The PolicySpeak Disaster for Health Care

Barack Obama ran the best-organized
and best-framed presidential campaign in history. How is it possible
that the same people who did so well in the campaign have done so badly
on health care?

And bad it is: The public option may
well be gone. Neither Obama himself nor Senior Advisor David Axelrod
even mentioned the public option in their pleas to the nation last Sunday
(August 16, 2009). Secretary Sibelius even said it was "not essential."
Cass Sunstein's co-author, Richard Thaler, in the Sunday NY Times
(August 16, 2009, p. BU 4) called it "neither necessary nor sufficient."
There has been a major drop in support for the president throughout
the country, with angry mobs disrupting town halls and the right wing
airing its views with vehemence nonstop on radio and tv all day every
day. As the NY Times reports, Organizing for America (the old Obama
campaign network) can't even get its own troops out to work for the
President's proposal.

What has been going wrong?

It's not too late to turn things
around, but we must first understand why
the administration is getting beat at the moment.

The answer is simple and unfortunate:
The president put both the conceptual framing and the messaging for
his health care plan in the hands of policy wonks. This led to twin
disasters.

The PolicyList Disaster

The whole is greater than the sum of
its parts.

Howard Dean was right when he said
that you can't get health care reform without a public alternative
to the insurance companies. Institutions matter. The list of what needs
reform makes sense under one conceptual umbrella. It is a public alternative
that unifies the long list of needed reforms: coverage for the
uninsured, cost control, no preconditions, no denial of care, keeping
care when you change jobs or get sick, equal treatment for women, exorbitant
deductibles, no lifetime caps, and on and on. It's a long list. But
one idea, properly articulated, takes care of the list: An American
Plan guarantees affordable care for all Americans. Simple. But not for
policy wonks.

The policymakers focus on the list,
not the unifying idea. So Obama's and Axelrod's statements last
Sunday were just the lists without the unifying institution. And without
a powerful institution, the insurance companies will just whittle away
at enforcement of any such list, and a future Republican administration
will just get rid of the regulators, reassigning them or eliminating
their jobs.

Why do policymakers think
this way?

One: The reality of how Congress is
lobbied. Legislators are lobbied to be against particular features,
depending on their constituencies. Blue Dogs are pressured by
the right's communication system operating in their districts. Congressional
leaders have a challenge: Keep the eye of centrists and Blue Dogs on
the central idea, despite the pressures of right-wing communications
and lobbyists' contributions.

Two: In classical logic, Leibniz'
Law takes an entity as being just a collection of properties. As if
you were no more than eyes, legs, arms, and so on, taken separately.
Without a public institution turning a unifying idea into a powerful
reality, health care becomes just a collection of reforms to be attacked,
undermined, and gotten around year after year.

Three: Current budget-making assumptions.
Health is actually systematic in character. Health is implicated in
just about all aspects of our culture: agriculture, the food industry,
advertising, education, business, the distribution of wealth, sports,
and so on. Keeping it as a line item -- what figure do you put down
on the following lines -- misses the systemic nature of health. The
image of Budget Director Peter Orszag running constantly in and out
of Senator Max Baucus' office shows how the systemic nature of health
has been turned into a list of items and costs. Without a sense of the
whole, and an institution responsible for it, health will be line-itemed
to death.

Obama had the right idea with the "recovery"
package. The economy is not just about banking. It is about public works,
education, health, energy, and a lot more. It is systemic. The whole
is more than the sum of its parts.

The
PolicySpeak Disaster

PolicySpeak is the principle that:
If you just tell people the policy facts, they will reason to the right
conclusion and support the policy wholeheartedly.

PolicySpeak is the principle behind
the President's new Reality Check Website. To my knowledge, the Reality
Check Website, has not had a reality check. That is, the administration
has not hired a first-class cognitive psychologist to take subjects
who have been convinced by right-wing myths and lies, have them read
the Reality Check website, and see if the Reality Check website has
changed their minds a couple of days or a week later. I have my doubts,
but do the test.

To many liberals, PolicySpeak sounds
like the high road: a rational, public discussion in the best tradition
of liberal democracy. Convince the populace rationally on the objective
policy merits. Give the facts and figures. Assume self-interest as the
motivator of rational choice. Convince people by the logic of the policymakers
that the policy is in their interest.

But to a cognitive scientist or neuroscientist,
this sounds nuts. The view of human reason and language behind PolicySpeak
is just false. Certainly reason should be used. It's just that you
should use real reason, the way people really think. Certainly the truth
should be told. It's just that it should be told so it makes sense
to people, resonates with them, and inspires them to act. Certainly
new media should be used. It's just that a system of communications
should be constructed and used effectively.

I believe that what went wrong is (a)
the choice of PolicySpeak and (b) the decision to depend on the campaign
apparatus (blogs, Town Hall meetings, presidential appearances, grassroots
support) instead of setting up an adequate communications system.

What Now?

It is not too late. The statistic
I've heard is that over 80% of citizens want a public plan, but the
right wing's framing has been overwhelming public debate, taking advantage
of the right's communication system and framing prowess.

The administration
has dug itself (and the country) into a hole. At the very least,
the old mistakes can be avoided, a clear and powerful narrative is still
available and true, and some powerful, memorable, and accurate language
should be substituted for PolicySpeak, or at least added and repeated
by spokespeople nationwide.

The narrative is simple:

Insurance company plans
have failed to care for our people. They profit from denying care. Americans
care about one another. An American plan is both the moral and practical
alternative to provide care for our people.

The insurance companies
are doing their worst, spreading lies in an attempt to maintain their
profits and keep Americans from getting the care they so desperately
need. You, our citizens, must be the heroes. Stand up, and speak up,
for an American plan.

Language

As for language, the
term "public option" is boring. Yes, it is public, and yes, it is
an option, but it does not get to the moral and inspiring idea. Call
it the American Plan, because that's what it really is.

The American Plan.
Health care is a patriotic issue. It is what your countrymen are engaged
in because Americans care about each other. The right wing understands
this well. It's got conservative veterans at Town Hall meeting shouting
things like, "I fought for this country in Vietnam, and I'm fight
for it here." Progressives should be stressing the patriotic nature
of having our nation guaranteeing care for our people.

A Health Care Emergency.
Americans are suffering and dying because of the failure of insurance
company health care. 50 million have no insurance at all, and millions
of those who do are denied necessary care or lose their insurance. We
can't wait any longer. It's an emergency. We have to act now to
end the suffering and death.

Doctor-Patient care.
This is what the public plan is really about. Call it that. You have
said it, buried in PolicySpeak. Use the slogan. Repeat it. Have every
spokesperson repeat it.

Coverage is not
care. You think you're insured. You very well may not be, because
insurance companies make money by denying you care.

Deny you care...
Use the words. That's what all the paperwork and administrative costs
of insurance companies are about - denying you care if they can.

Insurance company
profit-based plans. The bottom line is the bottom line for insurance
companies. Say it.

Private Taxation.
Insurance companies have the power to tax and they tax the public mightily.
When 20% - 30% of payments do not go to health care, but to denying
care and profiting from it, that constitutes a tax on the 96% of voters
that have health care. But the tax does not go to benefit those who
are taxed; it benefits managers and investors. And the people taxed
have no representation. Insurance company health care is a huge example
of taxation without representation. And you can't vote out the people
who have taxed you. The American Plan offers an alternative to private
taxation.

Is it time for progressive
tea parties at insurance company offices?

Doctors care; insurance
companies don't. A public plan aims to put care back into the
hands of doctors.

Insurance company
bureaucrats. Obama mentions
them, but there is no consistent uproar about them.
The term needs to come into common parlance.

Insurance companies
ration care. Say it and ask the right questions: Have you ever had
to wait more than a week for an authorization? Have you ever had an
authorization turned down? Have you had to wait months to see a specialist?
Does you primary care physician have to rush you through? Have your
out-of-pocket costs gone up? Ask these questions. You know the answers.
It's because insurance companies have been rationing care. Say it.

Insurance companies
are inefficient and wasteful. A large chunk of your health care
dollar is not going for health care when you buy from insurance companies.

Insurance companies
govern your lives. They have more power over you than even governments
have. They make life and death decisions. And they are accountable only
to profit, not to citizens.

The
health care failure is an insurance company failure.
Why keep a failing system? Augment it. Give an alternative.

The Needed Communication
System

A progressive communication
system should be started. It should go into every Congressional district.
It should concentrate on general progressive ideas. President Obama
has articulated what these are.

Appropriate language
can be found to express these values. They lie at the heart of all progressive
policies. If they are out there every day, it becomes easier to discuss
any issue. This is what it means to prepare the ground for specific
framings.

The Culture War
is On! You Can't Ignore it

President Obama wants
to unify the country, and he should. It is a noble idea. It is the right
idea. And he started out with the right way to do it. Campaign for what
you believe - for empathy, social responsibility, making the nation
better. Activate the progressive values in the many millions of Americans
who have some conservative values and some progressive values.

But also inhibit the
radical, harmful conservative ideology in the brains of our countrymen,
by directly saying what's wrong with it. Yes, there are villains.
They have a very potent communications system and can organize their
troops. Every victory makes them more powerful. They have put together
powerful narratives. We need more powerful ones.

And avoid PolicySpeak
and PolicyLists.

What should have
been done?

It is useful to review what should
and should not have been done, because we need to understand the past
to avoid future mistakes.

First, it was obvious
to the framing community what the right wing would do. Almost every
move could have been predicted, and most of them were. There should
have been a serious counter effort from right after the election.

Second, an effective
communication system should have been built. Not for dictating what
to say, but for creating a system of effectively trained spokespeople
who can get the basic progressive values out there every day, to compete
with the very effective conservative system. It should not work issue
by issue, but in addition to the issues of the day, it should promote
general values that apply to all issues.

The elements are all
in existence. The money is there. Indeed it would be a lot cheaper to
build than spending tens of millions of dollars on health care ads.
What it would accomplish is laying the groundwork in advance of any
particular issue. The work of such a communication system would be to
activate ideas already there in the millions of citizens who have progressive
as well as conservative worldviews in their brain circuitry. The idea
would be to make progressive ideas stronger and conservative ideas weaker,
balancing what the conservative communication system is doing now.

It is rather late in
the game for the stimulus, cap and trade, and health care, but better
late than never. And it would be indispensible for future policy campaigns.
Framing a powerful message is a lot easier when the groundwork for it
has already been laid. Without the groundwork, it is much harder.

Third, a serious framing
education effort with folks who do know the science should have been
organized, not just for the communications system, but for the policymakers
themselves.

Fourth, the villainizing
of real insurance company villains should have begun from the beginning.
As it is, the right wing turned the tables. They attributed to government
all the disasters of insurance company health care: rationing, long
lines, waits for authorizations and visits to specialists, denial of
care. The administration is trying to turn that around, but it is harder
now, and they are trying it using PolicySpeak, which is the most ineffective
of means.

Fifth, the positive
policy should have been made in moral terms, with clear and vivid language.
The term "public option" is a PolicySpeak loser. The public is the
American public, it is all of us, it is America, and it should have
been called the American Plan.

Sixth, the administration
should have been on the offensive not the defensive all the way. The
use of conservative language should never have been used in debunking.

Seventh, it was a mistake
to shut out single payer advocates. They should have been welcomed into
the debate. Though the term "single payer" is hopeless PolicySpeak
and "doctor-patient care" would have been more accurate, nonetheless
the doctors, nurses, and unions advocating for such a plan could have
done a lot of the work of villainizing the health care industry and
would have drawn fire from the Right. An alternative on the left would
have made the President's plan a compromise. Besides, there is so
much to be said in favor of single payer, that there might have been
fewer actual compromises with the right.

Eighth, it was a mistake
to put cost ahead of morality. Health care is a moral issue, and the
right-wing understands that and is using it. That's why the "death
panels" and "government takeover" language resonates with those
who have a conservative moral perspective and have effectively used
terms like "pro-life." Health care is a life and death issue, which
is as moral as anything could be. The insurance companies have been
on the side of death, and that needs to be said overtly.

Ninth, accepting the
idea that health is a line item separate from agriculture policy, the
food industry, regulation of food and drugs, education, the vitality
of business, banking reform, etc. is just bad economics. These are all
tied up together. In this, health care might have been treated like
the "recovery" package, but in reverse.

A causal approach to
economics would be appropriate. Instead of putting funds in many places,
it might have taken funds from sources of health problems. For example,
big agriculture and the food industry produce and heavily marketed foods
that have been central causes of the obesity epidemic and heart disease
-- corn syrup, too much meat, and so on. They might have been called
upon to pay the costs of treating heart disease, strokes, and diabetes.
It would not be popular with those industries, but it would be causally
fair, and might even save a lot of lives - and money.

Our take another example
of causal economics. Hugely high private taxation (that is, high costs
and profit taking) by the health insurance industry helped drive American
automakers into bankruptcy. The health insurance industry should have
had to use a portion of their profits for bailouts of the auto industry,
and the equivalent amount of bailout money could have been used for
providing health care to those without it.

Given the systemic
nature of our culture and our economy, a move in the direction of such
causal economics should start to be seriously considered. At the very
least it would bring up the question, alert the public to systemic causation,
and start people thinking about the justice of causal economics.

All this is not just
20-20 hindsight. My colleagues, Glenn Smith and Eric Haas and I have
made many of these points before. See our reply to the May 2009 memo
by Frank Luntz:

www.huffingtonpost.com/...lakoff/health-care-reform-some-b_b_200132.html.

And take a look at an even earlier
memo of the logic of the health care debate:

https://www.cognitivepolicyworks.com/wordpress/wp-content/uploads/2009/06/logic-of-the-health-care-debate.pdf.

Where PolicyLists
and PolicySpeak Come From

Framing is everywhere,
not just in language. What people do depends on how they think, on how
they understand the world -- and we all use framing to understand the
world. Truth matters. But it can only be comprehended when it is framed
effectively, and heard constantly.

This point is to often
misunderstood that it is important to understand why. It is also important
to understand where PolicyLists and PolicySpeak come from and why they
have the powerful grip that they have. This is especially important
now, when there might still be a chance to turn the health care debate
around.

The source of these political disasters
lies in an unlikely place: our most common understanding of reason itself.

What Is Reason Really Like?

PolicySpeak is supposed to be reasoned,
objective discourse. It thus assumes a theory of what reason itself
is -- a philosophical theory that dates back to the 17^th
Century and is still taught.

Over the past four decades, cognitive
science and neuroscience have provided a scientific view of how the
brain and mind really work. A handful of these results have come into
behavioral economics. But most social scientists and policymakers are
not trained in these fields. They still have the old view of mind
and language.

The old philosophical theory says
that reason is conscious, can fit the world directly,
is universal (we all think the same way), is dispassionate
(emotions get in the way of reason), is literal (no metaphor
or framing in reason), works by logic, is abstract (not
physical) and functions to serve our interests. Language on this
view is neutral and can directly fit, or not fit, reality.

The scientific research in neuroscience
and cognitive science has shown that most reason is unconscious.
Since we think with our brains, reason cannot directly fit the world.
Emotion is necessary for rational thought; if you cannot feel
emotion, you will not know what to want or how anyone else would react
to your actions. Rational decisions depend on emotion. Empathy with
others has a physical basis, and as much as self-interest, empathy lies
behind reason.

Ideas are physical, part of
brain circuitry. Ideas are constituted by brain structures called 'frames'
and 'metaphors,' and reason uses them. Frames form systems,
called worldviews. All language is defined relative to such frames and
metaphors. There are very different conservative and progressive worldviews,
and different words can activate different worldviews. Important words,
like freedom, can have entirely different meanings depending
on your worldview. In short, not everybody thinks the same way.

As a result, what is taken as "objective"
discourse is often worldview dependent. This is especially true of health
care. All progressive writing supporting some version of health care
assumes a progressive moral worldview, in which no one should be forced
to go without heath care, the government should play a role, market
regulation is necessary, and so on.

Those with radical conservative worldviews
may well think otherwise: that everyone should be responsible for their
own and their family's health care, that the government is oppressive
and should stay out of it, that the market should always dominate, and
so on.

Overall, the foundational assumptions
underlying PolicySpeak are false. It should be no wonder that PolicySpeak
isn't working.

The Bi-conceptual Audience

A property of brains called "mutual
inhibition" permits people to have contradictory worldviews and go
back and forth between them. Many people have both progressive
and conservative worldviews, but on different issues -- perhaps conservative
on financial issues and progressive on social issues. Such people are
called bi-conceptuals. President Obama understands this. He has said
that his "bipartisanship" means finding Republicans who happen to
share his progressive views on particular issues, and working with them
on those issues--and not accepting an ideology (radical conservatism)
rejected by the American people.

The people the President has to convince
are the millions of bi-conceptuals. That means he has to have them thinking
of health care in progressive moral terms, not conservative moral terms.
How can this be accomplished?

Why Do
the Nature of Reason and Language Matter?

It's all in the brain. Words activate
frame-and-metaphor circuits, which in turn activate worldview circuits.
Whenever brain circuitry is activated, the synapses get stronger, and
the circuits are easier to activate again. Conservative language will
activate conservative frames, which will activate and strengthen the
conservative worldview.

Conservative tacticians may not know
about brain research, but they know about marketing, and marketing theorists
use that brain research. That is why conservatives place such importance
on language choice, from the classic "socialized medicine," to Luntz's
"government takeover" to Palin's "death panels." When
repeated over and over, the words evoke a conservative worldview, with
many of the specific bogeymen -- abortion, socialism = communism =
nazism, euthanasia, foreigners, taxes, spending, the liberal elite,
Big Brother, and so on. The most effective language has emotional appeal
and, to conservatives, a moral appeal because it activates the conservative
moral worldview. And such language, repeated every day, changes brains,
strengthening the synapses of those who listen.

Conservative language will activate
and strengthen conservative worldviews -- even when negated! I titled
a book Don't Think of an Elephant!
to make this point. The classic example is Richard Nixon's "I am
not a crook," which made everyone think of him as a crook. And yet
I've heard President Obama say "We don't want a government takeover,"
which activates the idea of a government takeover. Mediamatters.org's
major story, as I write this, is: "The
media have debunked the death panels -- more than 40 times." It then
gives a list of 40 cases of debunking, each one of which uses the term
"death panels." And you wonder, after so many debunkings, why it
is still believed! Each "debunking" reinforced the idea. The first rule of effective communication is
stating the positive in your own terms, not quoting the other side's
language with a negation.

The Conservative Communication System

The serious reporting on role of conservative
think tanks began in the mid-1990's with works such as:

In 1996, my Moral Politics
appeared, outlining the conservative and progressive moral worldviews
and how the conservatives used language to frame public discourse their
way.

In 2004, Rob Stein tracked the conservative
communications system, traeling the country with his detailed powerpoint,
"The Conservative Message Machine Money Matrix." Stein tracked
not only conservative think tanks, but also the language experts and
training institutes training tens of thousands of conservative spokespeople
He also tracked the communications facilities, and the collections of
"experts" on every issue, together with a booking agency booking
the experts daily on media all over the country. Daily talking points
are repeated by those "experts." The conservative communications
system extends into every congressional district, including the districts
of democrats. In the case of the Blue Dog Democrats, who come from relatively
conservative districts, the Blue Dogs have to deal with constituents
who hear conservative framing over and over every day without anything
effective countering it. That is a major factor in Blue Dog resistance
to administration proposals.

With all this information, you might
think that progressives would set up their own communications network
going into the heart of conservative districts everywhere, day after
day, effectively countering the conservative framing.

It didn't happen. Instead, PolicySpeak
prevailed. The old philosophical theory, which is taught in every policy
school, won out. Progressives thought such a communications system would
be illegitimate -- what the conservatives do. They believe, in 17^th
Century fashion, that if they just state the facts, people should reason
to the right conclusion.

So progressives set up truth squad
websites and blogs to negate conservative lies - like Media Matters,
The Center for American Progress, the People for the American Way, the
Center for America's Future, MoveOn, Organizing for America, and so
on. These are all fine organizations, and we are fortunate to have them.

But ... they are preaching to the choir (because they don't have an
adequate communications system), and they are using PolicySpeak: just
stating the policy truths will be enough.

As I was writing this, I received the
viral email written by David Axelrod, which he refers to as "probably one of the longest
emails I've ever sent." It is indeed long. It is accurate. It lays
out the President's list of needed reforms. It answers the myths.
It appeals to people who would personally benefit from the President's
plan. It drops the Public Option, which makes sense of the list. And
it is written in PolicySpeak. It has 24 points - 3 sets of 8.

Ask yourself which
is more memorable: "Government takeover," "socialized medicine,"
and "death panels" -- or Axelrod's 24 points?

Did the administration
do a reality check on the 24 points? That is, did they have one of our
superb cognitive psychologists test subjects who were convinced of the
right-wing framing, have them read the 24 points, and test them a couple
days or a week later on whether Axelrod's 24 points had convinced
them? PolicySpeak folks don't tend to think of such things.

I genuinely hope the
24 points work. But this is the kind of messaging that created the problems
in the first place.

I respect Axelrod deeply.
But the strategist who ran the best-framed campaign I've ever seen
is giving in to PolicySpeak.

The Irony

There is a painful
irony in all this, and I am aware of it constantly. Highly educated
progressives, who argue for the importance of science, have been ignoring
or rejecting the science of the brain and mind. Why?

Because brains are
brains. A great many progressives have not grown up with, nor have they
learned, the new scientific understanding of reason. Instead they have
acquired the old philosophical theory of reason and assume it every
day in everything they do. The old view is inscribed indelibly
in the synapses of their brains. It will be hard for those progressives
to comprehend the new science that contradicts their daily practice.

They may find it hard
to comprehend framing, metaphor, and narrative as the way reason really
works -- as what you need to do to communicate truth. Instead, they
may well think of framing as merely manipulation and spin, as the mechanism
that the right wing uses to communicate lies.

An excellent example
of such old-theory thinking appears in the Rahm Emanuel/Bruce Reed book,
The Plan, where framing is seen only as manipulation, not as the
structure of ideas. Emanuel and Reed (p. 21) assume that policy is independent
of what they incorrectly understand framing to be. As a result, they
assume that framing can only be illegitimate manipulation.

This is, of course,
the very opposite of what I and other cognitive scientists have been
saying. They are right that real reason can be manipulated in that way,
as Frank Luntz has shown us. But it need not be. An understanding of
how the brain really works can be used to communicate the truth effectively,
and that's how it should be used.

In the Obama campaign,
honest, effective framing was used with great success. But in the Obama
administration, something has changed. It needs to change back.