The Moral Language of Health Care Reform

This blog article by Martin Bosworth (a blogger, strategist, and friend of mine) is so good that it deserves to be published here in its entirety.  The original version can be found at his Boztopia blog.

Martin explores the need for systemic health care reform and builds on George Lakoff’s argument that the health care debate needs to go beyond “policyspeak” and clearly articulate the moral principles involved in universal care.


Therefore all things whatsoever ye would that men should do to you, do ye even so to them (Matthew 7:12; cf. Luke 6:31).

This morning, via Radley Balko, I came across a fascinating piece in The Atlantic, where technology executive David Goldhill documents his quest to reform the health care system after the death of his father due to bad hospital care practices:

Indeed, I suspect that our collective search for villains—for someone to blame—has distracted us and our political leaders from addressing the fundamental causes of our nation’s health-care crisis. All of the actors in health care—from doctors to insurers to pharmaceutical companies—work in a heavily regulated, massively subsidized industry full of structural distortions. They all want to serve patients well. But they also all behave rationally in response to the economic incentives those distortions create. Accidentally, but relentlessly, America has built a health-care system with incentives that inexorably generate terrible and perverse results. Incentives that emphasize health care over any other aspect of health and well-being. That emphasize treatment over prevention. That disguise true costs. That favor complexity, and discourage transparent competition based on price or quality. That result in a generational pyramid scheme rather than sustainable financing. And that—most important—remove consumers from our irreplaceable role as the ultimate ensurer of value.

Goldhill makes a lot of key points, many of which I’ve made myself. The health care system is absolutely predicated on patients or users having as little knowledge of the process as possible, making them totally dependent on the whims of a system that puts their welfare dead last. We absolutely need transparency in pricing, implementation of simple procedures to prevent or reduce medical errors and overbilling, a vast and comprehensive ramp-up of health information technology updating (including portable, user-owned electronic medical records with strong privacy protections), a much wider adoption of prevention-focused treatment and support for chronic care, more prevalence of the simple, up-front cash-for-service model that many physicians of all stripes are adopting, and a greater move towards giving physicians regular salaries, scaled on order of their expertise, and away from the fee-for-service model that encourages expensive, often unnecessary treatments over basic diagnoses.

This is an argument I’ve made to colleagues who say the public option is the be-all and end-all of the health care debate. Not even close. We have huge amounts of work to do to reform our broken system even IF the public option becomes law–and I believe it will. Obama gets this, and makes this point frequently in his speeches–health care reform is a lot bigger than public health insurance, as important as that is. It is, quite simply, the biggest task our generation faces short of climate change.

But Goldhill drops the ball on a core aspect of his crusade, the same way John Mackey did in his op-ed, and the same way Obama often does in his speeches. Their calls for reform are utterly bloodless and passionless, couched in the language of decades of corporate-speak that views patients as perfectly rational, logical, far-seeing “consumers” who treat health care like shopping for shoes, computers, or food, and that ever more responsibility must be placed on them to “coupon clip” and bargain their health care down to the best service for the lowest price possible.

Simply put, this is bullshit. Having just been through a serious medical trauma myself, and having been privy to the illnesses and sicknesses of friends, family, and colleagues over the years, I can tell you that the only thought relating to money when it comes to health care many people have is “Oh my God, how am I going to pay for this?” In fact, it was that very terror over my hospital bill that stressed me out to the point my adrenals failed and made me sicker. That’s the cost of our system–one where the coverage you think you can rely on is gone in a minute, where it doesn’t cover half the things you want it to, and where even being fully covered doesn’t protect you from endless ancillary expenses, follow-up costs, etc.

Goldhill’s essay about his father’s death and his quest for reform is so completely bloodless you’d think he was talking about filing TPS reports. (If my father or mother died because of neglect in a hospital–God forbid–I’d be taking the scalps of those responsible, Inglourious Basterds-style.) He makes the same facile assumptions that people of a certain level of success make (and that both Mackey and Obama made)–that everyone can handle things the same way he can, that every decision is weighed on the scale of cost and benefit, and that turning health care into a “front-facing” “consumer-driven” enterprise will magically reform a broken system into a perfectly functioning engine of commerce. That’s the same kind of corporatized, free-market-uber-alles thinking that has plagued our discourse for generations now, and it’s contributed to the ruin of our financial system through the idea that things which should have moral values attached to them–home ownership, health care, education, environmental protection–are instead discussed in the utterly soulless terms of the banker, the market, and the financial guru.

In a completely cash-driven system, we’d have the same problems that we do now–people without cash would go without. Or at best, they’d have to put aside savings they intended for things like a house, a college education, a new car, etc., just for health care. Is that a bad thing? Depends. If we move away from an emphasis on consumer spending as a bulwark of economic growth and pay people higher wages, maybe not. But as long as we are not doing that, it’s a terrible idea. I’m lucky in that I can set aside some cash to take care of my health–and trust me, it ain’t easy in an expensive state like California. But not everyone has the same luck, access, options or ability that I do. Is it really fair to make them compete at the same level I do, or to make me compete on the level of a David Goldhill or John Mackey?

People do not make rational decisions. We are influenced by any one of a billion things that skews our opinion this way or that. Often, we make decisions in an instant without realizing the full extent of why we make them–this is the adaptive unconscious Malcolm Gladwell and others have documented. And health care is no exception. Read what this retiring primary care physician has to say about how his patients viewed their state of health (hat tip Newshoggers):

How many dozens of chest pain patients have I seen in the last month who I didn’t order an EKG, get a consult, set up nuclear imaging or send for a cath? Only I have the advantage of knowing just how anxious most of these patients are and that they have had the same symptoms time and again over the last 20 years. After a pointed history and exam, I am more than willing to make the call that 27 hours of chest pain is most likely not angina in nature. When I take the responsibility on my shoulders I am saving the system tens of thousands of dollars. Most of these patients present to my office directly and are worked into a busy day pushing me even deeper into that mire of tardiness for which I will be chastised by at least 6 patients before the end of the day. Most of those who scold me are retired and have more free time in a day than I get in a month. My reward for working these people in and making a call that puts me at some risk is at most $75 if I count the less than $25 I get paid for being able to read an EKG without sending it off to be interpreted by a cardiologist. My incentive pay for saving thousands of dollars on each patient for 1-2 days in the hospital, stress treadmill and cardiologist referral is $75. Now there is motivation on a busy day to not send someone to the ER.

I can totally sympathize with Vance’s bitterness, because again, our emphasis on costs and benefits in every example of our lives has distorted how we view our health care. If something’s cheap, it’s obviously either a scam or not worth it. Anything worth its salt has to be expensive in order to save our lives. We spend years of our lives running the treadmill of the exhaustion culture, chasing the dream of ambition, fueled by 60-hour-workweeks, coffee, pizza, and doughnuts, only to have that first troublesome chest X-ray or CAT scan reveal just how unhealthy we really are. Then we want the best, fastest, most complete medical care possible, and damn the price.

But I also see the other side of it as well, from my personal experience of being billed $13,000 for less than two hours of actual treatment, to my mother having to get a second surgery on her heart because her doctor thought it’d be brilliant to try an experimental procedure on a 71-year-old woman in ill health. Again, none of these reactions are rational or sensible, just as the system is not rational or sensible.

But they are human reactions. And when the language of rationalism fails (as it often does) to address the problem, that’s when the language of morality comes in. The language of providing a social safety net to those in need, whose jobs can’t pay for health insurance or for whom a cash-up-front system would break their bank. The language of providing free or low-cost medical care for all, emphasizing prevention, wellness, and lifetime attention to one’s health, in order to prevent visits to the emergency room and the death spiral of debt. The language of protecting and caring for our fellow citizens not because it’s a moral right, an economic benefit, or a national security advantage, but because, put simply, it is the right thing to do.

If you want a clear, simple way to sell health care reform to all Americans, it absolutely needs a moral dimension. Cognitive theorist George Lakoff acutely articulates this as the missing component of Obama’s plan, and why it’s failing as a result:

To many liberals, Policy Speak 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 Policy Speak 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.

We need to rediscover our moral language in so many forms of discourse, and health care is a perfect example of how to do it. If we can’t find a way to clearly state that providing good quality health care for all Americans, regardless of their status, is the right thing to do for our country and our countrymen, then we deserve to fail and deserve everything else we get as a result.

“Do unto others as you would have done unto you.” It’s a simple lesson that has endured since the dawn of time. We’ve forgotten this, and need to recapture it if we are to win the health care debate and change how we care for our sickest and neediest in America.


Martin Bosworth is managing editor of Consumer Affairs.  He can be found at his blog,


Cognitive Policy Works specializes in providing organizations and individuals with frame analysis, policy briefs, strategic advising, and training.