Daily Archives: July 27, 2009

Framing Health Reform: Why You Think the Way You Do

Back in 2004, Berkeley cognitive linguistics professor George Lakoff published the book Don’t Think of An Elephant! Know Your Values and Frame the Debate. It’s a fascinating book, and I encourage you to pick it up if you’ve never read it. More on that momentarily.

First, I’d like you to try out a little experiment. I’m going to describe two scenarios to you, and after you read them, I want you to think about which scenario you most identify with. Put aside for a moment the fact that you may identify to varying degrees with both scenarios, or that the scenarios seem to overlap in your view. Just pick one. Ok, here we go:

Case 1

“The world is and always will be dangerous and difficult. The world is competitive and there will always be winners and losers. There is an absolute right and an absolute wrong. Children are born bad and must be made good. The father, as head of the family, is the moral authority who must support and defend the family, tell his wife what to do, and teach his kids right from wrong. Doing that requires painful punishment–physical discipline that by adulthood will result in the children having developed internal discipline. This discipline is demonstrated by following certain moral precepts and becoming self-reliant through the pursuit of one’s self-interest. Once on their own, the father should not meddle in his children’s lives. Children who remain dependent should be further disciplined or cut off, forcing them to become independent by the discipline of the outside world. Disciplined individuals will be successful, and they will prosper and amass material wealth. They should be rewarded. Those who are not successful are not successful because they are not disciplined, and to provide them with any type of outside assistance would be to enable their lack of discipline, which would be a bad thing to do.”

Case 2

“The world, despite its dangers and difficulties, is basically good, can be made better, and it is our responsibility to work towards that. Children are born good and parents can make them better through empathy and responsibility. Both parents share the responsibility for raising the children. Their job is to raise their children: To protect them from all sorts of harm, help them have happy fulfilling lives, treat them fairly, and ensure their freedom (age appropriately of course). You realize that you will only be able to do these things for your child if you yourself are happy and fulfilled. Trust, two-way communication, and opportunity are essential if your children are to grow into fulfilled individuals.”

So which one are you? Do you see the world more as it is depicted in Case 1 or Case 2? I know you’re asking what in the world this has to do with health care, but as Lakoff describes in detail, these views of the family shape our views on nearly everything else we encounter. Individuals who are oriented more in favor of Case 1, the “strict father” model, tend to be more conservative, while individuals who see the world more in Case 2 terms, the “nurturing family” model, tend to be more progressive.

In fact, we often personify views of the family onto other issues. We even conceptualize entire nations as if they were individuals. North Korea is a hostile nation. But does that mean all of its people are hostile? No. If we were using mean population values to label nations, we would more accurately refer to North Korea as a starving nation. Similarly, for those of us who believe in a Supreme Being, we tend to view that being in one of two ways: A strict father, who demands obedience and punishes us for our mistakes; or a nurturing father, who models grace and love to us by example.

Nothing activates frames better than fear, and with the current economy in the shape it’s in, there’s plenty of fear to go around. According to Lakoff, every story conveyed by a frame has a “hero, a crime, a victim, and a villain.” I know that I have readers of this blog who are on both sides of the health reform debate. Therefore, I ask you to write a comment on not only who or what you believe to be deserving of each of these four titles, but also–and more importantly–why you think the particular title is deserved. This should give you an opportunity to explore the subconscious thoughts you have about health reform and assess their validity… well are your thoughts supported by the facts? If you’re honest with yourself, I believe you’ll find that facts often take a backseat to the frames we use to process information–no matter which side of the issue you’re on.

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Posted by on July 27, 2009 in Uncategorized


Tying Up Loose Ends: The Public Plan

This is not the post I had planned for today. That will follow later today. First, though, I have to tie up some loose ends in the form of comments that I’ve received on my “Fear Not” posts.

Here are some excerpts along with my replies…..

…I think it’s a little disingenuous to suggest the Canadian healthcare system is not state provided. Delivered by so called “private providers”, sure, but the state is certainly paying for at least 70% of it. The vast majority of Canadian physicians participate solely in the public sector, and the state is their exclusive source of revenue. This is certainly NOT how it is in the U.S….

While I’m not sure where the 70% figure comes from regarding Canada, I can state that the in the United States, roughly 46% of national health care expenditures are publicly financed. So, if the definition of “state-provided” health care has only to do with who is paying for things, then the American system is half “state-provided” already. I really don’t think that folks with Medicare see it that way. They go to the doctor just like they always have. They just have a different source of insurance than they had when they were younger.

…state run healthcare systems will attempt to control rising administrative costs and end up restricting healthcare supply. It is impossible to claim the government will not determine which benefits to provide, because the dollar always decides….

Here it is suggested that healthcare supply will be restricted to control rising administrative costs. The problem with this line of reasoning is that government insurance has administrative costs of around 2 – 3%, while private insurers come in around 20 – 30%. This is a case where the costs of competition (e.g., advertising) are passed on to the consumer. Government, as an entity not seeking a profit, is able to eliminate these administrative costs. They don’t do this by cutting benefits. They do it by operating more efficiently than the private sector. I know that’s hard to believe, because government is often bureaucratic and inefficient, but it’s based on sound empirical evidence in this case. The result is actually that the savings on the administrative side of the coin could be used to provide better benefits.

The claim that “the dollar always decides” is very true. One needs look no further than the series of explicit rationing decisions in the Oregon Plan. The issue is that our system operates on a fee-for-service model where the patients don’t know what they really need most of the time. Thus, providers have perverse incentives to do anything and everything they see fit to do, as long as there is any chance that it might be even minimally beneficial. That is inherently wasteful, especially once aggregated to the national level. Because we so prize life and health, and because we are shielded from many of the costs of our care, we seek to maximize our individual benefit, to the detriment of the whole.

…our system needs some major work…the primary culprit for our outrageous costs are the insurance companies. I very much support efforts to better regulate these crooks – but I certainly do not want a mandated public health plan. As best as I can tell, I believe the proposed legislation allows you to keep your current provider but not switch to a new one. Am I mistaken about this?

This is definitely a big concern for many people, but it’s just not true. First, there are multiple versions of legislation being drafted, and the only one that’s actually been made publicly available is the House bill. There is definitely talk of an insurance mandate, but not a “mandated public health plan.” That is, everyone is required to have insurance, but that could be employer-based, Medicaid, Medicare, the new public plan, or individual private insurance purchased through the Exchange.

The proposed legislation allows you to keep your current provider and puts consumer protections in place that will keep that provider from cutting benefits and/or increasing premiums at an unreasonable rate. However, you will also be able to switch to a new provider as you wish. The only stipulation is that to offer coverage, private insurers must participate in the Exchange. It’s helpful to think of the Exchange like a Farmer’s Market. This is where you go to buy your coverage. The public plan is on sale there, but so are all the private plans. The idea is that this will be how the government can regulate the private insurers through competitive practices. Would you buy tomatoes for $5 a pound if the exact same tomotoes were available for $2 a pound or $1 a pound? No. Likewise, if one private insurer offers the same benefits at a higher price than another private insurer or the public plan, most people will “vote with their feet” and switch to a less expensive plan with the same benefits.

The bottom line: The proposed public plan option is an option. No one is being forced to enroll in the public plan. It represents more choice, not less. And it also promises to keep the private insurers in line, which means that everyone will have better options to choose from.

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Posted by on July 27, 2009 in Uncategorized

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