H.O.P.E. Note: This post includes excerpts from the National Economic & Social Rights Initiative (NESRI) report. Find the full report here.
Mainstream media and public-opinion polls commonly state that the country has a choice between government and private insurance. This portrayal is inherently biased because it invokes government control while rendering insurance companies invisible, warping democratic discourse and policy-making. As leaked memos and decades of news reports and polls reveal, most journalists and pollsters only adopted this framing after the health insurance industry crafted it and, along with partisan strategists and right-wing think tanks and media, pressed it into common use. To balance their reporting, nonpartisan media, polling, and policy organizations must drop the insurance industry’s biased framing and instead contrast private with public insurance or name the role of both government and insurance companies in the health care system.
Describing the entire health care system as “government” health care is simply wrong. Medicare, Medicaid, public options, and Medicare for All are all publicly financed insurance programs that leave most of the health care system—including hospitals, physician practices, and drug and medical device manufacturers—in private hands. A third of Medicare plans and two-thirds of Medicaid plans are also run by private insurance companies.
I. The Strategic Construction of Anti-Government Spin
A. Construction of Spin by the Insurance Industry
Though there is a long history in American politics of opponents slandering proposals for universal health care as “socialized medicine,” before the 1990s, the term “government” was rarely used to define publicly financed health care programs. Public officials, journalists, academics, pollsters and others tended to refer to both public and private insurance programs without explicitly naming the insurer. They usually called publicly administered insurance “national health insurance,” “a national health program,” “single payer,” “Canadian-style health insurance,” “universal health insurance coverage,” or simply by the name of the program (Medicare, for example).
Drawing lessons from Big Tobacco, the insurance industry quietly commissioned strategist William D. McInturff to test effective messaging strategies, then secretly funded and ran “Harry and Louise” television ads for a full year, warning people that “the government may force us to pick from a few plans designed by government bureaucrats.” (The ads, explained Democratic strategist James Carville, were strategically placed just like George Bush’s 1988 “Willie Horton” ads less to reach the public directly than to manipulate how journalists and producers covered health care on the nightly news. It worked.)
The industry ran additional ads in California warning of a “government run health care,” a “new government-run bureaucracy,” and a “government health care takeover.”
B. Weaponization by Republican and Libertarian Strategists
In December 1993, Republican strategist Bill Kristol published an influential memo encouraging lawmakers in Congress to challenge Clinton’s “big government, tax-and-spend liberalism” not by negotiating over the bill in standard legislative fashion, but by blocking it altogether. This fed into a larger antagonistic, anti-government political strategy led by Kristol, McInturff, fellow strategist Frank Luntz, Representative Newt Gingrich, and Republican National Committee Chairman Haley Barbour.
The billionaire Koch brothers got involved too. Their organization Citizens for a Sound Economy (CSE) spent $4.9 million dollars and employed a staff of 53 people to coordinate 46 Congressional briefings in nine months, garner more than 500 press mentions, coordinate a task force of more than 30 organizations, mail 531,221 pieces of mail, and finance 104 rallies and 27 town hall meetings. CSE boasted that it was “the first to label the Clinton approach ‘government-run health care’—a term that ultimately would help kill the myriad plans that subsequently were offered.”
C. Mainstreaming by Right-Wing Strategists, Think Tanks, and Media
Following more than a decade of relative quietude, in 2007 Michael Moore’s film Sicko and a Congressional fight over the State Children’s Health Insurance Program ratcheted the corporate and right-wing messaging machines back into high gear.
To counter Sicko’s advocacy of publicly financed health care, America’s Health Insurance Plans (AHIP), the new political arm of the health insurance industry, laid out its communications strategy in two memos leaked to Bill Moyers. The industry’s strategy centered on framing Moore’s call for universal, publicly financed health care as “government-run” and “government-controlled health care” and on working to push this frame into use by the media:
The AHIP memos also named an “aggressive … media outreach” strategy that would include distributing a media toolkit and launching “an aggressive national paid and earned media campaign to disqualify government-run health care as a politically viable solution.” AHIP, along with the hospital and drug industries, put out press releases and ads hammering away at this messaging.
II. Mainstream Adoption of Insurance Industry Spin
A. Adoption by the Media
Immediately after the insurance industry’s June 2007 anti-Sicko campaign, and especially after the corporate and Republican messaging machines revved up against ObamaCare in February 2009, the contrived “government” phrasing began appearing across the mainstream press. In short order the phrase moved from quotations to descriptive text written by journalists themselves. Within months the Washington Post, New York Times, Wall Street Journal, Politico, The Hill, Kaiser Health News, CNN, ABC News, CBS News, NBC News, NPR, The Atlantic, Slate, and Time were all labeling the Affordable Care Act’s soon-to-be-defeated public option as “government” or “government-run.”
III. Moving from Biased to Balanced Language
A. Balance, Accuracy, and Symbolic Power
One might argue that describing “government” insurance and health care is an accurate way of describing public insurance plans. There are three problems with this.
First, language that explicitly invokes the role of government while eliding the role of corporations is precisely what linguist Geoffrey Nunberg calls “deceptive and oblique language” that “is calculated to obscure the relation between government and corporate interests.”
Second, portraying two distinct public and private spheres in health care misrepresents how health care works today. Two-thirds of people under 65 who have insurance are enrolled in employer-sponsored insurance, but nearly two-thirds of national health care expenditures are paid for by the public. A third of people enrolled in Medicare and two-thirds of people enrolled in Medicaid are on private plans financed by the government but administered by insurance companies. Two-thirds of insurance companies’ business is subsidized by the government through Medicare, Medicare, the Affordable Care Act, and the Federal Employee Health Benefits program, and the federal government spends $272 billion each year to subsidize employer-sponsored insurance, an average of $1,672 for every person in the labor force. In drawing distinctions between programs administered by the government and by insurance companies, journalists must take care to avoid inaccurate phrases like “government health care” and should strive to explain to portray the complicated, interwoven public and private roles in the health care system today.
Third, it is important to recognize that words are not neutral definitional terms, but carriers of symbolic meaning. As Frank Luntz says, “It’s not what you say, it’s what people hear,” and in contemporary American English, “government” carries powerful latent symbolism.
Journalists, editors, and polling professionals play a critical role in American democracy worthy of huge respect, especially in these trying times. In the face of enormous political, technological, and economic pressures, they are helping the country make sense of complex dynamics, sort through truth and lies, and process an endless stream of information, all on a 24-hour news cycle. Yet in light of the clear bias embedded in the contrast between “government” and “private” health care, media and polling organizations must change course. Journalists must correct their writing, editors must change their editorial policies, and pollsters much adapt their survey questions.
Here is a list of recommendations developed with input from journalists, polling professionals, and scholars on how to achieve balance in reporting and polls on health policy. The examples of biased language are drawn from actual reporting and public-opinion polls.
Journalists, editors, and pollsters play a hugely important role in society, and these days especially are under a great deal of strain. Health care is also an enormously complicated economic sector with competing stakeholders, making it difficult to understand and even harder to reform. Yet as this report has shown, well-intentioned professionals in media, polling, policy, and academia who strive to explain how the health care system works now and the choices the country faces moving forward have been manipulated. Through a well-funded, highly orchestrated campaign, the insurance industry and its allies have manipulated the media and public-opinion polls, and thereby warped American democracy. In light of the findings of this report, independent media, polling, and policy organizations have an obligation to drop the insurance industry’s spin. They must present a balanced picture of American health care by comparing private and public insurance (and health care, programs, etc.) and, when naming government as the public insurer, must also name insurance companies.