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).
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.
Barbour summed up Republicans’ health care talking points succinctly:
“It is important,” he said, “that people know three things about the Republicans and health care: No. 1, we’re for health care reform; the issue is not whether but how. No. 2, we can’t afford a government-run health care system financed by a massive payroll tax that will end up hurting the quality of care. And No. 3, we don’t have to have a government-run health care program to do health care reform.”
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.”
Public trust in many other institutions including doctors and medicine also declined over this period, but by focusing health care debates on government while leaving private actors out of the picture, the insurance industry and Republican strategists bent the public discourse to their advantage. Their strategy was a resounding success. The health insurance industry and the GOP together tanked initially high public support for Clinton’s health care plan, forced Clinton to withdraw his proposal, blocked McDermott’s bill from getting traction, led California voters to reject Proposition 186 by a margin of three-to-one, and won Republican control of Congress for the first time in 40 years.
Following their big victory, Republican politicians stuck to this anti-government rhetoric and kept Democrats on the defensive. Clinton shifted his rhetoric and policy to the right for the remainder of his presidency—declaring in his 1996 State of the Union speech “the era of big government is over”—and in the 2000, 2004, and 2008 elections, Al Gore, John Kerry, and Barack Obama were each accused by their opponent of promoting “government-run healthcare.”
By and large, however, so long as Republicans held power and passed legislation favorable to the insurance industry, anti-government health care rhetoric stayed on a slow burn.
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 (at left). 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 following month, AHIP distributed a messaging strategy document to allies, Republican staff and opinion leaders, and conservative media (below). The document gave explicit instructions to center health care rhetoric around the phrases “government-run” and “government plan”:
The memos outlined a strategy of working with libertarian think tanks to use the industry’s messaging. In June a week before the Sicko premiered, Cato Institute held a briefing for congressional staffers. Before the year was out, Ayn Rand Center and Freedom and Individual Rights in Medicine, Cato, Foundation for Economic Education, The Heritage Foundation, Hoover Institution, Manhattan Institute, National Center for Public Policy Research, and Washington Policy Center all published take-downs of “government” health care. The insurance industry established and pumped millions of dollars into new front groups including the Coalition for Responsible Healthcare Reform, and the pharmaceutical industry did too. AHIP and the Fraser Institute produced two issue briefs warning federal and state legislators against “government-run health care” and “single payer (government) insurance scheme[s].” Many of these think tanks receive funding directly from health care corporations and billionaires like the Koch brothers with a direct financial stake in maintaining ownership and control over the health care system.
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.
Then came the November 2008 election, which delivered Democrats the White House, both houses of Congress, and a mandate to pass health care legislation. Both the insurance industry and Republican strategists were quick to respond.
In February 2009, AHIP held focus groups to test messaging that would turn people against the public option. Recording their findings in a memo obtained by Politico, AHIP concluded that “government-run health insurance plan” and “a government-run health care plan” were the most negative, followed closely by other phrases associating health care with government:
Republican strategists, for their part, wasted no time. Before President Obama even assumed office, Republican-aligned think tanks the American Enterprise Institute and Ethics and Public Policy Center both published op-eds in the Wall Street Journal, the latter co-written with Representative Paul Ryan. “Government health care” is mismanaged, wrote AEI. “Beware of Big-Government,” “socialized health care,” and “government-run health care,” wrote EPPC and Ryan. The dangers were so great, they said, that “the stakes could hardly be higher for our way of life.”
Meanwhile Luntz circulated a memo called “The Language of Healthcare” and the Republican National Committee hired strategist Alex Castellanos to produce “GOP Health Care Strategy.” Both memos, leaked to Politico, directed Members of Congress to smear Democrats’ health care plans by association them with government control.
“The arguments against the Democrats’ healthcare plan,” wrote Luntz, “must center around ‘politicians,’ ‘bureaucrats,’ and ‘Washington.’”
Castellanos instructed Members of Congress to call Democrats’ proposal a “Washington-centered system,” the “Obama-Pelosi plan,” and “The Obama Experiment.” “Obama’s plan will put government in charge of the doctors you can see and the types of treatment you can receive” and “will tempt your employer to dump you into a cheaper, government-run health care program,” he wrote.
By early February, Republican Members of Congress were tightly on message, placing quotes in the press denouncing “socialized medicine,” “government-paid health plans,” and the “government dole.”
The party line was so strictly enforced, joked Texas Senator John Cornyn, “You get a fine that you have to put in the jar on the table if you say ‘public plan,’ instead of ‘government plan.’”
By the first week of March, Now-Senator Rick Scott launched a new organization, Conservatives for Patients’ Rights, that spent at least $20 million on television ads warning of “the serious consequences of a government takeover of health care.” All the while, Scott had a direct financial stake in keeping people uninsured. He owned Solantis, a company that ran clinics profiting from people who were uninsured and on the margins of the health care system. (Scott had previously resigned as Chairman and CEO of Columbia/HCA after it was discovered the company had defrauded the federal government out of $1.7 billion.)
That summer, while the Koch brothers’ network of organizations funded and orchestrated protests against “government-run health care,” Fox News ran multiple polls asking people their opinions on “a government-run health insurance plan” and “a government-run health care system.” Meanwhile a fracas erupted in the House, where Democrats blocked Republicans from including the phrase “government-run health care” in constituent letters paid for by the public, which are required to be free of partisan, politicized language.
In August, Luntz made an appearance on the network, where he instructed Sean Hannity on live television to stop talking about Democrats’ proposed “public” insurance option and instead call it a “government” option.
“If you call it a ‘public option,’” Luntz explained, “the American people are split. If you call it the ‘government option,’ the public is overwhelmingly against it.”
In October, in an email later obtained by Media Matters, Fox News’ Washington Managing Editor Bill Sammon gave Fox commentators and producers precise instructions:
1) Please use the term “government-run health insurance” or, when brevity is a concern, “government option,” whenever possible.
2) When it is necessary to use the term “public option” (which is, after all, firmly ensconced in the nation’s lexicon), use the qualifier “so-called,” as in “the so-called public option.”
3) Here’s another way to phrase it: “The public option, which is the government-run plan.”
4) When newsmakers and sources use the term “public option” in our stories, there’s not a lot we can do about it, since quotes are of course sacrosanct.
Just three months later, ABC News and the Washington Post would poll the public on “a government insurance option … the so-called public option.”
Fast forward to today, and the insurance, hospital, and pharmaceutical industries and Republican Party officials are all aligned in weaponizing the word “government,” which has been strategically imbued with negative connotations for decades, to malign Medicare for All and public-option proposals. All of the following companies, libertarian think tanks, and partisan Republican officials employ the phrases “government” and “government-run” as the central framing strategy in their public statements, press releases, and other media on health care:
Any labeling of publicly financed or operated health care programs as “government” or “government-run” employs powerfully charged, politicized language that produces profound psychological and political effects. It is no wonder that this framing has been so widely adopted by health care industries, conservative operatives, and Republican officials. What is more remarkable is how thoroughly this lexicon has been adopted by the mainstream media and health-policy think tanks in just the last twelve years.
Through the Clinton and Bush years, the media very rarely used “government” or “government-run” as way of defining Medicare, Medicaid, or universal, publicly financed insurance. In the New York Times, for example, the phrase “government-run” appeared in 12 articles on the American health care system from 1990 through 2006, an average of just two articles every three years. When the phrase did appear, it was more often than not a direct quote from a Republican official. The phrase was similarly rare in every other publication reviewed.
Starting in 2007, that changed dramatically.
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.”
200 from Forbes
200 from Kaiser Health News
199 from the Chicago Tribune
199 from Fox News
198 from the Washington Post
197 from USA Today
193 from the Los Angeles Times
183 from CNBC
162 from Bloomberg News
158 from Reuters
153 from Politico
149 from CBS News
140 from The Associated Press
135 from NBC News
130 from The Hill
116 from PBS
150 from AP News
116 from Vox
104 from New York Magazine
95 from Time Magazine
89 from The Atlantic
85 from Vice
74 from Slate
62 from Stat News
60 from Mother Jones
58 from Daily Kos
56 from Real Clear Politics
55 from Newsweek
49 from The Daily Beast
36 from Think Progress
34 from New Republic
32 from Salon
34 from MSNBC
32 from The Week
30 from Axios
30 from Fierce Healthcare
28 from Common Dreams
27 from Christian Science Monitor
25 from Roll Call
22 from The American Prospect
22 from The Nation
18 from Jacobin
17 from Talking Points Memo
15 from Morning Consult
15 from Splinter News
13 from The Intercept
12 from In These Times
8 from Rolling Stone
6 from Vanity Fair
1 from Dissent
Though such a rough search includes false positives, it also leaves out articles using such terms such as “government-run system,” “government-provided coverage,” and “government-run insurance plan,” among other phrases. And although there has been an increase in all health policy news since 2007, in earlier years, print and television news outlets reported on Medicare, Medicaid, the Veterans Administration, other countries’ health care systems, and the policy proposals of the Johnson, Carter, and Clinton eras. Before the insurance industry’s and Republican strategists’ 2007 and 2009 messaging campaigns, the media rarely framed these programs as “government-run” or “government” health care. Since then, they have adopted this framing nearly ubiquitously.
1. Pair equivalent subjects: There are two choices: name the actors on both the public and private sides of the health insurance and health care systems or leave them both out. If describing “private” insurance or insurers, stick with “public” insurance and insurers. If naming “government-run insurance plans” or the role of “government,” point to “corporate-run insurance” or “insurance companies” too. For example:
“Both proposals are clear that a single, government-run insurer would replace the private sector.”
2. Pair equivalent verbs: Today “government” is often paired with the verbs “run” and “controlled,” which in comparison to softer verbs like “administered,” “financed,” “managed,” “offered,” operated,” “provided,” and “sponsored,” imply a loss of control for the individual. Whichever tone of verb is used should be used on both sides of the comparison.
“Gov. Inslee is proposing a ‘public option’: a nonprofit health plan run by the state to compete against private health insurers.”
3. Pair equivalent sentence structures: Sentence constructions that turn a noun into an adjective, such as “government-run program” or “government plan,” imply more control than a passive sentence construction like “a program run by the government.” Whichever construction is used should be employed on both sides of the comparison.
“The majority of Americans … reject a government-run healthcare system, with 40% in favor and 54% preferring a system based on private insurance.”
4. Be careful about personalizing administrative mechanisms: Using possessives (“your” insurance, “their” plan, etc.) tends to individualize, personalize, and convey a misleadingly sense of ownership of the administrative mechanism through which an individual’s care is presently covered and payed for. When public-opinion polls personalize private insurance as “your insurance” or “your plan,” they introduce a bias that skews their results. If you are specifically asking about an individual’s current coverage, use another phrase (“the insurance plan you are enrolled in,” for example) or if using a possessive, use it for both private and public insurance.
“A health insurance plan would include any private insurance plan through your employer or a plan that you purchased yourself, as well as a government program like Medicare or Medicaid.”
5. Do not equate insurance with the entire health care system: There is much more to the health care system than insurance. The health care system includes hospitals, clinics, dentists, pharmacies, drug and medical device companies, biomedical research, school nurses, public health programs, and more. All of these sectors span the public and private sectors, so none of them, much less the entire health care system, can be accurately characterized as a “government system.” Be careful not to imply otherwise.
“House Speaker Nancy Pelosi has said repeatedly she does not want to push Medicare-for-all — a plan popular among progressive Democrats to move the country to government health care system.”
In addition to balancing your language through the recommendations above, take care when quoting people who employ partisan language on any side of an issue. Put what they say in context, pair linguistically biased assertions with quotes from someone on the other side, and don’t let new language enter your own vocabulary without thoughtful consideration. Strive to elucidate the complex dynamics of the health care system, particularly helping people see the ways in which the public and private sectors blend together: Medicare and Medicaid insurance and administration are increasingly managed by private insurance companies, private employer-sponsor insurance is publicly subsidized, insurance markets are created through public laws and regulation, etc. In addition to elucidating the role of public and private payers, help communicate to people the roles of legislators, administrative agencies, employers, hospitals, public and private clinics, drug companies, doctors, nurses, and other actors in the health care system. Look beyond debates between politicians to draw focus to the substantive implications of policy choices on real people’s lives.
In addition to balancing your language through the recommendations above, change your editorial policy and issue a public statement confirming the changes that your news organization is making.
Balance your polling questions either by adjusting them in keeping with the recommended changes above, or, if you want to maintain existing questions for longitudinal comparison, introduce new comparison questions that include equivalently biased language on the other side (emphasizing corporate actors while eliding the role of government) and well as questions that use internally balanced language.
In describing publicly and privately administered insurance, all of the following polling organizations contrast “government” (which explicitly names the public insurer) with the “private” or “current” insurance system, which obscures the role of private insurers and naturalizes the private insurance system. Few of these polls mention insurance companies at all. Many of these polls include additional biases in their language by contrasting active and passive voice (e.g., “government health insurance” versus “health insurance obtained through employment”) or utilizing possessives in a way that personalizes private insurance while externalizing public insurance (“your insurance” versus a “government program”).
The excerpts below show how each of the following poll refers to public and private insurance models. Language that explicitly names an actor (the government or insurance companies) is highlighted in bold.
|Polling organization||Date||Language describing publicly administered insurance||Language describing privately administered insurance|
|AP-NORC||April 2019||“a new government health insurance plan”; “government programs like Medicare and Medicaid”; “a single payer health care system, in which all Americans would get their health insurance from one government plan”||“private health insurance plan”; “health insurance obtained through employment or purchased directly”; “health insurance”; “insurance companies”; “their parents’ insurance plans”; “private insurance”; “insurance”; “health care plan”|
|CBS News||October 2018||“the government offering everyone a government administered health insurance plan/b><”||“private health insurance plans”|
|CNN||February 2019||“the government should provide a national health insurance program”; “the government instituted a national health insurance program”||“private health insurance”|
|Fox News||February 2019||“a national health insurance program for all Americans that would be run by the federal government and paid for through taxes”||n/a|
|Gallup||November 2018||“a government run health care system”||“a system based mostly on private health insurance”|
|Hill-HarrisX||February 2019||“the government should remove itself from paying for all health care”; “Medicare/Medicaid”||“the current healthcare system”; “private plans”; “their existing insurance”; “private health plans”; “private supplemental plans”|
|Ipsos/NPR||January 2017||“Medicare”, “Medicaid”, “government spending on Medicare,” “the U.S. government,” “a single-payer health insurance system, meaning a government-paid health insurance system”, “government funded health insurance (such as Medicare or Medicaid)”||“insurers,” “insurers,”
“health insurance that is all or partially paid for by an employer or union,” “health insurance out of pocket,”
|Kaiser Family Foundation/ Los Angeles Times||May 2019||“a government program like Medicare or Medicaid”; “Medicare, the government health insurance program”; “Medicaid, the government health insurance and long-term care program”||“private insurance plan through your employer or a plan that you purchased yourself”; “your health insurance plan from an employer or union”; “your health insurance plan”; “your insurance”; “the health insurance plan you have”; “your current health insurance plan”; “the insurance company”; “a choice of different health insurance plans”; “your own health insurance”; “your health insurance coverage”; “health insurance”; “the current health insurance system in the United States”; “people who get health insurance from an employer”; “people who buy their own insurance”|
|National Center for Health Statistics, Centers for Disease Control and Prevention||June 2019||"government programs like Medicare, Medicaid, and the Children's Health Insurance Program"; "an other government program"; "your Medicaid plan"; "your CHIP plan"; "a state-sponsored plan"; "an other government program"; "your other government plan"; |
your other government plan"; "military related health care"
|"any kind of health insurance or some other kind of health care plan"; "private health insurance"; "private health insurance plan"; "your health insurance or health coverage plan";|
|NBC News/Wall Street Journal||September 2018||“a single-payer health care system in which all Americans would get their health insurance from one government plan that is financed by taxes”||n/a|
|NPR/Robert Wood Johnson Foundation/Harvard T.H. Chan School of Public Health||May 2019||“Medicare, the government health program for people 65 and older and certain people with long-term disabilities”, Medicaid, the government program that provides health insurance to certain low-income adults and children and long-term care for some people”, “the VA or Tricare”, “the Indian Health Service”, “a government exchange or agency”||“a plan through your or your spouse’s employer or union”, “a plan you purchased yourself”|
|Pew Research Center||September 2018||“federal government”, “federal government”, “a single national health insurance system run by the government”, “the government”, “the government”, “a mix of private insurance companies and government programs”||“a mix of private insurance companies and government programs”|
|Politico/Harvard T.H. Chan School of Public Health||October 2018|
|“an insurance program in which all Americans would get their health insurance from one government insurance plan”; “government and private health insurance plans”||“the current health insurance system in the United States”; “government and private health insurance plans”|
|Quinnipiac||March 2019||“a single payer system, in which the federal government would expand Medicare to cover the medical expenses of every American citizen”||“the current health care system”|
|YouGov||June 2017||“a single-payer health care system, in which all Americans would get their health insurance from one government plan that is financed by taxes”||n/a|