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Chapter 12

Political Issues and Health Communication

“You lie!” This shout out from Representative Joe Wilson during President Obama’s State of the Union speech immediately got the nation’s attention as well as an instant barrage of press coverage. Rep. Wilson was referring to the President’s contention that illegal immigrants would not be covered by the proposed healthcare reform legislation. The culmination of intense rhetoric that had characterized the debate over reforming healthcare in the US resulted in this eruption of emotion and intensity. Supporters and opponents of the legislation had attempted to garner support through framing the debate in their favor.

Dan Nimmo, often referred to as the father of political communication, along with counterpart, Lynda Lee Kaid, often referred to as the mother of political communication both frequently stated that all communication is political. Although not all communication scholars agree, certainly the lens of political communication and health policy influences health communication in significant ways that we do not completely understand.

The Patient Protection and Affordable Care Act of 2010 (PPACA) that was passed in March 2010 very quickly started to change our healthcare system. PPACA, or healthcare reform, has caused much controversy and debate among citizens and policy-makers and will likely contribute greatly to transformation of the US healthcare system (Bevan et al., 2012).

Healthcare reform will impact almost every single American by changing legislation, regulating insurance laws and employee benefits, and covering an additional 32 million individuals (The Commonwealth Fund, 2010). Though there is continued debate about healthcare reform and the impact it will have on the health industry as well as the economy (Doherty, 2010), there is little systematic knowledge regarding how the public is acquiring information about healthcare reform and the public’s perceptions and understanding of healthcare reform itself (Bevan et al., 2012)

As an emerging health policy context, the changes that healthcare reform will bring are increasingly relevant to health communication researchers for several reasons (e.g. Bevan et al., 2012). Healthcare reform will have a direct impact on those who are sick, but also on those without health issues and problems … the healthy ones! Further, healthcare reform information also includes aspects of prevention, diagnosis, treatment, and intervention based on individuals’ current health status. Due to the politics and policy implications of healthcare reform as well as its partisan nature, public perceptions and understandings of it could be significantly impacted by the one-sided, divisive perspectives of the political entities and organizations that have a considerable stake in the success or failure of the legislation. Thus, determining how and where the public is acquiring healthcare reform information is of utmost importance for beginning to recognize public perceptions and understandings of the legislation (Bevan et al., 2012).

The debate over reforming healthcare from the earliest promises made during the presidential campaign of 2008 to the tea parties, protests, and town hall meetings that characterized the first half of Obama’s term could result in the most expensive advertising war ever fought over a piece of legislation. The back and forth of speeches on the House and Senate Floor, and the arguments from the White House as the Obama administration sought to regain control over the terms of the debate are still unfolding. The story of healthcare reform is, at its root, the story of how health messages (rhetoric) shaped the debate over what was desirable or even possible and ultimately the content of the law itself. Perhaps Drs Nimmo and Kaid were onto something!

The ways by which Americans received and processed the healthcare reform messages from elites, the media and even the town hall meetings and protests in which many American participated, we would argue are grounded in health and media literacy. It is an empirical question just how the public came to understand or misunderstand the most significant piece of healthcare legislation since the creation of Medicare and Medicaid nearly a half century ago.

But, the story does not end with the President signing the PPACA into law. The White House then faced the overwhelming and difficult task of selling the new law to the public. Interest groups engaged in outreach, educational, and advocacy efforts. For example, the AARP began what many consider the most costly campaign in the group’s history to explain the new law to its informed and active members. Despite these types of efforts, many Americans remained uninformed or misinformed. Why are so many Americans still uninformed on the most significant legislation to be passed in a generation? Likely because we have not given much thought to the merging of health and politics, but perhaps it is time to think differently, think critically, think mindfully about the intersection of health, politics, public policy, and the significant role health communication plays in our understanding of these often complicated issues affecting our daily lives.

Many people may not think of health and political issues as being interrelated at first glance. However, again, when you stop and consider many of the recent (and often heated) political debates regarding President Obama’s national healthcare law, debates about the legalization of marijuana for medical purposes, arguments among political figures for and against stem cell research, discussions about the corporate greed and the pharmaceutical industry, and the rights of marginalized groups in our society to have access to healthcare services, you can see that health and politics are frequently intertwined in interesting and complex ways.

As we saw in Chapter 8, the media play an important role in terms of influencing our knowledge, beliefs, and attitudes toward a variety of health-related concerns, and this is certainly the case when it comes to political issues. As a society, we are constantly exposed to television and radio news stories, political debates, websites, blogs, and even documentaries such as Michael Moore’s “Sicko” (2007), Morgan Spurlock’s (2004) film “Supersize Me,” Lee Fulkerson and Brian Wendel’s “Forks Over Knives” (2011), or Michael Pollan’s “Food, Inc.” (2008). These media sources provide us with a relatively wide spectrum of political viewpoints regarding health and healthcare, and many people gravitate toward media sources that present health information that is consistent with their existing political views. In addition, political/health issues intersect with communication in many other ways, such as individuals seeking medical and public legitimacy for diseases that the mainstream public may be relatively unfamiliar with, such as actor Michael J. Fox’s television efforts to raise awareness about Parkinson’s disease or people suffering from chronic fatigue syndrome, cancer, or diabetes using social networking sites to inform others about this condition. Moreover, when marginalized groups or people who lack access to adequate healthcare due to racial discrimination or low levels of income organize at the grassroots level to better their situation, or when concerned citizens create campaigns to change environmental policies, such as removing toxic waste sites from their neighborhoods in an effort to reduce exposure to carcinogens, communication is central in terms of creating social and political change.

This chapter explores the role of communication as it pertains to a variety of current political issues surrounding health and healthcare. We begin by providing an overview of politics and health communication and some background on the recent healthcare legislation, followed by a section on current political issues surrounding health and healthcare including a discussion of message framing and political communication, the impact of health disparities, disadvantaged groups, and access to healthcare and related policy issues, followed by a discussion of healthcare system problems, and medical tourism as a response to medical access problems, political issues surrounding death and dying, nutrition, and international health and policy issues.

Politics and Health Communication

No matter whether you are a democrat, republican, independent, or libertarian, or consider yourself fiscally conservative and/or socially liberal, health is an important issue for everyone. Consider for a moment the history of healthcare and healthcare reform in the US, from placing the new healthcare reform law into context with landmark legislation in 1935 that created Social Security and the legislation in 1965 that enacted Medicare and Medicaid. The landmark PPACA and the Health Care and Education Reconciliation Act of 2010, which comprised the healthcare reform legislation in 2010 are real and impacting our healthcare delivery systems and patient care in unique, complex, even radical ways that we have yet to fully understand.

A New York Times report on July 29, 2012 summarized that in March 2010, Congress passed the healthcare bill put forth by President Obama. The law put in motion the creation of a nationwide insurance system that would provide most Americans with basic healthcare coverage, a goal that had been on the Democratic agenda for 75 years. In 2012, the Supreme Court in a 5–4 vote, largely upheld it after considering a several challenges to much of the law’s key provisions. The healthcare law seeks to extend insurance to more than 30 million people, primarily by expanding Medicaid and providing federal subsidies to help lower- and middle-income Americans to purchase private coverage. It will create insurance exchanges for those buying individual policies and prohibit insurers from denying coverage on the basis of pre-existing conditions. To reduce the increasing cost of Medicare, it puts together a panel of experts to limit government reimbursement to only those treatments shown to be effective, and creates incentives for providers to package services rather than charge by individual procedure.

The Congressional Budget Office claims that the law will cost the government about $938 billion over 10 years, and also estimates that it will reduce the federal deficit by $138 billion over a decade (see Crowley 2012).

This legislation is not without controversy, as it has components involving significant disagreement among politicians, corporate stakeholders, physicians, citizens, and the insurance industry. If you have not paid much attention to healthcare in America, it is time to do so because it will very likely impact you and your loved ones in the future.

Bevan et al.’s (2012) exploration of healthcare reform information sources in relation to information quality, information seeking, and uncertainty found that magazines are the preferred source for such quality information and decreased uncertainty.

In particular, when magazines were employed as a source of healthcare reform information, individuals employed information seeking, and revealed that this information was satisfying and easier to obtain, and were more certain about their understanding of healthcare reform (Bevan et al., 2012). Further, when newspapers were rated the most important healthcare reform information source, participants sought more information. These findings are particularly consistent with Dutta-Bergman’s (2004) research, which found that those who obtained health information from newspapers or magazines were more health-oriented than individuals who did not.

Both newspapers and magazines can provide active, cognitively involved, in-depth coverage of a health issue and can also be archived for future information-seeking (Bevan et al., 2012). These qualities may make magazines, and to a lesser extent, newspapers, particularly appealing as an information source to individuals who are learning about healthcare reform and may thus explain this pattern of findings. The growth of magazines as a health information source (Gill & Babrow, 2007) means that this media channel has the potential to be an invaluable resource for individuals seeking healthcare reform information (Bevan et al., 2012).

When healthcare reform information was obtained from interpersonal sources such as family or friends, participants felt that knowledge was less satisfying, more difficult to obtain, and felt more uncertain about healthcare reform than those who did not. This pattern aligns with Pecchioni and Sparks’ (2007) health information sources research on family caregivers who reported more satisfaction with Internet sources of health information, but differs from their findings related to patient satisfaction and preferences for interpersonal-based health information sources (i.e. doctors and nurses). In addition, when family or friends were selected as the most important healthcare reform information source, less information seeking occurred. However, the authors suggest that the Internet is still a frequently used and important source of healthcare reform information, and should also be considered by those who are invested in the continuation and success of the healthcare reform legislation.

Debates about health and healthcare policies are frequent topics on television and in other media. While most people would probably agree that health is an important attribute that is essential to happy life, differences quickly appear when the discussion turns to issues such as how to best fund healthcare, questions regarding where life begins and ends, what is considered to be a legitimate treatment for a health issue, and even debates over what types of food are considered healthy and unhealthy. In short, health issues are often political and complex, and it important for people who are interested in health communication to try to understand political issues surrounding heath and how communication plays a role in terms of helping people to share their political beliefs with others as well as how political messages about health affect individuals attitudes, beliefs, and behaviors.

Message Framing Theory and Political Communication

A great deal of health communication research has examined the framing of health messages in the mass media. While theories of message framing do not always deal with political issues, they can be a helpful framework to better understand politicized health messages within the mass media. Entman (1991) argued that to frame is to select some aspect of an issue and make it more salient in a message, in such a way as to promote a particular definition, viewpoint, interpretation, moral evaluation, and/or treatment recommendation. Message framing has had a long history in media effects research within the communication discipline (Price & Tewksbury, 1997). When examining the media, framing effects are important to consider because the manner in which information is presented may ultimately decisions and judgements toward issues (see Levin & Gaeth, 1998), including health issues.

A great deal of message framing research is focused on the way in which information is presented in gain- versus loss-framed scenarios, and how this affects people’s cognitions, intentions, and dispositions toward issues (Block & Keller, 1995; Rothman et al., 1999). Gain-framed messages emphasize the advantages or benefits of certain behaviors or the potential of adopting such behaviors, while loss-framed messages highlight the disadvantages or costs associated with engaging in certain behaviors. For example, as we will see later in the chapter, people who are for medical marijuana usage will often use gain-framed messages, such as emphasizing how marijuana causes cancer patients going through chemotherapy to feel less nauseous, while people who are against medical marijuana usage will typically use loss-framed messages, such as emphasizing the link between smoking marijuana and lung cancer or the distortion of spatial perception resulting from being under the influence of marijuana and how this might lead to more accidents (i.e. if a medical marijuana patient is driving under the influence of the drug). See also, Sparks (2011).

As you can imagine, an individual’s or group’s political beliefs can influence the way health-related messages are framed within the media. In short, people who are for an issue are more likely to emphasize positive aspects of their position on an issue while downplaying the negative elements than individuals who are against the same issue. You have probably noticed that you can hear radically different viewpoints on the same political issue depending upon whether you are watching Fox News or the Daily Show on Comedy Central.

Some researchers have found that loss frames tend to be more influential in terms of influencing people’s attitudes, beliefs, and behaviors (Hale & Dillard, 1995; Meyerowitz & Chaiken, 1987) while others have found gain-framed messages to be more effective in persuading people to change health-related cognitions and behaviors (Rothman, Bartels, Wlaschin, & Salovey, 2006). However, both types of messages have been found to persuade audiences, although many other variables, such as the perceived credibility of the message source and people’s cognitive processing abilities, complicate things. As we discuss a variety of political issues related to health in this chapter, think of how you have seen these issues framed in the media by different sources or people/groups with differing political viewpoints.

Current Political Issues Surrounding Health and Healthcare

In this section, we highlight a number of current political issues associated with health and healthcare in the US and, in some cases, how they relate to more global healthcare issues. Toward that end, we focus on the central role of communication plays within these issues, with a particular focus on how health-related political issues are framed within the media.

Health Disparities, Disadvantaged Groups, and Access to Healthcare Issues

Health Disparities 

Unfortunately, who we are, where we live, and how much money we make directly influence our access to quality healthcare and our political power to make changes to the healthcare system. Over a decade ago, the US government set a number of goals for reducing health disparities within the US through a program entitled Healthy People 2010. Despite considerable research, efforts to change health-related policies and legislation, and initiatives to improve the quality of healthcare and provide greater access to traditionally marginalized groups across the country, many of the goals of this program are far from being met. Access to quality healthcare remains inaccessible to disadvantaged populations in the US, including low income people from minority groups, such as African Americans and Latinos, people living in rural areas of the country, and low income older adults, women, and children. Discrimination and health disparities has also been linked to sexual orientation, with gay, lesbian, and transgendered individuals facing higher levels of depression and substance abuse (Archer, Hoff, & Snook, 2009). For example, African Americans have the highest rates of heart disease, diabetes, and cancer (CDC, 2005). People living in rural areas of the country are less likely than people in urban areas to use recommended preventive screenings for disease, receive treatment for cancer, and visit health providers on a regular basis (Ndiaye et al., 2008). These groups often have lower levels of health literacy and education than more privileged groups in society, and this adds to the difficulty of helping these individuals understand the impact of lifestyle and preventive behaviors on their health. Literacy is related to political power, and it likely influences a person’s ability to change their health situation, such as influencing politicians or organizing at a grassroots level.

Many of these disadvantaged populations are marginalized due to factors such as racism, discrimination, inadequacies in government health programs, such as Medicaid and Medicare, and economic policies and practices that favor urban over rural residents in terms of access to adequate healthcare (e.g. it is more economically viable to build a technologically cutting-edge hospital in a large city than in an isolated small town). Individuals from marginalized racial/ethnic groups report dissatisfaction with the US mainstream healthcare system (Ford & Yep, 2008). Studies of African American, Asian American, and Hispanic patients have found that members of these groups frequently report low levels of cultural sensitivity, discrimination, and unsatisfactory treatment from providers (Ford & Yep, 2008; Merrill & Allen, 2003; Saha, Arbelaez, & Cooper, 2003). Lower income individuals and older adults have also been found to encounter negative stereotyping or inadequate treatment by healthcare providers (Becker & Newsom, 2003; Greene & Adelman, 2002). Individuals from rural areas also have been found to face negative stereotypes and discrimination from healthcare providers (Krieger, Moreland, & Sabo, 2010) and often lack adequate access to healthcare due to shortages of providers (especially specialists) in rural areas (Gamm, Castillo, & Pittman, 2003). Discrimination based on race/ethnicity, age, and sexual orientation has been linked to higher levels of substance abuse (Kam & Cleveland, 2011).

Further, large disparities exist between individuals and basic healthcare knowledge, resulting in generally low health literacy levels. While this general lack of health literacy is prominent in many sectors of the population, it is particularly disproportionate among certain demographic groups, showing that certain populations are marginalized under current health education practices. Those who are more vulnerable to health risks, due to lower levels of health literacy, include ethnic minorities, recent immigrants, the elderly, those who suffer from a limited formal education, are socio-economically deprived and have poor access to relevant healthcare information (Kreps, 1986; Kreps & Sparks, 2008; Sparks & Nussbaum, 2008). This also gives evidence that opportunities to increase health literacy may provide a way to lessen inequities in health concerns. Considering healthcare is a public and personal issue, discrepancies over health literacy in terms of patient treatment may also translate into discrepancies over knowledge of the public healthcare system, healthcare reform law, and healthcare decision-making (Sparks, 2008).

For example, the recently passed healthcare legislation is over 2000 pages of complex, legal language. With some 25 percent of the US population being functionally illiterate, it may be assumed that those who receive a limited formal education may have increased difficulty in information acquisition, having to navigate a complex system of healthcare reform law. Therefore these groups may fall into a perpetual cycle of inequity with low health literacy levels and therefore increased vulnerability to personal health risks and confusion in a complex healthcare system. Health literacy has vast implications for health communication researchers and practitioners interested in health information delivery, comprehension, and subsequent medical adherence issues that may arise.

Politicians, government officials, healthcare administrators, physicians, and a variety of interest groups who have economic interests in the healthcare system are also the same individuals who tend to have more political power than those people facing health disparities. Therefore, despite widespread interest in reforming the healthcare system, the individuals with the greatest disparities do not have the political and economic resources to make changes to healthcare that are in their best interest.

Healthcare System Problems 

Despite frequent claims in the media that the US has the best healthcare system in the world, the US actually ranks 37th in the world in terms of healthcare performance ranking. Yet, as a country, we spend more money on healthcare than any other country in the world, and a large number (find percentage) of individuals in the US lack access to adequate healthcare. Even for those individuals who do have some type of health insurance, out-of-pocket expenses related to medical services create a financial burden that many families cannot afford. Recently, one of the authors of this textbook broke his hand and paid more than $5000 for services not covered by his health insurance, including certain physician fees, lab fees, and physical therapy costs. As you can imagine, such a financial burden would be difficult for someone who makes far less money than a university professor (and most likely has less health insurance coverage). The healthcare reform law spearheaded by President Obama is one response to the healthcare crisis. However, as you have likely seen and heard, members of the Tea Party and other groups who oppose what is often referred to as “Obama-care” are frequently seen presenting their arguments against this law in the media. However, in many ways, it may be too early to judge the positive and negative impact of this law since it will take time to assess the degree to which it might help to reduce healthcare costs in the long run. This issue is not going away anytime soon. It will be a crucial and important political health issue to follow all the way to the Supreme Court.

Medical Tourism as a Response to Medical Access Problems 

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