Breakthrough

Jointly authored with Ted Nordhaus, and drawing on research conducted by American Environics and Lake Research Partners for the Herndon Alliance

Anyone who remembers how the last Democratic effort on health care went down in flames -- dividing the party and leading to the Republican takeover of the Congress in 1994 -- remembers the infamous "Harry and Louise" attack ad. The ad was nothing fancy -- just a typical middle class couple discussing the Clinton health care reform legislation. What fewer people remember is why the ad worked.

The ad worked because it spoke, directly and in a very intimate way, to the things that Americans worry about when they consider changes to the health care system: what the changes will cost them and how the changes will affect their own health care and choices.

The television ad was created by the health insurance lobby and ran in swing congressional districts. Those who were involved in creating and pushing the 1994 Clinton plan tend to lament that the "Harry and Louise" ad was misleading, and point to polling that showed that the specific content of the Clinton plan remained popular to the bitter end.

Voters, however, do not make up their minds based on the specific content of policies, but rather on their impression of what the policies will do. Voters in 1994, confused by the complexity of the proposal, feared it would result in less, not more, choice, and higher, not lower, costs. If progressives are going to win on health care reform, they must avoid this trap. And that means understanding how -- not just what -- middle- class voters like "Harry and Louise" think about health care reform.

1. Recognize that most voters have health care

Advocates of health care reform have spent much of the last 15 years talking to the 260 million Americans who have insurance about the 40 million Americans who don’t. To be sure, many insured American voters are truly and deeply concerned about the plight of the uninsured. But when it comes down to really evaluating reform, regardless of how sincerely they agree with a relatively general survey question, insured voters think first about how it will affect their own health care. It may be true that a big part of the solution to rising health care costs is to insure everyone. However, insured voters, who are 95% of all voters, generally don’t see it that way. The health care crisis that insured voters experience every day is characterized by things like rising costs and co-pays, denial of care due to preexisting conditions, the lack of portability, and obstacles to seeing specialists. They see these problems as the result of profiteering by insurers and drug companies, not as the result of too many uninsured Americans.

Indeed, many believe that covering the uninsured will likely make these problems worse, not better. Their intuitive solution is to demand that "somebody do something" to protect consumers -- namely, through restraining drug companies and insurers. This does not mean that they are opposed to covering the uninsured—but it does mean that health care proposals that focus centrally around covering the uninsured often fail to speak powerfully to the problems that many voters actually experience themselves.

2. Solve the Consumer Crisis First — it will inspire greater empathy toward the uninsured.

In the past, progressives and democrats have sought to emphasize to insured Americans that they are at risk of losing their coverage or are in some other way insecure. But when Harry and Louise get scared—watch out. fear-based appeals overwhelmingly tend to trigger a zero-sum, conservative reaction, not a generous and progressive one. When voters are worried about losing or paying more, they become change averse.

But the opposite is also true: when voters believe a health care reform proposal would address the problems that they care about, they are more likely to embrace efforts to extend coverage to the uninsured.

Insured voters are a lot more likely to turn a compassionate eye toward the uninsured when they feel secure that their own health care needs are going to be met. A reform proposal that protects the insured so that they a) have access to basic services, b) can’t be denied insurance due to their age or a preexisting condition, c) can keep insurance if they lose or change jobs, d) can’t be denied specialist care by insurers, and e) are protected from price gouging will help create the psychological conditions for voters to feel secure and thus more compassionate and more generous toward the uninsured.

3. Embrace personal responsibility

When voters talk among themselves about covering the uninsured, the conversation quickly turns to whether or not the uninsured are themselves to blame for their situation. This is something that is missed in most polling, which doesn’t allow the space for these concerns to emerge.

Voters do not want to pay more in insurance, co-pays, or taxes to cover those they consider to be "undeserving," such as illegal immigrants, people who refuse to work, people who do not take good care of their children, people who do not take good care of their own health, and people who have enough money to pay for insurance but are irresponsible.

To feel positive about any reform proposal, voters need to be reassured that the new system will inspire greater personal responsibility. To this end, voters respond positively to new rules, such as the notion that "everybody should have to pay something" for their health care. Voters are quick to qualify this belief with a recognition that what people pay should depend on their means. Voters strongly embraced the progressive notion of a "sliding scale," where people pay what is fair to their income levels.

In Sum

Public cynicism toward government has long driven concerns that a government-run health care system could be worse than our current private health insurance system. Voters support government insurance for seniors and children — but not necessarily for themselves. To win reform we need to propose legislation that voters perceive as solving the consumer crisis. Then, and only then, will Harry and Louise be in the mood for comprehensive reform that covers the uninsured.