to see their core value of freedom maintained, not challenged, the Republicans promise will erode enough for the Democrats to create their own foundation of core values. The second step is to provide the public with promises that appeal directly to other core values such as choice, autonomy, and equity (29). One suggestion is a campaign called “My Choice”. The “My Choice” campaign would run promotional advertising with slogans like, “I choose to help kids stay healthy,” “I choose to find insurance,” and “I choose to stay with my health plan”. These slogans reframe the concept of freedom into a core value people, as consumers, are accustomed to – choice (30). By slightly changing the focus of health reform to the core value of choice, the Democrats move away from the negative connotations spread by the Republicans, while also creating a new foundation for the discussion moving forward. Although the passage of legislation cost the Democrats dearly in popularity and political capital, they cannot walk away from health reform. Discrediting the Republican promises, while also appealing to the core value of choice, strengthens the Democrats position and allows them to appeal for new support from the public.

The Role of Information

When a freedom is threatened by a social pressure reactance will lead the target audience to resist that pressure (18). Well aware of this fact, the Republicans used accusations of “backroom deals” that were “hidden from the people” to heighten negative reactance regarding the issue of health reform (27). The Democrats failure to properly control the level of reactance seen in the general public nearly prevented the passage of the bill and their attempts to manage the positive and negative feelings going forward will decide the success of health reform. In order to increase the level of positive reactance within the public discussion, the Democrats need to increase their credibility (31). The offering of a new Obamacare provides a platform for the Democrats to promote credibility-strengthening tenets of health reform such as transparency and successful cost controlling pilot programs. Once credibility among the public is established, the Democrats will be able to shift their focus towards decreasing reactance through the above-mentioned My Choice campaign. When looking to control the magnitude of reactance the use of concrete, low controlling language, and the restoration of freedom through inclusion of a choice, has been proven to be the best solution (32). The My Choice campaign presents a simple message that fosters the concept of freedom through choice. By using the Obamacare brand and the My Choice campaign, the Democrats can effectively control the level of negative reactance currently found in the general population. Encouraging a positive future outlook on the health of our nation allows the Democrats to gain support from the public and to begin applying the legislation to the country’s health care system.

The fight for health reform legislation created incredible amounts of political and public backlash. In the upcoming months many Democrats will try to distance themselves from the bill in order to appease their constituents. By distancing themselves from health reform, they will be missing a chance to help solidify the foundation of their Party. The passage of health reform cannot be seen as an end product. With possibly nine state attorney generals suing to block health reform and the hovering personal mandate to be implemented in 2014, the Democrats must obtain some support for the bill moving forward or risk wasting large amounts of political capital on a failed reform (33). Effectively rebranding reform, establishing mutual core values that connects to the public, and controlling the level of negative reactance through the sharing of information are all essential efforts in securing support for health care legislation. The successful implementation of the legislation hinges on the public’s willingness to embrace health reform. The Democrats must realize this, and provide a reason for why and how health reform will make America a healthier nation and a better country.

References

1. Obama, Barack. State of the Union Address. Joint Session of Congress. US Capitol, Washington, DC. 27 January: 2010.

2. Blitstein JL, and Evans WD, Driscoll DL. What is a Public Health Brand? (Chapter 2). In: Evans WD, Hastings G, eds. Public Health Branding: Applying Marketing for Social Change. Oxford: Oxford University Press: 2008.

3. Blacksher, Erika. Health: The Value at Stake. The Hasting Center: Connecting American Values with Health Reform: 2009.

4. Menzel, Paul. Justice and Fairness: Mandating Universal Participation. The Hastings Center: Connecting American Values with Health Reform: 2009.

5. Shapiro, Ari. Brand Obama: A Hit Abroad, But What About Loyalty? National Public Radio. 6 April: 2010.

6. Hacker, Jacob. Putting Politics First. Health Affairs. Vol. 27. No. 3: 2008.

7. NBC News / Wall Street Journal. NBC / WSJ Poll, March: 2010.

8. The White House Website. Urgency of Reform. 9 September: 2009, from website: http://www.whitehouse.gov/video/The-Urgency-of-Reform-Laura-in-Green-Bay.

9. Washington Post / ABC News. Washington Post Poll. March: 2010.

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12. Kaiser Family Foundation. Kaiser Health Tracking Poll, March: 2010.

13. Grier, Sonya and Bryant, Carol. Social Marketing in Public Health. Annual Review of Public Health, Vol. 26: 2005.

14. Rasmussen, Scott. Health Reform and The Polls. The New York Times. 7 August: 2009.

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17. Jennings, Bruce. Liberty: Free and Equal. The Hastings Center: Connecting American Values with Health Reform: 2009.

18. Brehm, JW. A Theory of Psychological Reactance. New York, NY: Academic Press: 1966.

19. Otellini, Paul. We Need a Personal Health Reformation. The Politico. 27 July: 2009.

20. Gallup. In Their Own Words: Why Americans Favor or Oppose Healthcare Reform, March: 2010.

21. Worchel, S. and Brehm, Jack. Attitude Change as a Function of Felt Competence and Threat to Attitudinal Freedom. Journal of Experimental Social Psychology, Vol. 4: 1968.

22. Litvan, Laura. Gregg Aims to Use Health-Care Bill to Stir Town-Hall Backlash. Bloomberg: Business Week. 23 March: 2010.

23. Obama, Barack. Remarks on Healthcare. Joint Session of Congress. US Capitol, Washington, DC. 9 September: 2009.

24. Rich, Frank. The Rage is Not About Healthcare. The New York Times. 28 March: 2010.

25. CNN / Opinion Research Corporation. CNN Poll: American’s Don’t Like the Health Care Bill. 22 March: 2010.

26. Evans WD, Hastings G. Public Health Branding: Recognition, Promise, and Delivery of Healthy Lifestyles (Chapter 1). In: Evans WD, Hastings G, eds. Public Health Branding: Applying Marketing for Social Change. Oxford: Oxford University Press: 2008.

27. Boehner, John. Floor Speech on Health Care Legislation. Final Vote on Health Care Legislation. US Capitol, Washington, DC. 22 March: 2010.

28. Gallup. One Week Later, Americans Divided on Healthcare. 29 March: 2010.

29. Feldman, Stanley. Structure and Consistency in Public Opinion: The Role of Core Beliefs and Values. American Journal of Political Science. Vol. 32. No. 2. May: 1988.

30. Clee, Mona and Wickland, Robert. Consumer Behavior and Psychological Reactance. Journal of Consumer Research, Vol. 6: 1980.

31. Silvia, PJ. Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance. Basic and Applied Social Psychology, Vol. 27: 2005.

32. Miller, Claude H. and Lane, Lindsay. Physiological Reactance and Promotional Health Messages: The Effects of Controlling Language, Lexical Concreteness, and the Restoration of Freedom. Human Communication Research, Vol. 33: 2007.

33. Herszenhorn, David and Pear, Robert. Health Vote is Done But Partisan Debate Rages On. The New York Times. 22 March: 2010.

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