Anatomy of Health Care Messaging Part 3: How an Orwellian Word Invented by Insurance Bureaucrats Can Turn the Health Care Debate

by Robert Kraig
Executive Director

Part 2 of our five part series Anatomy of Health Care Messaging, we concluded with the strategic imperative to match the emotional intensity of the right’s anti-ObamaCare rhetoric. The conservative message pivots on the specter of big government violating freedom by “taking away” health care or eviscerating individual control over personal medical decisions. Modern persuasion research shows (and most of the rhetoric authorities going back 2000 years also hold) that the side with the more compelling emotional case almost always wins. Progressives therefore face the challenge of making visceral the more abstract and positive value that everyone ought to have guaranteed access to basic health security, and the complicated set of policies that make this possible.

This is the nub of the messaging challenge for progressives in most every issue area in 21st Century America. Because progressives are analyzing societal problems in a more fact-based (i.e. less ideological) fashion than the right, proposing policy avenues for achieving progress, and advancing a more abstract conception of freedom (i.e. positive governmental structures needed to empower everyone to thrive) we face a chronic emotional intensity gap.

This is exacerbated in health care by the complexity of the Affordable Care Act (ACA), a grand compromise which rather than sweeping away convoluted legacy structures built up piecemeal since World War 2 instead grafts a series of reforms onto the existing system. The result is a level of complexity beyond the grasp of most opinion leaders, let alone average citizens.

The process of crafting simple and emotionally compelling health care messages starts with getting clear on which American values provide the strongest moral rationale for the set of policies in the ACA, and from this understanding developing a long term message strategy for emotionalizing these values.

pre-existing-condition-cartoon.jpgThis is where a most unlikely hero comes in: a bit of Orwellian obfuscation insurance bureaucrats invented to deflect attention from a deeply immoral business model. The term “pre-existing condition” was invented to conceal one of the most odious of insurance industry corporate behaviors: denying coverage to people who are sick, or based on past medical history are at higher risk of becoming sick.

The big for-profit insurance companies use to find ways to kick people off insurance when they were diagnosed with a major illness. One of the biggest national health insurance corporations infamously devised a computer algorithm to trigger fraud investigations of women diagnosed with breast cancer. These outrages were part and parcel of a calculated attempt to pick through the population for healthy people who are less likely to make insurance claims, and to leave the part of the population more likely to need medical care for someone else to worry about (a corporate dumping of responsibility comparable to polluting upstream).

This systematic discrimination made a major impression, as surely as the Robber Barons of the late 19th Century blackened the reputation of early industrial Capitalism through the outright slaughter of workers. What is absolutely astounding about “pre-existing conditions” is that this seemingly innocuous term seems to be known by virtually every adult. That most Americans know such an obscure de-emotionalized term tells you that it represents s
ask me about my pre existing.jpgomething really important to people. (It is also a demonstration that our language is not fixed in meaning, and words can take on a different meaning than originally intended).

Why do so many people not only know about pre-existing conditions, but look disgusted when the term is uttered? Most have never been denied coverage or tossed off coverage due to a pre-existing condition. It must have been passed by word of mouth through family and social networks as outrageously memorable stories, such as you won’t believe what UnitedHealthCare did to my Uncle Bob! Until the 2010 debate over ACA, there was no organized effort I know of to talk about pre-existing conditions.

Google Ngram, which tracks the frequency a word or term is used over time, is surprisingly revealing.

Ngram - pre exisitng conditions.JPG

It shows the term spiked in use during the years leading up to the passage of Medicare in the early 1960s, a period of intense public issue campaigning prompted by the fact that only 25% of seniors were able to acquire good private health insurance coverage. The term spiked again around 1992-1994, during the debate over health care reform the culminated in the demise of the Clinton Health Care Plan. Unfortunately, the most recent Nygram data currently ends in 2008, before the latest health care debate, but there can be little doubt usage went through the roof.

All of this strongly suggests that the idea of someone being denied or thrown off health insurance because they have a medical condition strikes a deep emotional chord in American culture, and that it seems deeply immoral to most people. This is critically important to know, because it is imperative in all effective persuasion to start where your audience already is, rather than wasting energy vainly trying to build brand new attitudes and values. A critical part of creating a strategic communication roadmap is developing a deep enough understanding of public opinion in general, and specific target audiences, to build on what is already strongly believed and valued. And opinion polls have regularly confirmed, and continue to confirm, that outlawing pre-existing condition is the most popular single policy in the entire health care debate.

One reason pre-existing condition discrimination is emotionally powerful is that it exists in the domain of negative freedom usually dominated by conservatives (
See Part 2 of this series). It is about large powerful corporations snatching away life and death medical care away from people when they need it most. The visceral constraint of freedom is what gives it emotional power. As important, the idea has an emotional impact on people who have never been directly affected, meaning it is seen as an issue of right and wrong, and not just a matter of narrow self interest.

There are plenty of things people get emotional about, many of them unhelpful for building support for progressive public policy. Strategically the next critical thing about pre-existing discrimination is that it provides an emotional trigger that can be used, with the message discipline of repeating it over and over again, to make the complex set of structures in the health care law more popular.

One of the few policy advantages health care reformers have is that there is no good way to affordably guarantee coverage to everyone, no matter their age or medical conditions, unless you include everyone in the system to spread the cost. This is why conservatives keep promising to protect people with pre-existing conditions (they get how powerful it is) but can never deliver a policy that actually does it.
Pre-existing condition discrimination is the ultimate wedge issue. It isolates all the leaders who don’t really believe that everyone should have somewhere to go to get health care, no matter what!

This is a critical important thought transition we need to make in progressive messaging generally. The default position for progressive advocates is to talk about something like pre-existing condition exclusions as one of many many policy issues, which means we are not thinking at the broader level of frames and values. We need to use pre-existing condition discrimination to drive home the immoral character of conservative health care policy, and the moral necessity of protecting ACA and building on it. To do that, it needs to be a story we tell over and over again, each and every time we discuss health care reform.

We need to have the mental dexterity to see pre-existing condition discrimination both as a specific policy issue, and also more broadly as a metaphor for the two dominant competing positions on health care in America.

What we are talking about here is a special kind of metaphor called a
synecdoche: where rather than comparing two unlike things, a part of something is used to define the whole. For example, the world famous pandas represent the entire National Zoo in Washington, Martin Luther King, Jr.  represents the Civil Rights Movement, and the Berlin Wall represents Soviet repression in Eastern Europe during the Cold War. In the use of pre-existing condition discrimination, a smaller part of the system is used to define the fundamental moral and emotional difference between the pre and post-ACA worlds, and the conservative and progressive positions on health care.

Now that we have looked at how to emotionalize the progressive position in the health care debate, in Part 4 of this series we will dig into how to create simple conceptual models for both justifying the complex series of policies we call ObamaCare and the next steps in health care reform.

The Anatomy of Health Care Messaging Series
Part 1: The Northern Ireland of American Politics
Part 2: Negativland: Health Care & Conservative Freedom

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  • commented 2016-04-17 22:27:41 -0500
    The pre-existing image is kind of like the auto insurance stigma.
    ‘Pay that premium on time, put are you really sure you want to file a claim for that minor fender bender’. Cancellation comes pretty easily in the auto insurance industry.