Public perceptions, associations, and beliefs regarding healthcare and its role in society represent a hidden set of assets that can be used to re-shape public perception of the problem and its solution.  They can be used to alter relationships among individuals, social groups, government, and society as they concern healthcare, and to change the tacit agreements (social contracts) that underlie these relationships.

These assets include cultural symbols and associations ; and the values, ideologies, and belief sets that can be used as persuasion tools in the advocacy process. 

Together they form an intangible but nevertheless very real set of resources that can be used to  a) forge new social contracts,  b)  build support for new change initiatives, and c)  change outmoded or excessively limited modes of thinking about the delivery of healthcare – modes that restrict our flexibility and imagination in addressing the problem of uncovered healthcare.

This ‘cultural goodwill’ set includes the following:

•  Unstated Ideological Positions About Healthcare:  While not all Americans would explicitly state that healthcare is a ‘right,’ many (probably most) would agree that it is a good thing to provide healthcare to people who don’t have access to it.  Initiatives that provide medical treatment to indigent and underserved populations are favorably received across social and political lines, for example, unless they cross other cultural lines or taboos for some segments of the population (example:  most people approve of free clinics for the poor, but there is controversy about needle-sharing programs for addicts).
• Cultural Associations Regarding Healthcare:  The delivery of healthcare has a special place in American culture and traditions.  This has been successfully leveraged in the past for political or other reasons.  These cultural associations represent another lever that can be used to promote change in the healthcare delivery system.  These associations include a set of “symbols” about healthcare that have powerful associations – e.g. the Norman Rockwell-like image of the caring doctor at a sick child’s bedside, which translates into a ‘cultural symbol’ of doctors as selfless caregivers.
• Belief System About Healthcare:  As a result of these ideologies and cultural associations, Americans have formed a set of stated and unstated beliefs about healthcare, such as:  “Nobody should be turned a away from a hospital.”  “Doctors should act altruistically whenever possible.”  “The doctor/patient relationship is sacrosanct,” etc.  Without judging the accuracy or inaccuracy of statements like these, each represents a fragment of a larger, normative belief system regarding healthcare:  That it is more an altruistic activity than it is a service, that doctors chose their career because they want to “help people,” that nobody in need of healthcare should be denied it, etc.  While this belief system is not universal, nor is it uniform for all Americans, overall it is a powerful social force.

Practical Examples

How have these belief sets, unstated ideologies, and cultural symbols about healthcare been used politically?  Here are two examples that involve the use of the ideological/belief sets and symbols we’ve been describing (although without using that terminology and, in all likelihood, not as a conscious choice):

AMA vs. National Insurance:  The American Medical Association has waged an ongoing struggle against national health insurance for more than sixty years.  It has been able to do so because it successfully exploited aspects of this “health care belief set” (doctors are altruistic, doctors do not act in their own economic self-interest, doctors are a trusted “member of the family”), linked them with another cause and belief set (anti-Communism – “socialized medicine”), and conducted a concerted public relations campaign (one that included an early attempt at ‘viral marketing’ using LP records and the voice of actor Ronald Reagan, thereby launching his political career.)

Yale-New Haven Hospital controversy:  The Connecticut Center for a New Economy, (CCNE) a progressive organization dedicated to representing the economic interests of working families, published a report in 2003 entitled “Uncharitable Care” that documented debt collection practices by Yale-New Haven Hospital (YNNH).  CCNE has an organizational mission to reduce the impact of medical debt resulting from gaps in the insurance “safety net.”  As their website explains, medical debt accounts for 60% of all personal bankruptcies nationwide. 

“Uncharitable Care” documented aggressive debt collection practices on the part of Yale-New Haven Hospital, and provoked a strong public response.  That response was due to at least four core (if unstated) beliefs associated with “healthcare as a public good.”  Those beliefs are: 

1. Healthcare is something everyone should receive, regardless of ability to pay.
2. Nobody should be forced into bankruptcy because of the cost of medical care.
3. Healthcare providers and institutions should be held to a different and higher moral standard in their business practices.   They should not behave like typical businesses when it comes matters such as collecting debt, and to do so is a betrayal of their social mission.
4. Institutions with an especially high prestige level, like Yale-New Haven Hospital, must be even more high-minded in their financial dealings with the public.  They are a privileged member of the community, and with privilege comes responsibility.

While these articulations of the belief set around Yale-New Haven Hospital may not be exact, they give a sense of the social and cultural dynamic CCNE was able to bring to bear against the hospital.  As a result the hospital has forgiven the debts of more than 18,000 people, and their debt and collection practices have been changed substantially.  It is unlikely this public pressure would have been successful had the organization involved been in another line of business.

New Social Contracts

The term “social contract” has a variety of meanings and uses, but our definition here resembles that of the New America Foundation’s, in that we refer to “an evolving, complex web of legal and informal relationships between households, employers, government, and civil society that extends beyond particular federal programs.”  But whereas the New America Foundation uses that language to refer to a global social contract that applies to the nation as a whole, for the purposes of this leverage point we are also speaking of potential “new social contracts” involving diverse segments of the populations.  These “contracts” may apply primarily to a specific community (in the geographic sense), professional association, faith group, or to a number of them acting in informal association.  Our use of the term is therefore more informal and flexible.

The new social contracts we envision may include global shifts in relationships among the parties listed above, or may involve new understandings among smaller groups such as the ones listed above.  In every instance, however, we envision a shift in “ideological belief sets” that change a web of legal and informal relationships among organizations and groups.  Since the concept is abstract, here are some concrete examples:

Alcoholics Anonymous:  Alcoholics Anonymous was created in 1939 by “Bill W.” (Bill Wilson) and “Dr. Bob” (Robert Smith, M.D.) as an informal, spiritually-based organization to promote recovery from alcoholism.  The organization needed two things in order to survive:  membership growth, and a new social understanding regarding the nature of alcoholism.  Both these goals required publicity, the support of prestigious individuals and institutions, and a cultural shift in the perception of alcoholism (from moral failing to disease).

 A.A. drew on pre-existing cultural beliefs and symbols in order to promote its cause.  From the intellectual elite it drew several concepts from the new and growing field of psychiatry.  It also appropriated scientific language at times, even to describe scientifically unproven concepts (such as the notion that alcoholism is an “allergy”).  It drew from the American cultural element of self-reliance and independence, drawing heavily from its early association with a nativist political and religious group called Moral Rearmament.  Lastly, it drew from American culture’s high regard for religion.

As a result, A.A. was able to attract the support of a number of leading philanthropists who could not (or would not) donate to the organization directly but provided publicity and social connections.  This led to immediate favorable publicity, both for the organization and its belief that alcoholism is a disease.  The result was a significant shift in the cultural assumptions behind alcoholism, resulting in its formal recognition as an illness (one whose treatment is now usually reimbursable under insurance programs).  Interestingly, we have now reached the point where alcoholism is less stigmatized than mental illness, and more commonly seen as a disease, even though there are clearer indicators that other forms of mental illness are organic in nature.

A rapid growth in membership also followed, and his been sustained to this day.

Medi-Share/Samaritan Ministries

The U.S. healthcare crisis provided an opportunity for two Christian organizations to address a social problem, reinforce the group loyalty of their members, and support their evangelical outreach efforts – while addressing their Christian mission to provide aid and comfort to the needy in their communities.   Both Medi-Share and Samaritan Ministries combine different cultural/social/religious belief sets in order to reinforce a new social contract based on core Christian values.

Medi-Share and Samaritan Ministries are organizations which address the uncovered portion of healthcare costs by pooling their obligations and paying each others’ bills as a group.  Their programs resemble insurance more than their literature suggests, in that fees are pre-determined.  They differ from typical insurance in that, after paying an administrative fee, plan members set aside their share amounts for future use.  When a member incurs medical expenses they are “published” and then paid by other plan members out of their predetermined fees.

These organizations draw on specifically Christian cultural and ideological beliefs.  They therefore accomplish two goals:  providing their members with financial resources for health expenditures, and reinforcing those cultural and ideological beliefs.  Medi-Share’s website encourages members to “be good stewards” of their financial resources, cites Biblical precedent for mutual aid within the Christian community, and uses as its toll-free number “1 800 PSALM 23” (“the Lord is my shepherd, I shall not want …”)

Most importantly, these organizations demand an adherence to evangelical Christian behavioral norms in return for the benefits of membership.  As Samaritan Ministries describes it, members are to remain Christians who believe in a “triune God,” are required to attend church at least three out of every four weeks (weather and health permitting), and must refrain from homosexuality, extramarital sex, tobacco, and illegal drug use.  They are to strictly limit their alcohol intake or abstain entirely, and must agree not to sue other Christians (specifically the organization).  Their church pastor must state they have met these requirements.

In addition to helping people meet the uncovered portion of healthcare expense, these organizations have become enforcement mechanisms for evangelical Christian behavioral norms.  They have been able to meet these two goals by drawing on both national and specifically Christian “ideological belief sets.”  In so doing, they have created a new social contract that includes their members, the churches affected by the program, and the greater Christian community.

Grameen Bank

Enough has been written about the Grameen Bank and its loans to very-low-income individuals, so we will not describe the program at length.  We will, however, make the following observations about Grameen Bank regarding social contracts: 

• Grameen Bank loans use peer pressure at the village level to ensure compliance.  Since a group of villagers are collectively at financial risk, the social organization among them forms the “collateral” for these otherwise uncollateralized loans.
• Failure to pay debt is a social value/belief among the villagers involved.
• The presence of these microloans has created a new social compact at the village level based on repayment of these debts.

With this in mind, we can ask ourselves the following questions:

• What are the belief sets and cultural symbols about healthcare that relate directly to the uncovered portion?  (i.e., how can we document them as a set of tools?)
• How can these tools be used to support the specific mission of Healthcare Uncovered?
• What sort of new social contracts – or changes to the existing contract – would help address the uncovered portion?

Under most leverage points, “components” refers to tangible parts of systems that are addressing this or another problem.  Components associated with this Leverage Point, however, also include belief sets, associations, and symbols: such as the following

• Assumption:  Illness is ‘blameless’ and ‘just happens’
• It’s not my ‘fault’ I became ill
• Therefore I shouldn’t be penalized for illness
• Our health-related debts are not our fault, either, so I shouldn’t be penalized for them

• Belief:  Health care providers provide a needed social service and are “not like other people/businesses”
• Therefore they should be compensated well, because they are valuable to society
• They must have chosen their profession for altruistic, not financial, reasons
• They should not, therefore, behave like a ‘business’
• They should be more forgiving of debts than other businesses

• Symbols:  Healthcare Providers as Caregivers
• Norman Rockwell Doctors:  Elderly gentlemen (always men) who work day and night, regardless of compensation, to help others. 
• Florence Nightingale nurses:  Selfless women (always women) who risk their lives to help wounded soldiers or the suffering needy on battlefields and in grimy hospitals for the poor
• Hospitals/clinics as battlefields for saving lives:  The Albert Schweitzer image of the field hospital serving the neediest among us, struggling to ‘make do’ with inadequate resources and staff who sacrifice themselves to fulfill the hospital’s mission.

One of the primary missions of the Leverage Point team is to find additional ‘cultural’ components such as these.  These components can then be combined with others that provide a mechanism for applying these cultural beliefs toward a specific end.  These include: 

• Mass Media:  Ad campaigns, viral videos, etc. designed to build support for a specific agenda.
• Social Activism:  Campaigns like the Yale-New Haven debt program that use these cultural components to support a specific agenda.