Challenging Dogma

...Using social sciences to improve the practice of public health

Friday, April 27, 2007

Using Communication Theory to Critique the current framework promoting National Health Care Reform: Why America Can’t Achieve Action- Lisbeth Balligan

The Issue
Many health care professionals currently engaged in the medical profession would agree that the present system of delivering heath care is inadequate and fails to meet the nation’s needs. A 2005 report found that at least 45 million people, 15.6% of the population, in the United States are without basic medical services (1). Ironically, the United States spends more than any other industrialized country on health care yet it has some of the lowest life expectancy rates (2). In addition, health care accounts for the largest portion of gross domestic spending at 15.3% in 2003, and this portion has been rising yearly (3).
The majority of Americans agree that everyone in the country should have access to and coverage for necessary services (4). These services should include, dental care, eye care, primary care, and emergency care. Contrary to the public sentiment in favor of reform efforts, the nation has been unable to achieve national health care coverage for decades. The efforts to pass a comprehensive system have been unable to rise above the partisan divides within our state and federal government. A good example of this failure is the attempted reform during former President Bill Clinton’s first term in office. In 1993, first lady Hilary Clinton campaigned for national health care reform. The proposal ultimately failed to pass because agreement could not be reached between congressional Democrats and Republicans (5). Little has changed since this time. Currently, no constitutionally recognized right to health care has been articulated. Portions of the population are covered under piecemeal government programs such as Medicare, Medicaid, Children’s Health Insurance Program (CHIP), and the Veteran’s Administration. Coverage under these programs varies from state to state and is often inadequate at meeting individual’s health needs because many needed procedures are not covered.
Framing and Contextualization
The context in which the issue is presented in the popular press and journal articles affects the general populations’ perceptions of health care reform. The term “framing” comes from cognitive science, which defines a frame as a conceptual structure used to influence individual’s perceptions of their worldview (6). Issue framing, developing and implementing a way of understanding a particular issue, is one of the central and best-documented methods available to political players to structure political debates (7). The framing technique involves developing a strategic way of presenting an issue to meet a particular goal. The frame has a core position that it holds as its main belief. Often this belief is expressed by appealing to different values that individuals may hold, such as, freedom, justice, autonomy, health, and equity. Frames can often be recognized by certain catch phrases and implied solutions. Also, framing often provokes certain metaphors and images that help strengthen the frame and its ability to gain acceptance and integration by its target audience.
The frame most often used in the health care debate is the Universal Health Care frame. This frame is flawed for several reasons which will be explained in the following section. One important inadequacy of the current frame is that it aims to communicate on a level three analysis and not on a level one analysis (8). A level three analysis focuses on programs and policy reforms while a level one analysis focuses on values and principles. Individual’s values and principles must be considered when articulating an adequate frame to promote national health care reform. Health care reform is a collective issue that requires the coordination of all members of the U.S. population. By currently focusing on policy- level reforms the frame does not allow individuals to feel empowered to advocate for changes in their health care benefits. Values and principles are what stir individuals to action. By using social science theory and addressing the importance of efficacy in influencing behavior changes a new frame promoting reform can be developed. This new approach can empower individuals to influence their legislators and request that changes be made.
The Frames
There are three frames that dominate the popular literature are used to characterize health care reform proposals. They are universal health care, a right to health care, and socialized medicine (9). The goal of health care reform efforts is to achieve a comprehensive health care system that includes access to care and coverage of necessary services. None of the existing frames meet this goal. A new frame can be developed by critiquing these frames and highlighting their strengths and weaknesses.
The first and most popular frame, universal health care, focuses on the core value of health. This is a weak core value because it does not illicit strong personal emotions. Other core values such as justice and freedom are stronger because they appeal to virtues that individuals tend to care more about and find more value in. Key phrases for the universal health care frame include “full coverage,” “universal,” and “single payer.” The metaphor used in this frame is, ‘other countries have a national health care system so should the U.S.’ This metaphor is also weak because it does not resonate with Americans. Americans pride themselves on being unique, autonomous individuals, so knowing that our actions are different then other countries is often perceived as a compliment by Americans. The frame also does not promote any strong images which are essential if individuals are to internalize the frame. Overall, the universal health care frame is very weak and this is the main reason that health care reform initiatives have not received the momentum needed to achieve successful reform.
Another frame, a right to health care, is flawed based on its reliance of a ‘right’ to health care. Currently, there is no recognized right to health care in the Federal or any State Constitution. Without this right, the frame loses its force. Alternately, the core values on which the frame relies, fairness and justice, are strong. Also, the metaphor of the civil rights movement is engaging because it resonates with many individuals. The Civil Rights movement is an example of a successful nationwide system reform. The movement elicits visions of peaceful protest and a call for action. These sentiments and the parallel conceptualization they provide are helpful in making the issue of health care reform important to the general public. Regardless of how successful these images of reform are, without the constitutionally recognized right to health care the frame for health care as a right has no foundation and is thus ineffective.
The socialized medicine frame asserts that governments can and should meet their citizens needs for health care. In our current democratic nation, this sentiment holds sway but the frame neglects to propose a solution to the problem. Taxes would need to be increased to allow the government to implement and run a socialized national health care system. Some Americans are opposed to the idea of funding a health care system that is already very costly and has no mechanisms for cost control in place. In addition, ideas of socialized medicine bring to mind images of Big Brother regulations and are in direct conflict with the core values of freedom and autonomy which are highly valued by Americans. Thus, the idea of complete health care coverage by government implementation and control fails to address some fundamental inadequacies that currently exist.
The Remedy
Because all of the existing frames promoting national health care reform are flawed, a new approach must be articulated. By drawing from social science theory and social cognitive theory in particular a new frame that addresses the failures of the existing frames can be articulated.
Social Cognitive Theory
Self efficacy is the belief that one has the capacity and ability to execute the courses of action required to meet a particular purpose or goal (10). Self efficacy is particular to an individual. Whether or not they perceive an act to be self efficacious can be influenced by outside forces, but the ultimate belief is an individual construct. There are four sources that influence a person’s self efficacy; modeling, experience, persuasions, and physiological/emotional factors .
Self efficacy becomes important in the context of the health care reform debate because in order for people to engage in the promotion of systematic health care reform, they must be able to act as self efficacious individuals. They must see the reform as achievable and they must see the proposed health care system as accessible. Self efficacy plays a direct role in motivation. Low self efficacy can lead people to believe that tasks are harder then they really are and can cause a lack of motivation to attempt the task. Alternately, high self efficacy occurs when an individual believes the task is possible and provides the motivation to attempt the task. By reframing health care reform in a way that promotes individual self efficacy, people can be motivated to act for change.
Implications for a new national health care reform frame
The nation’s current health care system is in need of overhaul and reform. The frames used to articulate the debate have focused entirely on policies and programs and have done little to capture the importance of individual perceptions and behaviors. By neglecting to address the importance of an individual’s contribution to reform and failing to incorporate them into the vision of a national health reform program, the motivation for a fundamental change in the nation’s health system has been lost. In order for the reform to gain the momentum and acceptance it needs to pass and be successfully implemented, the proposed changes must be seen as effective and necessary in the eyes of the general population. Individuals must feel that the new system and the frame used to promote it are empowering. A successful frame will promote individual self efficacy and allow individuals to use their motivations as fuel for legislative action.
(1)Health and Human Services. Working Paper: Estimating the number of individuals in the United States without health insurance. Actuarial Research Corportaion, Annandale, VA.
(2)Bodenheimer T. Understanding Health Policy: A Clinical Approach, 4th Edition. New York, NY: McGraw Hill Medical Publishing Division, 2005.
(3)Health and Human Services. Effects of Health Care Spending on U.S. Economy.
(4)Kaiser Family Foundation. Public Opinion Spotlight.
(5)Clinton B. My Life. New York, NY: Knopf, 2004.
(6)Chua K. Introduction to Framing.
(7)Terkildsen N. Interest Groups , the media, and policy debate formation: an analysis of message structure, rhetoric, and cues. Political Communication 1998; 15:45-61.
(8) Chua K. Introduction to Framing.
(9) Table
(10) Self Efficacy. Wikpedia.

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