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BY: MATTHEW J. THIBEAU and JEFF TIEMAN

Mr. Thibeau is senior vice president, strategy and organizational effectiveness, and Mr. Tieman is communications director, Covering a Nation, Catholic Health Association.

If genuine reform requires public support, then a U.S. health care system that works for everyone should not be far in the future. A large number of Americans continue to identify health care reform as a top priority for government. Most voters understand that costs are too high and that the current financing and delivery systems involve too much waste, fraud, and abuse. Many feel a pressing need to address the shortcomings of a system that leaves 45 million people without basic health insurance. For these reasons and others, people believe that their health care system needs repair—and that the need is fairly urgent.

However, despite widespread agreement on the nation's need for an equitable, high-quality health care system, Americans continue to be split along ideological and other fault lines. Republicans view the health care system and its problems differently than Democrats do. Women have different priorities than men. African-Americans tend to see one health care "landscape," while Caucasians see another. Rural and urban people have different takes on the issue.

There are areas of agreement. In a recent public opinion survey commissioned by CHA and conducted by Public Opinion Strategies, Inc., an Alexandria, VA, firm, respondents said that affordable, high-quality health care was the domestic issue that should receive the greatest attention from government at this time. Slightly more than one in four (26 percent) of the people surveyed ranked health care first, putting it above homeland security, jobs, taxes, education, and fighting drugs and crime.¹

It comes as no surprise that the survey highlights differences among various groups of respondents. Democrats, as well as moderate and liberal voters, tend to view health care reform as a top priority for Congress, whereas Republicans tend to expect Congress to address homeland security and taxes instead.

When asked which domestic issue should receive the greatest attention from government, 14 percent of self-identified "strong Republicans" named affordable, high-quality health care (37 percent of that group named homeland security). Perhaps not surprisingly, the priorities are reversed for "strong Democrats," 35 percent of whom named health care as the top priority (11 percent named homeland security).

In an indication of gender-based perception differences, significantly more women than men—surveyed across several age categories—identified affordable, high-quality health care as an issue that should receive more attention than others from government. For instance, only 19 percent of salaried men identified expanding health care coverage as the issue congressional leaders should focus on before the next election. By comparison, 33 percent of salaried women named expanding health care coverage as Congress's top priority.

Differences in opinion are to be found throughout the nation, in all geographic regions, racial and ethnic groups, income categories, and at all education levels. For advocates of expanded coverage—including the Catholic health ministry—the key is to help bridge those gaps by framing the argument about health care for everyone in ways that better resonate among key demographic groups.

Different Views, Different Priorities
"Different groups, because of their political frames, do make different selections," says Jack Glaser, senior vice president of theology and ethics, St. Joseph Health System (SJHS), Orange, CA, and a member of CHA's Covering a Nation steering committee. "What we want to try to do is find the common ground."

"We'll really only get out of this morass if we can find a terrain where we all recognize that we're all in this together," says Glaser, who is also director of SJHS's Center for Healthcare Reform. "We have to align our minds and hearts and our resources along those lines."

To advance the notion that health care should be available to everyone, those of us who work for reform must ensure that our priorities are clearly stated, broadly discussed, and eventually shared. We all care about homeland security and taxes—to choose two non-health care issues—because they seem essential to our way of life. The question, then, is why does health care not seem similarly essential to so many voters? Without adequate health, after all, homeland security and taxes quickly become second-tier concerns.

Like education, good health is fundamental to one's well-being and success in life. Catholic social teaching tells us that health care is not an economic commodity but rather a social good. We Americans don't tell children that they cannot go to school because their parents are unemployed. Our system does, however, deny kids health insurance for that reason. If we want our children to thrive in school, we have to make sure they're healthy. And under the current system, we do not make sure all kids are healthy enough to listen and learn and participate.

The facts bear this out. According to a study published in a recent issue of the New England Journal of Medicine, 6.6 percent of a large sample of children under the age of 18 had no health insurance coverage over a 12-month period in 2000 and 2001.² "When children with no insurance for part of the year were included, the proportion of uninsured children more than doubled, to an average of 14.3 percent each year for 2000 and 2001," the authors concluded.

Even more troubling than the number of children without coverage is the effect of not having coverage. According to the New England Journal of Medicine study, 15.9 percent of the children uninsured over a full year put off seeking health care; 38 percent had no source of regular care.³ Among fully insured children, on the other hand, only 1.5 percent put off seeking care and only 2.8 percent had no source of regular care.

Children without a usual source of care "are likely to receive their care in hospital outpatient clinics and emergency rooms—facilities that generally are not designed to provide strong primary care," writes Barbara Starfield, MD, MPH, in an editorial coinciding with the study.⁴

"Framing" the Conversation
The problem of uninsured kids is a kind of springboard from which the Catholic health ministry can help change the focus of the national conversation concerning broader health system issues. As things currently stand, the merits of various health reform plans are debated ad nauseam. One goal of CHA's Covering a Nation program is to take a step back and ask more fundamental questions about our health care system. By answering those questions together, we can find true common ground. This process will demand that we consider the arguments for health care change in a new light—inside new "frames" that better connect our issue to the values people understand and espouse.

"Frames," according to the linguist George Lakoff, are part of what he calls the "cognitive unconscious."⁵ Certain words and phrases evoke certain preconceptions or viewpoints in most people—they "frame" our understanding of public issues, Lakoff believes. Framing, he writes, "is about getting language that fits your worldview. . . . Just speaking truth to power doesn't work. You need to frame the truths effectively from your perspective."⁶

One can give a particular point of view traction by persuading the public to consider it in terms that are different than those normally used. Again, consider the issue of children's health. Everyone agrees that children's health is important, that it is a major determinant of their ability to contribute to and compete in society. When advocating coverage for the uninsured, we should use frames that speak to our collective future and our shared identity. Children evoke frames that do that.

In 1965 Congress created Medicare because it seemed unjust that seniors, some of the most vulnerable among us, could not afford their own health care. Today's children are no less vulnerable—and yet 8 million American kids lack coverage. "A society that leaves so many people without access to something we believe is fundamental—health care—is a society in moral trouble," says John Carr, director, social development and world peace, U.S. Conference of Catholic Bishops (USCCB).

How can we use framing to remind our nation and our leaders of this? One way is to replace some of the language we use so commonly with new phrases and concepts. Instead of talking about the "uninsured," which can evoke negative themes or frames, we could convey the same arguments through language that, like a megaphone, makes a different sound.

"In a sense, I think we ought to get away from the phrase 'covering the uninsured,'" says Sr. Mary Roch Rocklage, RSM, chair, sponsorship council, Sisters of Mercy Health System, Chesterfield, MO. "I'd rather say: 'Let's uncover them'—bring them up in our consciousness so that we all see [the problem] and respond to it."

Protecting Our Children
Children represent one group of people through which we can begin to "uncover the uninsured," as Sr. Mary Roch puts it. The most common frame evoked by children is youth, followed by the corollary frames of possibility, play, energy, and freedom. A related frame is protection. We watch out for kids. We shelter them. We realize they cannot fend for themselves. Both sets of frames are positive—and useful in advocating coverage. The most effective Robert Wood Johnson Foundation advertisement for Cover the Uninsured Week features a little girl. Why? Because the image of a little girl resonates among people more strongly than would any adult—and certainly more strongly than any policy argument or set of facts from the U.S. Census Bureau.

For insights into effectively using the frames evoked by children to spark interest in health care reform, we might look back at the public opinion survey mentioned earlier. Twelve percent of men aged 18 to 34 named expanding health care coverage as the top issue that Congress should focus on between now and the next election. More than twice as many women in the same age group—28 percent—had the same top priority. This fact suggests that young women are much more likely than young men to consider health care the most important public issue.

If that's the case, then women aged 18 to 34—many of whom are or soon will be mothers—should receive messages about the importance of covering kids, about the impact of not doing it, and about what it would mean for their own families if they could not afford to provide their children with needed medical treatment. We do not have to talk about the "uninsured," or even about "health care reform," to let the public know that we strongly agree on the need for the kids in the nation's communities and schools to be healthy. Obviously, young women are one group ready to help carry that message.

"There is a deeper reality about health care, not about the uninsured but about health care," Glaser says. "Let's not ask about what program people want, but what should this system do?" One thing we know it should do: It should provide care for kids.

Other messages need to be carried, too. Despite years of public education and awareness campaigns conducted by a host of groups, the public continues to harbor misconceptions about the uninsured. Although research shows that roughly 8 of 10 uninsured Americans are members of working families, the people surveyed by in our poll apparently did not know this. Half said the uninsured were employed or members of a family in which someone was employed, and the other half said the uninsured were unemployed or members of families in which someone is unemployed.

In the survey, only 15 percent of those respondents who stipulated cutting taxes as something Congress should get done in this session also identified working families as a group likely to be uninsured. If that 15 percent really understood who the uninsured are, their overall priorities would be more likely to shift, argues Edward Howard, executive vice president of the Alliance for Health Reform, Washington, DC.

Race-based differences in perception are especially pronounced on the question of employment as it relates to coverage. Forty-seven percent of Caucasian voters said the uninsured are unemployed. But far more African-Amerian respondents—67 percent—said the same thing. If we can begin to close the gaps in the way the problem is perceived, we will find it easier to make progress toward the problem's solution. "The challenge is for us not simply to hammer one another until one side wins but to move beyond whatever the foundation is—race, gender, income, education—to help the larger community," Glaser says. "When a community's members move from a certain set of assumptions that makes them confrontational and oppositional to the point where they see a deeper shared truth, we can move forward in a more focused and concerted way."

Political differences often seem to erect obstacles to significantly expanding coverage. Democrats in the survey, when determining priorities among the issues that government should address, predominantly identified health care and jobs. Republicans, on the other hand, identified security and spending. In ranking the biggest problem facing the health care system, 23 percent of GOP respondents said it was waste, fraud, and abuse. Only 6 percent of Democrats agreed. Eight percent of Republicans said insufficient coverage for the poor and elderly was the biggest problem; 19 percent of Democrats said the same thing. And 22 percent of GOP respondents said that medical malpractice is the biggest problem facing health care, whereas only 6 percent of Democrats agreed.

Reaching Common Ground
Part of reaching common ground is helping everyone—Democrats and Republicans, left and right, farm belt and urban center—realize that it is part of our enlightened self-interest to fix this system. If some voters still disapprove of coverage expansions because they see it as a handout, we need to use the right frames to remind them that costs go up for everyone when people are uninsured, and that our own health and well-being depend on the effectiveness and reach of our health care system.

We already have some common ground. We all want health care services to be available, safe, and affordable. We prefer to be surrounded by healthy people, rather than by sick people. And many of us place the development of a more just health care system above other important domestic priorities. The common ground we already share can be a starting point for advancing the discussion and changing the terms of the debate.

"We have to build up a sense of common ground so that we can pursue the common good of health care for all," Carr says. "To do that, we have to talk about what needs to be done, the sacrifices that will be required, and the benefits that will be gained."

The USCCB, Carr adds, "will be working with CHA and others to talk about this in our parishes, in our schools, in our hospitals—and coming together to find a way for us to make the case that this is wrong and we can do better."

Carr, Glaser, and others argue that public dialogue is a critical component of changing hearts, minds, and—eventually—policy. Leaders in Catholic health care can play a role in shaping and advancing that dialogue. Covering a Nation, CHA's program to help develop a more favorable environment for significantly expanding health insurance coverage, will serve as a resource to ministry leaders whose voices and actions carry the message that health care that works for everyone is a shared value worth fulfilling.

Carr well summarizes the important task of reaching—and energizing—the American electorate: "We need political will, and political will doesn't come from a poll. It doesn't come from campaign contributions. It comes from citizens who decide we have to act."

NOTES

1. The survey was conducted by Public Opinion Strategies, Inc., Alexandria, VA. Between June 14 and June 16, 2005, the organization conducted a phone survey of 800 registered voters. The survey's margin of error was plus or minus 3.46 percent.
2. Lynn M. Olson, Suk-fong S. Tang, and Paul W. Newacheck, "Children in the United States with Discontinuous Health Insurance Coverage," New England Journal of Medicine, July 28, 2005, pp. 382-391.
3. Olson, p. 387.
4. Barbara Starfield, "Insurance and the U.S. Health Care System," New England Journal of Medicine, July 28, 2005, p. 418.
5. George Lakoff, Don't Think of an Elephant: Know Your Values and Frame the Debate—The Essential Guide for Progressives, Chelsea Green Publishing, White River Junction, VT, 2004, p. xv.
6. Lakoff, p. 4.