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Although Americans routinely express support for universal health care, there is little political momentum for such a change. Contracted by the Herndon Alliance, we worked with Celinda Lake and Lake Research Partners to achieve two goals. The first was to come up with a set of findings to identify how Americans reason about health care. These findings then could be used as the basis for any number of health care reform strategies. The second goal was to create a set of Strategic Initiatives that would advance our goal of universal health coverage by putting forward proposals that are logical entailments of the existing worldviews of most Americans.
We began by creating the Road Map for a Health Justice Majority, a segmentation of the population which identifies the Health Justice Base and Anti-Base from a values analysis, identifying the underlying worldviews and characteristics of those who most strongly support or oppose health care reform. The Road Map also identifies the Constituencies of Opportunity, which are those constituencies not commonly associated with the Health Justice Base but who share many of the values that make them possible supporters of health care changes. For example, the Health Justice Base-heavily female, older, diverse and financially struggling-supports universal health care both from financial necessity and from their strong belief that government has a responsibility to help the less fortunate. Our largest Constituency of Opportunity, the "Proper Patriots," looks very different from the Base by enjoying a position of greater stability and affluence. Yet the Proper Patriots embrace a worldview that holds work, responsibility and patriotism in high esteem-values that provide several openings for building political support for health care reform.
In order to more fully understand the different worldviews and narratives that form opinions on health and health care, our cognitive team created the report Health Care: The Stories We Tell. Examining health care advocacy materials and media coverage, the report identified four pairs of meta-narratives primarily used in health care discourses. One of each pair of the meta-narratives is, loosely speaking, commonly associated with the ideological Left, and the other is similarly associated with the ideological Right. For example, in the meta-narrative, "Who's getting between you and your doctor?" the Right side of the narrative identifies government as the intruder, meaning that government involvement in health care will only limit choices for individuals. Correspondingly, the Left side identifies corporations as the intruder, pointing the finger at greedy HMOs whose motivations for profit have restricted options for patients and doctors. Each basic narrative has presuppositions, or assumptions on which the meta-narrative depends for its coherence and applicability, and entailments, or the conclusions that logically follow given the other two elements.
Relying on our research into the values-defined Constituencies of Opportunity and underlying attitudes about health care, we convened a series of Strategic Initiative workshops with members of the Herndon Alliance. While the conventional approach to expanding universal coverage has been to take a population-based approach (for example, adding children under a certain age, seniors, or those below a socio-economic line), we believed a different approach would win far greater support. We asked, would it get us closer to universal coverage if we took a benefits-based approach instead of a population-based approach?
In collaboration with Lake Research Partners, we held eight psychographic and demographically recruited focus groups to test the policy initiatives developed during our workshops. These focus groups allowed us to refine the most promising initiatives, and to better understand how these initiatives flowed from and played into the worldviews of our constituencies. The focus groups revealed just how much Americans see health care through a consumer frame, and that we must solve the consumer crisis first if we want to generate generosity instead of indifference. Other attitudes revealed that government confidence is at an all-time low, meaning that individuals are looking to government to provide simple and enforceable rules-not new services and programs.
Based on our research and refinement, we identified four Strategic Initiatives that have the most potential in creating new health care reform support. The first Strategic Initiative, "Generation Next," challenges Americans to make our children the healthiest generation this country has ever seen, by using a junk food tax to fund pediatric care, preventive treatments, oral health care, obesity prevention in schools, restored physical fitness classes and incentives for healthier community designs. Tapping into Americans' desire for an aspirational vision of our country's future, initial testing of Generation Next encouraged optimism and feelings of generosity for providing health care and increasing wellbeing for all.
The second initiative, "Universal Cancer Screening," builds on values of responsibility and ethical behavior to propose cancer screening services for all Americans, even those who are uninsured. This act would ensure that everyone can choose whether to get this screening from their own doctor, another health provider or a publicly funded health clinic. Rather than focusing on one segment of the population, which is the population-based approach to incremental universal coverage, we proposed extending a single benefit to the entire population. Psychologically speaking, this establishes a right in people's minds that is a strong basis for new benefits in the future. As we heard in our focus groups, "We can't test women for breast cancer and then not treat them if they have it."
The initiative for a "Health Care Bill of Rights" fits into the pervasive consumer frame. The Bill of Rights would establish a minimum core of essential and preventive services that all health plans have to provide, protect consumers if they lose or change their jobs and prevent insurance companies from denying coverage due to pre-existing conditions. These initiatives speak directly to patients' experience as consumers and their desire for better protections, offering them the sense of security that results in greater generosity and support for change.
The final initiative, "Guaranteed Choice," would allow every American guaranteed access to a choice of standard, affordable health plans, either buying it from a private insurer or from a public plan provided by an independent nonprofit agency. This choice of plans, public and private, would be affordable and based on a sliding pay scale. This approach would put consumers and families in control of their health care and make sure every American has access to affordable health coverage that meets their needs.
Click Here to view a presentation summarizing our work and these initiatives. With Lake Research Partners, we are continuing to test these health initiatives with a larger survey in order to better measure if they are working in the way we intend. After we determine which proposals are most salient to our Constituencies of Opportunity, we will work with the Herndon Alliance to introduce these initiatives and test them over time.
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