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Sept. 17, 2018
Political speak, when it comes to healthcare, is an art form for candidates for public office. It’s intentional obfuscation that contributes to the public’s lack of understanding about our complicated, costly system.
Focus-group-tested phrases are used by the campaigns to sway voters and convey a candidate’s knowledge about an issue. It’s especially the case when healthcare is the focus—the rule of thumb is the less said, the better. It makes sense, after all.
Health literacy is low in the U.S.—per the CDC, only 12% of the population is “proficient” and that’s a relatively low bar. Campaigns know that most voters think about “the health system” in the context of their personal experiences with the doctors and hospitals they use, the insurance they have, and what they learn from friends and online.
So, for campaigns on both sides, it’s political malpractice to allow candidates to get into the weeds on healthcare issues. It can expose a candidate’s ignorance and fuel attacks by opponents. Healthcare political speak is safe ground, especially in ads and position papers produced by the campaign and in controlled setting where media questions are limited.
Semanticists study the meaning of words and phrases. Understanding their denotation (dictionary definitions) and connotation (how they’re understood by various audiences in context) is especially important to understanding the public’s opinions.
Polls indicate healthcare will be a key issue for voters in 50 days, especially for Democrats, seniors Independents and women. It’s been front and center in campaign politics for a decade and, therefore, healthcare political speak using loaded terms and phrases has taken on added import to campaigners.
Illustration: During the 2009-2010 debate about the Patient Protection and Affordable Care Act, opponents rallied their followers against “government run healthcare” and the likelihood of “rationing.” Proponents countered that “expanding access to health insurance coverage” was synonymous with access to care though the two are far from the same. “Mandates” have been vilified as usurpation of individual rights rather than an economic requisite for health insurance risk sharing with roots in conservative theology (Heritage Foundation) and alternative to “the public option.” And “repeal and replace” has been the battle cry for GOP incumbents and challengers through the past three election cycles, including President Trump’s promise to do it on his first day in office.
Since its passage in March 2010, fueled by widespread use of healthcare political speak, public opinion has calcified for and against “the Affordable Care Act” aka “Obamacare,” but public literacy on its key elements remains low (Kaiser Family Foundation Tracking Polls).
In the next 50 days, healthcare political speak will be at its peak. Healthcare spending is 29% of the federal budget and up to 34% of state outlays. Yet, public satisfaction with the system is slipping, and anticipation of better options from Amazon, Apple and others is growing.
Based on campaign ads running around the country in this election cycle, the shortlist for healthcare political speak will be headlined by these loaded phrases:
“Medicare for All”
Its denotation is straightforward—insurance coverage would be provided through the federal government’s Medicare program. Private insurance would cease to play a substantive role in our system. Its connotation, however, depends on how it’s used. Some candidates infer it would reduce health costs and make care more accessible and affordable. Others call it Armageddon for innovation, personal choice and quality in U.S. healthcare. Some say it will lower costs; others envision more spending. But in political double speak, the phrase, “Medicare for all” polls more favorably than “single payer” and is favorably seen by a growing majority of Millennials, young Boomers, urban and educated voters.
“Affordable Care”
Its denotation in the Affordable Care Act is the amount of out-of-pocket household income spent for health insurance coverage. Spending above 9.5% of household income was deemed unaffordable for employer-sponsored coverage, allowing the employee access to cost-sharing subsidies through state-run marketplaces. Eligibility for state and federal benefits programs, including Medicaid, Supplemental Nutrition Assistance, CHIP and others, is means-tested calibrated to a multiple of the federal poverty level that’s adjusted for inflation annually. But a widely accepted connotation of “affordable care” is elusive. While all agree costs are high and prices unexplainable, the public’s view of affordability is limited to what they pay directly—premiums, co-pays, deductibles, out-of-pocket costs for over-the counter remedies et al—and not the total costs associated with an episode of care or the city, state and federal taxes we pay. “Affordable care” is great for healthcare political speak: candidates can claim it’s their concern, blame bureaucracy and promise changes that fail to address the elephant in the room: healthcare is expensive because Americans expect the latest and best while living lifestyles that drive demand and unnecessary costs.
“Access to Care”
In health services research, it denotes an individual’s ability to receive healthcare services in a timely manner. In the debate about health reform, insurance coverage was used as a surrogate for access, though it’s more complicated. Its connotation, therefore, is fodder for political speak. Access is collateral damage when hospitals close or physicians limit their practices to new patients. It’s enhanced by digital health and retail providers and compounded when social isolation and food insecurity are factored in. Polls indicate consumers think access to needed health services is slipping. Pew found 13% of U.S. communities have shortages of primary care services posing access issues. Half say they delay needed care due to costs. Waiting times for new patients to see general internists are up to six months in many urban markets. In political speak, calling attention to “access” is safe but risky if a candidate is pressed to specify remedies.
“Quality of Care”
Its denotation is specific to the clinical characteristics of health delivery—processes, outcomes, safety, clinician training and performance and more. The accuracy of a diagnosis and appropriateness of a treatment based on scientific evidence is widely associated with healthcare quality. But its connotation is broader: Voters think quality of care means healthcare services are local, but for many services, they’re better and cheaper out of town. Voters think medical doctors practice per the latest evidence: many don’t, but the concept of inappropriate variability is foreign to the concept of quality held by most consumers. Voters think the lion’s share of tests and procedures are necessary: a third aren’t. They believe our system produces the world’s best outcomes: other systems (French, Swiss, et al) get comparable results and higher citizen satisfaction by integrating their medical and social services programs more effectively than we do. In healthcare political speak, it’s kosher to say our quality is the best in the world without addressing its widely recognized flaws or the widely varied effectiveness of therapies, hospitals and clinicians.
In 1994, on the heels of my dad’s heart surgery, I wrote 99 Questions You Should Ask Your Doctor and Why (Rutledge Hill Press). It closed with this surmise: “Amazingly, doctors and patients know very little about each other and surprisingly little about the healthcare industry in general. This lack of communication and understanding hurts all of us financially and medically.”
In the next 50 days, healthcare political speak will be at its peak. But it’s unlikely voters will be better informed about the issues and trends vital to the sustainability of our health system. It’s easier to default to political healthcare speak.
Paul
PS: In the past two weeks, court actions in two states mean the ACA’s future is still unsettled. In the Northern District of Texas September 5, an argument brought by 20 Republican attorneys generals and two governors challenged the constitutionality of the individual mandate (only). The lawsuit was filed in response to the tax and jobs law which overturned the penalty for individuals without health coverage. The GOP contingent asserted that the individual mandate, without a tax penalty, is unconstitutional and other provisions including the pre-existing conditions exclusion are “inseverable” from the individual mandate rendering the entire law invalid.
In Maryland’s District Court last Tuesday, September 13, MD Attorney General Brian Frosh filed a complaint petitioning the court to uphold the constitutionality of the ACA’s individual mandate as a retort to the Texas case. Frosh asserted that striking down the law will cause harm to Maryland residents.
Both cases will be closely watched by industry leaders and legislators as the ACA’s fate lies in the balance. Speculation is mounting that the Affordable Care Act will end up in the Supreme Court again!
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