The Politics of Framing and Public Engagement in a Polarized Age

Whose voices matter and what arguments are most persuasive in US policy making? In an era in which policy discourse has become politicized, we need to understand how citizens and officeholders understand health policy issues.

The first article in this issue, by Sarah E. Gollust, Colleen L. Barry, and Jeff Niederdeppe, uses a survey experiment to examine public opinion formation around an important, ideologically charged public health issue, sugary drink taxes. Evidence suggests that a tax on sugary drinks can curb the consumption of high-calorie beverages. However, divisive public opinion toward such taxes is a barrier to their adoption. Understanding what strategies work best—and among whom—may provide useful information for public health advocates. The results of the survey experiment show that a strong protax public health argument in support of a sugary tax is not effective at boosting support. Further, when pro- and antitax frames compete, the antitax frame wins. The experimental results also show that calling out the negative role of soda companies in lobbying against scientific studies may backfire with Republicans. These findings reinforce the communication challenge of changing public opinion about public health interventions in an increasingly polarized environment.

A second political engagement issue concerns public participation in the decisions of government agencies. Since the Supreme Court ruled that the Affordable Care Act's (ACA) Medicaid expansion is optional for states, a number of states have used Section 1115 waivers to expand Medicaid while changing the coverage and benefits design. The ACA established a public comment process under which citizens can express their views on pending waiver applications. But who participates in this process? In our second article, Marian Jarlenski, Philip Rocco, Renuka Tipirneni, Amy Jo Kennedy, Nivedita Gunturi, and Julie Donohue investigate comments submitted to federal regulators pertaining to Medicaid waiver applications in five states. They discovered that individual citizens submitted the majority of the letters, including a sizeable response from those who identified themselves as Medicaid-eligible. In contrast to prior work suggesting that the substantive quality of citizen comments is usually low, the study found that most of the letters mentioned specific provisions of the waiver applications. Overall, the study observed robust public engagement, reflecting the salience of debates over Medicaid's future.

Over the past quarter century, Congress as well as many state governments has passed “parity” laws to secure nondiscriminatory insurance coverage of mental health and substance disorder services in the private health insurance market and through certain public insurance programs. However, many advocates have brought lawsuits alleging that federal and state parity laws have been violated. In their article, Kelsey N. Berry, Haiden A. Huskamp, Howard H. Goldman, Lainie Rutkow, and Colleen L. Barry examine the critical issues underlying this litigation. Their analysis offers many practical insights for public officials and stakeholder groups working to make the implementation of insurance parity a reality.

How can we make sense of the value disagreements that underpin political battles over harm reduction proposals, such as efforts to regulate tobacco products? In our Beneath the Surface section, Lynn T. Kozlowski draws on moral psychology to highlight how fast-thinking, moral-emotional intuitions (such as the anger many feel when conceptions of fairness are violated) can serve as rationalizations for policy judgments. The article suggests that being conscious of moral psychology may help people resist relying on moral intuitions too much when crafting policies to promote public health.

Finally, our section on the Politics and Policy of Health Reform includes two articles. The first, by Judy Feder, Alan R. Weil, Robert Berenson, Rachel Dolan, Nicole Lallemand, and Emily Hayes reports on interviews with key stakeholders in five states about their strategies for payment and delivery reform. The second piece, by Lynn A. Blewett, Donna Spencer, and Peter Huckfeldt, describes the origins and early implementation results of Minnesota's Medicaid accountable care organization.