• Talking about Obamacare: Does policy debate matter?

    ReidMcconnellAmerican politicians have debated the Affordable Care Act since it was introduced to Congress in 2009. Have these debates affected what citizens think about the ACA? Daniel Hopkins can’t find evidence that those myriads of words mattered.

    So, health policy bloggers: If Reid, Boehner, and McConnell can’t sway public opinion, despite the audiences they command, what do you hope to accomplish?

    Hopkins is interested in the relationship between, on the one hand, the public debate about the ACA carried on in the media by the political elite and, on the other hand, public attitudes toward the ACA. To study the elite debate, he gathered 1488 press releases about the ACA issued by Senators in 2009 and 2010. To study public attitudes, he obtained text written by 30,000 survey respondents to the Kaiser monthly survey of public opinion on health policy. These masses of text allowed him to look at how elite debate and public attitudes evolved over time.

    Hopkins then applied some very cool data mining technology to determine what the elites and the public were thinking as the debate progressed. His statistical methods found clusters of co-occurring words in the press releases and survey answers. These clusters formed meaningful rhetorical patterns. For example,

    Supporters… make heavy use of a frame emphasizing universal access and affordability…, one defined by words such as “access,” “affordable,” “provide,” and “universal.”

    Opponents of the ACA used different words.

    For mass- and elite-level opponents of the ACA, the legislation’s cost and the increased governmental role it authorized were central reasons behind their opposition.

    Hopkins interpreted these word patterns as ‘frames’, that is, contexts of meaning that structured how people thought about the ACA. Classic studies by Tversky and Kahneman showed that manipulating the framing of a survey question strongly affects how people understand and respond to the facts in that question.

    Issue frames are rhetorical structures which emphasize a subset of the considerations relevant to an issue. Political issues are usually complex, giving elites the capacity to focus on aspects of the problem that advantage their side of the argument.

    Hopkins viewed the elite debate as a contest over whose framing of the argument would prevail in public discourse. The Senators were trying to shape how the public processed information about the ACA and thereby influence public approval of the bill.

    To see whether the elite debate had such influence, Hopkins charted the rise and fall of many rhetorical frames in both the Senatorial debate and in public opinion. If elite debate swayed public opinion, we would expect that a change in the prevalence of a frame in elite discourse would be echoed, at some lag, in public opinion.

    So how much influence did Senators have on public opinion? Not much.

    …in contrast to the variability of elite frames over this period, public opinion moves only gradually, and the arguments Americans use prove stable. Before health care reform became highly salient in the fall of 2009, Americans explained their views using much the same language they used during and after the most publicized chapters of the debate.

    Moreover, Ezra Klein and Evan Soltas noted that not only were the frames stable underneath public opinion toward the ACA, but also public approval of the ACA has remained more or less constant.


    Klein and Soltas:

    Congrats, spinmeisters.

    So if two years of Senatorial debate were futile, what can health policy bloggers hope to achieve?

    The immutability of public opinion should give pause to partisan bloggers. If you view yourself as a writer in service to a political movement, a soldier in the skirmishes over the daily meme, then give up. You are throwing pebbles, hoping to breach a castle wall.

    Instead, we should be more ambitious. Public opinion may have moved glacially over two years. But if you look back four decades, public opinion has changed profoundly about race, gender roles, and sexual preferences.

    Great writers play a role in great changes. Consider J. S. Mill, writing about the liberation of women in 1869, when this was about as plausible as the colonization of Jupiter. (Or consider Andrew Sullivan writing about gay marriage in 1995.) And yet much of what J. S. and Harriet Taylor Mill imagined has come to pass, in part because Mills’ writing helped make it seem possible.

    By developing new and powerful ways of helping people understand their situations, public intellectuals and politicians can prepare people to take effective action to improve those situations. Joshua Cohen wrote that

    some ethical explanations-for example, about slavery, sexual subordination, and suffrage extension-have force. That force derives from the general claim that the injustice of a social arrangement limits its viability… Social arrangements better able to elicit voluntary cooperation have both moral and practical advantages over their more coercive counterparts.

    This ethical force explains why, as Theodore Parker and Martin Luther King said,

    The arc of the moral universe is long but it bends toward justice.

    Few bloggers will be the moral architects of great social movements. But we can perhaps be the finish carpenters of moral and political frames. We can improve the day’s debate by providing a critical scientific reading of the stylized facts in rhetorical frames. We can try partisan values against the best reasoned moral arguments. Through slow, collective work, the quality of argument will improve on both sides and at both the public and elite level. If there is ethical force in these frames, our refinement may bring it to the surface.


    • “Social arrangements better able to elicit voluntary cooperation have both moral and practical advantages over their more coercive counterparts.”

      This is literally the Hayekian moral argument against giant centralized social programs.

      • RC,
        Yes, that’s an important insight and thanks for pointing it out. I can’t comment on Hayek, because except for the essay on the use of information in society, my knowledge is second hand.

        I’m deeply impressed, however, by Ostrom’s arguments for the advantages of “bottom-up” self-regulation in society.

        But keep in mind that different institutions operate best at different scales. Health care systems need to operate at large scales. So how can we create big organizations that elicit voluntary cooperation?

        Not sure, but democratic process is critical. My sense is that here in Canada, there is a high level of voluntary cooperation and legitimacy for Medicare despite the centralized character of the institution. I think it might also work in my home state of Massachusetts. Your mileage may differ in Mississippi.

        • Despite “the centralized character of the institution” I don’t think most Canadians, me included, perceive our system as centralized.

          I deal with the doctor of my choice first hand. When I think I need to see her, I phone and book an appointment. When she prescribes blood tests, I go to whichever lab is convenient. If I’m in a serious accident, I call 911 and the ambulance takes me to the most appropriate hospital.

          When I’m prescribed drugs, I go to the pharmacy of my choice and pay vastly less than my American friends. And then I simply submit the receipts for 100% reimbursement to my employer organized extended health insurance. (Which I pay the full premiums because they are so low, and because I paid them has significant beneficial tax implications if I need to make a claim against my long term disability coverage.)

          I have no co-pays, no deductibles, and no worries about the premium, which is the same for everyone in the province, and also provides significant premium support for low income earners and selected other groups (anywhere for 10% to 100% premium support.)

          So yes, there are “centralized” institutions in each province, and I suppose an overall federal institution. But I quite literally never deal with them. So for me they don’t exist.

          There’s only me, and my doctor. (Emphasis on “my”.)

    • I take a much more prosaic view of this. Massive policy initiatives that are not wars, sales taxes, or feel-good marketing ploys are complicated and will never be readily comprehensible. Obamacare (which I have no stake in) is complicated, fairly untested, and a reform to a system that already evokes strong feelings. It’s more complex than TARP, which nobody understands beyond “it was a stimulus”. Perhaps some of the negativity is caution.

      It’s a bit of a stretch to put Obamacare in the realm of giving women the franchise or eliminating slavery. It is a highly flawed and compromised initiative to even worse system, but nonetheless had to be attempted. Factoring out predictable partisan hysteria from both sides, exhaustion and caution seem like reasonable responses to that.

    • Bill
      Public intellectuals and politicians may lead, or choose to lead, but in citing the changes we have seen in perceptions of race, gender, etc., do you think more than rhetoric and framing, leaders react to greater events. Without those greater events as catalysts, any and all proactive proselytizing would be for naught?

      Images of Selma, Magic Johnson, Will and Grace, and Steven Hawkings, changed us, and perhaps the elites (interesting stylized frame btw) stepped in because something changed. Whether for or against, without that prime, we would not move forward.

      Think of the death panel rigamarole–an as yet unresolved societal issue. Frame your position? We might spend years doing the very things you mention above. However, one president or vital US figure winds up on a vent with sepsis–and poof, do we give credit to the elites or frames, or does the event do the job for us.

      Causation or correlation to greater moments in history?

      hope i made my point clear. I cant touch your elegantly written post above.

    • “Images of Selma, Magic Johnson, Will and Grace, and Steven Hawkings, changed us,”

      I think I get your point that the pundits pick whichever images and memes seem to support their points of view. I do not, however, follow your examples. Perhaps too inside baseball, but please help me. How did images of these people, including Selma (I assume the city) and Will and Grace (who are they?) change us?

      Maybe the negative feelings about the ACA persist because most do not like it, rather than because it has not been explained well.