Selling Health Care? Watch What You Say.

By Drew Westen
Sunday, June 28, 2009

"Universal health care." "The uninsured." "Public option." These are the buzzwords you often hear from Democrats and proponents of President Obama's plan for health-care reform. But if they want to see that plan enacted, they'd do well to excise those phrases from their vocabulary.

Words send messages, but they're not always the messages we intend. Recent polls show overwhelming support for health-care reform, including the "public option" in Obama's plan. But the reality is that which side prevails in this battle will depend as much on which one has its messaging right as on which has its policies right.

Republicans and other opponents of Obama's plan are already operating on this assumption, guided by a memo on "the language of health care" that conservative wordsmith Frank Luntz circulated to GOP members of Congress last month. In it, he conceded that the public wants real reform and argued that the only way Republicans can defeat Obama's plan is by co-opting the language of reform, describing the president's plan as a "government takeover" and painting it as a bureaucrat's dream and a patient's nightmare.

In fact, as easy a sell as health-care reform ought to be, ideas do not sell themselves -- particularly when someone is trying to sell them short. Reform advocates need to remember the four things that persuasive leaders do well: tell compelling stories, focus on principles, move people emotionally and send clear messages.

Humans are a storytelling species. People have trouble remembering lists of facts, figures and 12-point plans, which is why candidates who run on them get taken to the cleaners. In politics, if you want people to get the gist of what you're saying, give it to them: What's the problem? How did it come about? Who are the protagonists and antagonists? How are we going to get out of this mess? That's a story.

Remember Harry and Louise? They were the average middle-aged couple who took on another couple named Bill and Hillary in insurance-industry-sponsored television ads during the last health-care debate 15 years ago. Their first ad, set "sometime in the future," showed the couple at their kitchen table, going through bills, musing about the good old days when their health insurance plan covered their costs and government bureaucrats didn't control their health care.

The Harry and Louise campaign capped a well-funded effort to defeat the Clintons' effort at health-care reform in 1994. It was effective because it told a story that resonated with Americans' values and concerns (particularly regarding freedom and control): Let the government get a foothold in your health care, and soon you'll be on the receiving end of socialized medicine and big government bureaucracy.

This year's implicit story line from the Republicans, as they follow Luntz's guidelines, is similar: "Watch out for these guys. They'll tell you they just want to include a government plan as one option among many. But their real agenda is a single-payer system, where you won't have any choices because they believe the government knows what's good for you."

Luntz recognizes that opponents of reform face an uphill battle: Americans want comprehensive reform. But they're ambivalent. Though 85 percent have insurance, they are worried about what it no longer covers and what it will look like next year. The trick for conservatives is to make middle-class Americans fear the devil they don't know. So Luntz also advises the GOP to talk about long lines and delayed care.

Luckily for Democrats, they have a storyteller in chief whose talents rival those of Bill Clinton and Ronald Reagan. Obama's recent address to the American Medical Association included an evocative story about a young mother with breast cancer, as well as the personal story he tells of watching his mother struggle with her health insurance company as she battled cancer in her final months. He made clear why their stories are our stories.

Obama is also focusing on principles -- on the moral of the story. Campaigns that focus on principles tend to be far more effective than those that barrage voters with facts and policy details. And those principles, like the personal stories that exemplify them, should be emotionally compelling. They should speak to our values and interests. They should indicate that our leaders understand what matters most to us -- in this case, choice, security, cost and the quality of the doctor-patient relationship.

In a May 11 speech, Obama spelled out the principles that have become his mantra. "Whatever plan we design upholds three basic principles," he said. "First, the rising cost of health care must be brought down; second, Americans must have the freedom to keep whatever doctor and health care plan they have, or to choose a new doctor or health care plan if they want it; and third, all Americans must have quality, affordable health care." Lower cost, freedom to choose and coverage for all Americans -- that's memorable, principled and emotionally compelling.

If Obama's storytelling has a flaw, it's that he leaves out the antagonists. In his AMA speech, he never called the group on its opposition to Medicare in the 1960s. Nor did he mention that the insurance and pharmaceutical industries blocked reform for decades, even as their profits rose with skyrocketing premiums and out-of-pocket expenses. Whether Obama can win through inspiration and without benefit of populist anger or anxiety is unclear -- especially when the other side is selling fear.

Finally, perhaps the most important element of effective communication is knowing what messages you're sending. Every word we utter activates what neuroscientists call networks of association -- interconnected sets of thoughts, memories and emotions. Consider the term "universal health care." Every time Democrats use it, they reduce the chance of reform. Why? Because it evokes precisely the associations that conservatives want to evoke: socialized medicine, government bureaucracy, impersonal clinics and lack of choice.

Over the past few weeks, the health care debate has centered on the "public option" in Obama's plan. Unfortunately, "public option" shares the negative connotations of "universal health care" -- with additional associations to low quality and welfare. It's no accident that Republicans have seized on this, because the longer people hear about the "public option," the more they are likely to associate the entire plan with government control. Advocates could counter by asking Americans whether they prefer choices dictated by the insurance industry or the range of choices that their elected representatives get, including a high-quality plan that doesn't rely on the goodwill of industry executives.

Reform advocates also set back their agenda every time they talk about "the uninsured" or "the underinsured." Those phrases turn an "us" into a "them," which decreases empathy and activates what social psychologists call the "just world hypothesis," the idea that somehow people get what they deserve. It also activates the "welfare" network, tainting by association people who work full-time or want to work but still can't afford insurance. (Most people on welfare have access to Medicaid. It is the "working poor" -- another term that distances and depersonalizes -- who constitute most of "the uninsured.")

Can these simple phrases really make that much difference? Yes, they can.

Last year a coalition of nonprofits dedicated to health-care reform commissioned Democratic pollster Celinda Lake and me to figure out how to translate a set of policies into everyday language that would speak to Americans' concerns. Messages that laid out the principles behind reform -- such as giving people control over their own health care decisions and making sure no one could be denied health insurance because of "pre-existing conditions" -- beat the best conservative messages, whereas messages that turned people into statistics or focused on policy details fared poorly. The same people who expressed strong negative feelings toward a candidate who proclaimed his belief in "universal health care" strongly supported a candidate who began a message with the statement, "I believe in a family doctor for every family." To the average American, a family doctor for every family connotes something warm, comforting, human and nostalgic, whereas universal health care connotes something cold, sterile, distant and creepy-futuresque.

The American people want health-care reform, and the battle of images and narratives has begun. If Obama and his party want to win, they'll stand up and say what they believe, clearly and with conviction. There's no more important principle of political communication than that.

Drew Westen teaches psychology at Emory University and is the author of "The Political Brain."

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