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The Policy-Speak Disaster for Health Care

Thursday, 20 August 2009 09:46 By George Lakoff, t r u t h o u t | Perspective | name.

Obama on stage at a town hall meeting.
President Obama takes a question at a Grand Junction, Colorado, town hall meeting on August 15. (Photo: AP)



    Barack Obama ran the best-organized and best-framed presidential campaign in history. How is it possible that the same people who did so well in the campaign have done so badly on health care?

    And bad it is: The public option may well be gone. Neither Obama himself nor senior adviser David Axelrod even mentioned the public option in their pleas to the nation last Sunday (August 16, 2009). Secretary Sibelius even said it was "not essential." Cass Sunstein's co-author, Richard Thaler, in the Sunday New York Times (August 16, 2009, p. BU 4), called it "neither necessary nor sufficient." There has been a major drop in support for the president throughout the country, with angry mobs disrupting town halls and the right wing airing its views with vehemence nonstop on radio and TV all day, every day. As The New York Times reports, Organizing for America (the old Obama campaign network) can't even get its own troops out to work for the president's proposal.

    What has been going wrong?

    It's not too late to turn things around, but we must first understand why the administration is getting beat at the moment.

    The answer is simple and unfortunate: The president put both the conceptual framing and the messaging for his health care plan in the hands of policy wonks. This led to twin disasters.

    The Policy-List Disaster

    The whole is greater than the sum of its parts.

    Howard Dean was right when he said that you can't get health care reform without a public alternative to the insurance companies. Institutions matter. The list of what needs reform makes sense under one conceptual umbrella. It is a public alternative that unifies the long list of needed reforms: coverage for the uninsured, cost control, no preconditions, no denial of care, keeping care when you change jobs or get sick, equal treatment for women, exorbitant deductibles, no lifetime caps, and on and on. It's a long list. But one idea, properly articulated, takes care of the list: An American Plan guarantees affordable care for all Americans. Simple. But not for policy wonks.

    The policymakers focus on the list, not the unifying idea. So, Obama's and Axelrod's statements last Sunday were just the lists without the unifying institution. And without a powerful institution, the insurance companies will just whittle away at enforcement of any such list, and a future Republican administration will just get rid of the regulators, reassigning them or eliminating their jobs.

    Why Do Policymakers Think This Way?

    One: The reality of how Congress is lobbied. Legislators are lobbied to be against particular features, depending on their constituencies. Blue Dogs are pressured by the right's communication system operating in their districts. Congressional leaders have a challenge: Keep the eye of centrists and Blue Dogs on the central idea, despite the pressures of right-wing communications and lobbyists' contributions.

    Two: In classical logic, Leibniz's Law takes an entity as being just a collection of properties. As if you were no more than eyes, legs, arms, and so on, taken separately. Without a public institution turning a unifying idea into a powerful reality, health care becomes just a collection of reforms to be attacked, undermined and gotten around year after year.

    Three: Current budget-making assumptions. Health is actually systematic in character. Health is implicated in just about all aspects of our culture: agriculture, the food industry, advertising, education, business, the distribution of wealth, sports, and so on. Keeping it as a line item - what figure you put down on the following lines - misses the systemic nature of health. The image of Budget Director Peter Orszag running constantly in and out of Sen. Max Baucus's office shows how the systemic nature of health has been turned into a list of items and costs. Without a sense of the whole, and an institution responsible for it, health will be line-itemed to death.

    Obama had the right idea with the "recovery" package. The economy is not just about banking. It is about public works, education, health, energy, and a lot more. It is systemic. The whole is more than the sum of its parts.

    The Policy-Speak Disaster

    Policy Speak is the principle that: If you just tell people the policy facts, they will reason to the right conclusion and support the policy wholeheartedly.

    Policy Speak is the principle behind the president's new Reality Check web site. To my knowledge, the Reality Check web site, has not had a reality check. That is, the administration has not hired a first-class cognitive psychologist to take subjects who have been convinced by right-wing myths and lies, have them read the Reality Check web site, and see if the Reality Check web site has changed their minds a couple of days or a week later. I have my doubts, but do the test.

    To many liberals, Policy Speak sounds like the high road: a rational, public discussion in the best tradition of liberal democracy. Convince the populace rationally on the objective policy merits. Give the facts and figures. Assume self-interest as the motivator of rational choice. Convince people by the logic of the policymakers that the policy is in their interest.

    But to a cognitive scientist or neuroscientist, this sounds nuts. The view of human reason and language behind Policy Speak is just false. Certainly reason should be used. It's just that you should use real reason, the way people really think. Certainly the truth should be told. It's just that it should be told so it makes sense to people, resonates with them and inspires them to act. Certainly new media should be used. It's just that a system of communications should be constructed and used effectively.

    I believe that what went wrong is (a) the choice of Policy Speak and (b) the decision to depend on the campaign apparatus (blogs, town hall meetings, presidential appearances, grassroots support) instead of setting up an adequate communications system.

    What Now?

    It is not too late. The statistic I've heard is that over 80 percent of citizens want a public plan, but the right-wing's framing has been overwhelming public debate, taking advantage of the right's communication system and framing prowess.

    The administration has dug itself (and the country) into a hole. At the very least, the old mistakes can be avoided, a clear and powerful narrative is still available and true, and some powerful, memorable and accurate language should be substituted for Policy Speak, or at least added and repeated by spokespeople nationwide.

    The narrative is simple:

    Insurance company plans have failed to care for our people. They profit from denying care. Americans care about one another. An American plan is both the moral and practical alternative to provide care for our people.

    The insurance companies are doing their worst, spreading lies in an attempt to maintain their profits and keep Americans from getting the care they so desperately need. You, our citizens, must be the heroes. Stand up, and speak up, for an American plan.

    Language

    As for language, the term "public option" is boring. Yes, it is public, and yes, it is an option, but it does not get to the moral and inspiring idea. Call it the American Plan, because that's what it really is.

    The American Plan. Health care is a patriotic issue. It is what your countrymen are engaged in because Americans care about each other. The right wing understands this well. It's got conservative veterans at town hall meeting shouting things like, "I fought for this country in Vietnam and I'll fight for it here." Progressives should be stressing the patriotic nature of having our nation guaranteeing care for our people.

    A Health Care Emergency. Americans are suffering and dying because of the failure of insurance company health care. Fifty million have no insurance at all, and millions of those who do are denied necessary care or lose their insurance. We can't wait any longer. It's an emergency. We have to act now to end the suffering and death.

    Doctor-Patient Care. This is what the public plan is really about. Call it that. You have said it, buried in Policy Speak. Use the slogan. Repeat it. Have every spokesperson repeat it.

    Coverage Is Not Care. You think you're insured. You very well may not be, because insurance companies make money by denying you care.

    Deny You Care ... Use the words. That's what all the paperwork and administrative costs of insurance companies are about - denying you care if they can.

    Insurance Company Profit-Based Plans. The bottom line is the bottom line for insurance companies. Say it.

    Private Taxation. Insurance companies have the power to tax and they tax the public mightily. When 20 percent to 30 percent of payments do not go to health care, but to denying care and profiting from it, that constitutes a tax on the 96 percent of voters that have health care. But the tax does not go to benefit those who are taxed; it benefits managers and investors. And the people taxed have no representation. Insurance company health care is a huge example of taxation without representation. And you can't vote out the people who have taxed you. The American Plan offers an alternative to private taxation.

    Is it time for progressive tea parties at insurance company offices?

    Doctors Care; Insurance Companies Don't. A public plan aims to put care back into the hands of doctors.

    Insurance Company Bureaucrats. Obama mentions them, but there is no consistent uproar about them. The term needs to come into common parlance.

    Insurance Companies Ration Care. Say it and ask the right questions: Have you ever had to wait more than a week for an authorization? Have you ever had an authorization turned down? Have you had to wait months to see a specialist? Does your primary care physician have to rush you through? Have your out-of-pocket costs gone up? Ask these questions. You know the answers. It's because insurance companies have been rationing care. Say it.

    Insurance Companies Are Inefficient and Wasteful. A large chunk of your health care dollar is not going for health care when you buy from insurance companies.

    Insurance Companies Govern Your Lives. They have more power over you than even governments have. They make life and death decisions. And they are accountable only to profit, not to citizens.

    The Health Care Failure Is an Insurance Company Failure. Why keep a failing system? Augment it. Give an alternative.

    The Needed Communication System

    A progressive communication system should be started. It should go into every Congressional district. It should concentrate on general progressive ideas. President Obama has articulated what these are.

  • The basic values are empathy (we care about people), responsibility for ourselves and others, and the ethic of excellence (making ourselves better and the world better).

  • These values form the basis of democracy: It's because we care about our fellow citizens that we have values like freedom and fairness, for everyone, not just the powerful.

  • From that, it follows that government has two moral missions: protection (of consumers, workers, the environment, the old, the sick, the powerless; and empowerment through public works; communication, energy and water systems; education; banks that work; a court system, and so on. Without them, no one makes it in America. Taxes are what you pay for protection and empowerment by the government, and the more you make the greater your responsibility to maintain the system.
  •     Appropriate language can be found to express these values. They lie at the heart of all progressive policies. If they are out there every day, it becomes easier to discuss any issue. This is what it means to prepare the ground for specific framings.

        The Culture War Is On! You Can't Ignore it

        President Obama wants to unify the country, and he should. It is a noble idea. It is the right idea. And he started out with the right way to do it. Campaign for what you believe - for empathy, social responsibility, making the nation better. Activate the progressive values in the many millions of Americans who have some conservative values and some progressive values.

        But also inhibit the radical, harmful conservative ideology in the brains of our countrymen by directly saying what's wrong with it. Yes, there are villains. They have a very potent communications system and can organize their troops. Every victory makes them more powerful. They have put together powerful narratives. We need more powerful ones.

        And avoid Policy Speak and Policy Lists.

        What Should Have Been Done?

        It is useful to review what should and should not have been done, because we need to understand the past to avoid future mistakes.

        First, it was obvious to the framing community what the right wing would do. Almost every move could have been predicted and most of them were. There should have been a serious counter effort from right after the election.

        Second, an effective communication system should have been built. Not for dictating what to say, but for creating a system of effectively trained spokespeople, who can get the basic progressive values out there every day to compete with the very effective conservative system. It should not work issue by issue, but in addition to the issues of the day; it should promote general values that apply to all issues.

        The elements are all in existence. The money is there. Indeed it would be a lot cheaper to build than spending tens of millions of dollars on health care ads. What it would accomplish is laying the groundwork in advance of any particular issue. The work of such a communication system would be to activate ideas already there in the millions of citizens who have progressive as well as conservative worldviews in their brain circuitry. The idea would be to make progressive ideas stronger and conservative ideas weaker, balancing what the conservative communication system is doing now.

        It is rather late in the game for the stimulus, cap and trade and health care, but better late than never. And it would be indispensable for future policy campaigns. Framing a powerful message is a lot easier when the groundwork for it has already been laid. Without the groundwork, it is much harder.

        Third, a serious framing education effort with folks who do know the science should have been organized, not just for the communications system, but for the policymakers themselves.

        Fourth, the villainizing of real insurance company villains should have begun from the beginning. As it is, the right wing turned the tables. They attributed to government all the disasters of insurance company health care: rationing, long lines, waits for authorizations and visits to specialists, denial of care. The administration is trying to turn that around, but it is harder now, and they are trying it using Policy Speak, which is the most ineffective of means.

        Fifth, the positive policy should have been made in moral terms, with clear and vivid language. The term "public option" is a Policy-Speak loser. The public is the American public; it is all of us; it is America, and it should have been called the American Plan.

        Sixth, the administration should have been on the offensive not the defensive all the way. The use of conservative language should never have been used in debunking.

        Seventh, it was a mistake to shut out single-payer advocates. They should have been welcomed into the debate. Though the term "single payer" is hopeless Policy Speak and "doctor-patient care" would have been more accurate, nonetheless, the doctors, nurses and unions advocating for such a plan could have done a lot of the work of villainizing the health care industry and would have drawn fire from the right. An alternative on the left would have made the president's plan a compromise. Besides, there is so much to be said in favor of single payer, that there might have been fewer actual compromises with the right.

        Eighth, it was a mistake to put cost ahead of morality. Health care is a moral issue, and the right wing understands that and is using it. That's why the "death panels" and "government takeover" language resonates with those who have a conservative moral perspective and have effectively used terms like "pro-life." Health care is a life and death issue, which is as moral as anything could be. The insurance companies have been on the side of death, and that needs to be said overtly.

        Ninth, accepting the idea that health is a line item separate from agriculture policy, the food industry, regulation of food and drugs, education, the vitality of business, banking reform etc. is just bad economics. These are all tied up together. In this, health care might have been treated like the "recovery" package, but in reverse.

        A causal approach to economics would be appropriate. Instead of putting funds in many places, it might have taken funds from sources of health problems. For example, big agriculture and the food industry produce and heavily market foods that have been central causes of the obesity epidemic and heart disease - corn syrup, too much meat, and so on. They might have been called upon to pay the costs of treating heart disease, strokes and diabetes. It would not be popular with those industries, but it would be causally fair, and might even save a lot of lives - and money.

        Or, take another example of causal economics. Hugely high private taxation (that is, high costs and profit taking) by the health insurance industry helped drive American automakers into bankruptcy. The health insurance industry should have had to use a portion of their profits for bailouts of the auto industry, and the equivalent amount of bailout money could have been used for providing health care to those without it.

        Given the systemic nature of our culture and our economy, a move in the direction of such causal economics should start to be seriously considered. At the very least, it would bring up the question, alert the public to systemic causation and start people thinking about the justice of causal economics.

        All this is not just 20-20 hindsight. My colleagues Glenn Smith and Eric Haas and I have made many of these points before. See our reply to the May 2009 memo by Frank Luntz.

        And take a look at an even earlier memo of the logic of the health care debate.

        Where Policy Lists and Policy Speak Come From

        Framing is everywhere, not just in language. What people do depends on how they think, on how they understand the world - and we all use framing to understand the world. Truth matters. But it can only be comprehended when it is framed effectively and heard constantly.

        This point is too often misunderstood that it is important to understand why. It is also important to understand where Policy Lists and Policy Speak come from and why they have the powerful grip that they have. This is especially important now, when there might still be a chance to turn the health care debate around.

        The source of these political disasters lies in an unlikely place: our most common understanding of reason itself.

        What Is Reason Really Like?

        Policy Speak is supposed to be reasoned, objective discourse. It, thus, assumes a theory of what reason itself is - a philosophical theory that dates back to the 17th century and is still taught.

        Over the past four decades, cognitive science and neuroscience have provided a scientific view of how the brain and mind really work. A handful of these results have come into behavioral economics. But most social scientists and policymakers are not trained in these fields. They still have the old view of mind and language.

        The old philosophical theory says that reason is conscious, can fit the world directly, is universal (we all think the same way), is dispassionate (emotions get in the way of reason), is literal (no metaphor or framing in reason), works by logic, is abstract (not physical) and functions to serve our interests. Language on this view is neutral and can directly fit, or not fit, reality.

        The scientific research in neuroscience and cognitive science has shown that most reason is unconscious. Since we think with our brains, reason cannot directly fit the world. Emotion is necessary for rational thought; if you cannot feel emotion, you will not know what to want or how anyone else would react to your actions. Rational decisions depend on emotion. Empathy with others has a physical basis, and as much as self-interest, empathy lies behind reason.

        Ideas are physical, part of brain circuitry. Ideas are constituted by brain structures called "frames" and "metaphors," and reason uses them. Frames form systems called worldviews. All language is defined relative to such frames and metaphors. There are very different conservative and progressive worldviews, and different words can activate different worldviews. Important words, like freedom, can have entirely different meanings depending on your worldview. In short, not everybody thinks the same way.

        As a result, what is taken as "objective" discourse is often worldview dependent. This is especially true of health care. All progressive writing supporting some version of health care assumes a progressive moral worldview in which no one should be forced to go without heath care, the government should play a role, market regulation is necessary, and so on.

        Those with radical conservative worldviews may well think otherwise: that everyone should be responsible for their own and their family's health care, that the government is oppressive and should stay out of it, that the market should always dominate, and so on.

        Overall, the foundational assumptions underlying Policy Speak are false. It should be no wonder that Policy Speak isn't working.

        The Biconceptual Audience

        A property of brains called "mutual inhibition" permits people to have contradictory worldviews and go back and forth between them. Many people have both progressive and conservative worldviews, but on different issues - perhaps conservative on financial issues and progressive on social issues. Such people are called biconceptuals. President Obama understands this. He has said that his "bipartisanship" means finding Republicans who happen to share his progressive views on particular issues and working with them on those issues - and not accepting an ideology (radical conservatism) rejected by the American people.

        The people the president has to convince are the millions of biconceptuals. That means he has to have them thinking of health care in progressive moral terms, not conservative moral terms. How can this be accomplished?

        Why Do the Nature of Reason and Language Matter?

        It's all in the brain. Words activate frame-and-metaphor circuits, which in turn activate worldview circuits. Whenever brain circuitry is activated, the synapses get stronger and the circuits are easier to activate again. Conservative language will activate conservative frames, which will activate and strengthen the conservative worldview.

        Conservative tacticians may not know about brain research, but they know about marketing, and marketing theorists use that brain research. That is why conservatives place such importance on language choice, from the classic "socialized medicine," to Luntz's "government takeover" to Palin's "death panels." When repeated over and over, the words evoke a conservative worldview, with many of the specific bogeymen - abortion, socialism = communism = nazism, euthanasia, foreigners, taxes, spending, the liberal elite, Big Brother, and so on. The most effective language has emotional appeal and, to conservatives, a moral appeal because it activates the conservative moral worldview. And such language, repeated every day, changes brains, strengthening the synapses of those who listen.

        Conservative language will activate and strengthen conservative worldviews - even when negated! I titled a book "Don't Think of an Elephant!" to make this point. The classic example is Richard Nixon's "I am not a crook," which made everyone think of him as a crook. And yet I've heard President Obama say, "We don't want a government takeover," which activates the idea of a government takeover. Mediamatters.org's major story, as I write this, is: "The media have debunked the death panels - more than 40 times." It then gives a list of 40 cases of debunking, each one of which uses the term "death panels." And you wonder, after so many debunkings, why it is still believed! Each "debunking" reinforced the idea. The first rule of effective communication is stating the positive in your own terms, not quoting the other side's language with a negation.

        The Conservative Communication System

        The serious reporting on the role of conservative think tanks began in the mid-1990's with works such as:

  • "Buying a Movement: Right-Wing Foundations and American Politics" (People for the American Way, 1996).

  • Sally Covington, "Moving a Public Policy Agenda: The Strategic Philanthropy of Conservative Foundations" (National Committee for Responsive Philanthropy, 1998).

  • Jean Stefancic and Richard Delgado, "No Mercy: How Conservative Think Tanks and Foundations Changed America's Social Agenda" (Temple University Press, 1996).
  •     In 1996, my "Moral Politics" appeared, outlining the conservative and progressive moral worldviews and how the conservatives used language to frame public discourse their way.

        In 2004, Rob Stein tracked the conservative communications system, traveling the country with his detailed PowerPoint, "The Conservative Message Machine Money Matrix." Stein tracked not only conservative think tanks, but also the language experts and training institutes training tens of thousands of conservative spokespeople. He also tracked the communications facilities and the collections of "experts" on every issue, together with a booking agency booking the experts daily on media all over the country. Daily talking points are repeated by those "experts." The conservative communications system extends into every Congressional district, including the districts of democrats. In the case of the Blue Dog Democrats, who come from relatively conservative districts, the Blue Dogs have to deal with constituents who hear conservative framing over and over every day without anything effective countering it. That is a major factor in Blue Dog resistance to administration proposals.

        With all this information, you might think that progressives would set up their own communications network going into the heart of conservative districts everywhere, day after day, effectively countering the conservative framing.

        It didn't happen. Instead, Policy Speak prevailed. The old philosophical theory, which is taught in every policy school, won out. Progressives thought such a communications system would be illegitimate - what the conservatives do. They believe, in 17th-century fashion, that if they just state the facts, people should reason to the right conclusion.

        So, progressives set up truth squad web sites and blogs to negate conservative lies - like Media Matters, The Center for American Progress, the People for the American Way, the Center for America's Future, MoveOn, Organizing for America, and so on. These are all fine organizations, and we are fortunate to have them. But ... they are preaching to the choir (because they don't have an adequate communications system), and they are using Policy Speak: just stating the policy truths will be enough.

        As I was writing this, I received the viral email written by David Axelrod, which he refers to as "probably one of the longest emails I've ever sent." It is indeed long. It is accurate. It lays out the president's list of needed reforms. It answers the myths. It appeals to people who would personally benefit from the president's plan. It drops the public option, which makes sense of the list. And it is written in Policy Speak. It has 24 points - three sets of eight.

        Ask yourself which is more memorable: "Government takeover," "socialized medicine" and "death panels" - or Axelrod's 24 points?

        Did the administration do a reality check on the 24 points? That is, did they have one of our superb cognitive psychologists test subjects who were convinced of the right-wing framing, have them read the 24 points and test them a couple days or a week later on whether Axelrod's 24 points had convinced them? Policy Speak folks don't tend to think of such things.

        I genuinely hope the 24 points work. But this is the kind of messaging that created the problems in the first place.

        I respect Axelrod deeply. But the strategist who ran the best-framed campaign I've ever seen is giving in to Policy Speak.

        The Irony

        There is a painful irony in all this and I am aware of it constantly. Highly educated progressives, who argue for the importance of science, have been ignoring or rejecting the science of the brain and mind. Why?

        Because brains are brains. A great many progressives have not grown up with, nor have they learned, the new scientific understanding of reason. Instead, they have acquired the old philosophical theory of reason and assume it every day in everything they do. The old view is inscribed indelibly in the synapses of their brains. It will be hard for those progressives to comprehend the new science that contradicts their daily practice.

        They may find it hard to comprehend framing, metaphor and narrative as the way reason really works - as what you need to do to communicate truth. Instead, they may well think of framing as merely manipulation and spin, as the mechanism that the right wing uses to communicate lies.

        An excellent example of such old-theory thinking appears in the Rahm Emanuel/Bruce Reed book, "The Plan," where framing is seen only as manipulation, not as the structure of ideas. Emanuel and Reed (p. 21) assume that policy is independent of what they incorrectly understand framing to be. As a result, they assume that framing can only be illegitimate manipulation.

        This is, of course, the very opposite of what I and other cognitive scientists have been saying. They are right that real reason can be manipulated in that way, as Frank Luntz has shown us. But it need not be. An understanding of how the brain really works can be used to communicate the truth effectively, and that's how it should be used.

        In the Obama campaign, honest, effective framing was used with great success. But in the Obama administration, something has changed. It needs to change back.

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    President Obama takes a question at a Grand Junction, Colorado, town hall meeting on August 15. (Photo: AP)
    Last modified on Thursday, 20 August 2009 10:07