Coles E. Health reform in the U.S. HPHR. Fall 2018;14.
Though many celebrated the Republican failure last year to pass health care reform, it also contained a dark lining. For those who want wholesale changes to our broken system, it is discouraging to see that Republicans, who controlled both houses of Congress and the White House, were unable to overcome internal divisions and form a sufficient, guiding coalition for change. A key lesson from this experience for both parties is that a massive, concentrated effort will be needed to build enough buy-in to overhaul our health system.
The obvious next question then is: How can such a reform coalition be built? Jonathan Haidt and Jesse Graham, two psychologists, offer an approach. In their Moral Foundation Theory, they argue that liberals and conservatives prioritize different sets of five key moral values; caring, fairness, authority, loyalty, and sanctity. Liberals emphasize caring and fairness above the others. On the other hand, conservatives value all five more or less equally, with slightly more emphasis on the latter three.
For policymakers, this theory means that evidence about healthcare should be framed differently for audiences to appeal to their most salient values. To be clear, this does not mean that different ‘facts’ are needed — only that how the facts are framed should vary. The same evidence can be used to build support from people with different values. The crucial difference is the salient value that is referenced.
For example, it is a fact that 11% of adults in the United States are uninsured. But how should the fact be framed for a liberal or conservative audience? For liberals, it can appeal to their sense of ‘caring’ for fellow citizens, as in: “We should care for our fellow citizens by ensuring everyone has access to health care through insurance.” Since ‘caring’ is a value that liberals highly prioritize, this message is likely to resonate. Liberals would then be more likely to support the reform.
For a conservative audience, approaching the problem from a ‘caring’ perspective would be less effective because caring, according to Haidt and Graham, is not prioritized as highly by conservatives. A more effective frame is on loyalty, such as: “We are loyal to each other and take care of our own. It is disloyal to allow someone to forego care.” Loyalty, in this case, means ensuring each person is cared for when they are in need. Conservatives are more likely to see a problem with the uninsured if they see it as a question of loyalty rather than caring.
A second example of framing differences is the fact that there are large disparities in life expectancy between social classes, races, and ethnicities. To a liberal audience, this problem may be framed as an issue of equality and fairness: “We are not treating people fairly, as shown by the fact that certain segments of the population die sooner. We should eliminate disparities so that everyone has an equal opportunity at a healthy life.” In this appeal to fairness, we are again aiming at a highly prioritized value of liberals.
For a conservative audience, appeals to fairness are, again, less effective. A more appropriate value is the sanctity of life: “We are not sustaining all the lives we could. Life is a precious gift and through resolving health disparities we would create more life in this world.” Framing the message as a question of sanctity increases the likelihood of conservatives seeing a problem.
Major health care reform in the US does not have to be a fantasy. A change will only happen when a broad coalition is created. If the evidence of our system’s problems is presented appropriately to the audience in question, then we are more likely to create a coalition calling for change. Policymakers on both sides of the aisle can be better at appealing to values that resonate with their audiences. Sticking to a single frame for facts may inhibit reform and keep us with the dark reality of our current system.
Gallup, I. (2017, April 10). U.S. Uninsured Rate Edges Up Slightly. Retrieved August 06, 2017, from http://www.gallup.com/poll/208196/uninsured-rate-edgesslightly.aspx
Graham, J., Haidt, J., & Nosek, B. A. (2009). Liberals and conservatives rely on different sets of moral foundations. Journal of personality and social psychology, 96(5), 1029.
National Center for Health Statistics (US). (2016). Health, United States, 2015: with special feature on racial and ethnic health disparities.
Sabatier P, ed. (2007) Theories of the Policy Process. Cambridge, MA: Westview Press, 2007.
Eric Coles is a DrPH candidate at the Harvard T.H. Chan School of Public Health, in Boston, MA.