Blogging about the Affordable Care Act: A rhetorical analysis of weblogs kept by the Democratic and Republican Parties and the White House

Abstract

Political parties in the United States have used public relations tools to promote their opinions about health care reform since the subject first entered the lexicon in the 20th century. As the Affordable Care Act was introduced and debated in Congress in 2008 and 2009, political parties’ public relations teams used political weblogs or ‘blogs’ to disseminate their messages. The language used in those blogs illustrated attitudes underlying the explicit messages, including assumptions of victimhood and villainy, which were used to support party positions regarding the law. This rhetorical analysis examines content of the blogs within the ‘zones of meaning’ Heath proposed as models of effective public relations. Differences between the parties’ content and the administration’s is particularly noticeable in the uses of humor and sarcasm, the social positioning of women and families, and the villainy or victimhood inherent in many of the social roles depicted by the uses of language.

Keywords

Affordable Care Act health care health communication health reform Obamacare political discourse public relations rhetorical analysis

Introduction: Health care reform and public relations

Health care reform in the United States is understood as the redesign of the American health care reimbursement and delivery structure, from a for-profit model that includes multiple payers, multiple insurers, and hundreds of thousands of individual, independent health care providers to a more cohesive system in which fewer people lack access to affordable care. What may seem a complicated, detailed issue that would interest only those companies that benefit from it and those uninsured people who might derive medical care as a result has sparked vituperative public debate and concurrent public relations efforts since the idea was first proposed nearly a century ago.

The public relations war over health care reform grew increasingly contentious during the administration of President Barack Obama, as he proposed and passed a law that implemented only incremental change in the United States’ model. That debate and its tone have received much attention in mainstream and scholarly media, but what has not been analyzed in previous studies is the public relations discourse that took place in the online outlets maintained by the two majority political parties in America and the White House that drove reform. This study examines political entities’ efforts to inform ‘enlightened decision making’, in Heath’s (2006) words, and to evaluate the meaning(s) they attempt to co-create with their audiences.

The study uses rhetorical analysis (RA) of online promotional content to investigate the language and messages used by supporters and opponents of the law as it was shaped, passed, and implemented, and to determine how that language might affect audiences trying to navigate a chaotic, partisan debate over public policy. This is the first RA to evaluate public relations efforts about the United States’ efforts at health care reform as communicated on political parties’ weblogs or blogs. Those media tools may reflect the rhetoric used more broadly to express the viewpoints of their producers. Used as outlets for policy promotion, these blogs comprise content not mediated through the gatekeepers inherent in news production and thus present unmediated insight into the attitudes of those producers toward their audiences. The content of the hundreds of succinct daily entries is written in a style intended to convey specific pieces of information about the law in order to persuade audiences to adopt or embrace a stated or implied political position. This analysis uses RA to show how carefully constructed language was used by the stakeholders in this important policy debate to portray its effects differently in order to pursue their goals of promoting or defeating the new law.

Health care reform in the 21st century

The Patient Protection and Affordable Care Act, also known as the Affordable Care Act (ACA) and ‘Obamacare’, was introduced early in President Barack Obama’s first term and passed by Congress in July 2010. Various elements of the law were enacted in the years between 2010 and 2014, culminating in introduction of the state and federal exchanges, or marketplaces, in January 2014. Much political debate and public communication has surrounded the law since its initial introduction, and confusion abounds about its details and coverage provisions among its supporters, detractors, and potential beneficiaries.

That confusion is often fed by public relations priorities and deliberate misstatements, such as that the law would create ‘death panels’ (Lukas, 2012) or that it would ‘expand government in health care’ (Keating, 2010). Many who could apply for insurance coverage under the law are unaware of its benefits (Kohut et al., 2009) or their own eligibility (Sommers, 2015) and are influenced against it by arguments propagated by conservative commentators in mainstream and online media. Sommers (2015) pointed out that ‘Many Americans remain unaware of the ACA’s coverage options’. He recommended ‘ongoing media and community-based outreach’ (p. 2395).

The ACA has been accused of creating death panels and socialized medicine, of straining the US budget, of pushing employers to reduce employees’ hours or fire them altogether. At the same time, nearly 11 million non-elderly adults, who might qualify for coverage under the new law, remain uninsured and most of those have not attempted to gain coverage under the new law (Garfield and Young, 2015).

This study uses RA to analyze online political journals created, maintained, and used as public relations tools by the three entities most invested in the new law. The blogs, a term shortened from the older more self-explanatory ‘weblogs’, disseminated information about the health care reform law passed during the Obama administration in 2010. Combining RA with simple quantitative examination of word and phrase frequency, key messages, genres, themes, and intertextuality of online discourse about the ACA are examined. The blogs studied for this research are those of the Republican Party, the Democratic Party, and the White House itself. The three blogs are hosted on the two parties’ websites, at https://gop.com/the-case-against-obamacare and http://www.democrats.org/issues/health_care, and on the White House website, at http://www.whitehouse.gov/healthreform.

Literature review

RA

RA and the rhetorical paradigm have been used by various scholars (Heath, 1993; Nicoll and Edwards, 2004; Winton, 2013) to qualitatively analyze content of print and other verbal media. RA helps determine how stakeholders use language to influence the meanings audiences glean from the messages they receive, potentially in an attempt to influence their actions. The rhetorical paradigm has been applied to analysis of risk and crisis communication (Heath and Waymer, 2014; Palenchar and Heath, 2002), HIV/AIDS (Bush and Boller, 1991), and even medical quackery (Widder and Anderson, 2015) to capture ‘the meaning that shapes the social reality’ (Heath, 1993: 142) of policies and programs that affect different publics.

RA employs detailed examination and analysis of text to determine prevailing concepts and attitudes revealed within messages that are intended to be persuasive. In analysis of such texts, the goal is to find the social meaning intended by use of specific language. As Heath (1993) puts it, these ‘zones’ of meaning ‘are vital to efforts by governmental officials to gain support for their policies’ (p. 146). This study examines just such efforts, by government groups interested in the outcomes and implementation of a sweeping change in US government policy: a move to more expansive coverage of health care for low-income Americans.

Rhetoric is a tool of persuasion, the use of language to convince an audience of the validity of an argument (Watson, 1995). In the case of health care and its reform in the United States, the rhetoric used to persuade audiences to support the divergent viewpoints of the country’s political parties reflects decades of positioning the issue as a financial one, with patients as consumers ‘empowered’ to make informed decisions pitted against organized for-profit medicine (Lee, 2015). More broadly, as countries around the world wrestle with increasing health costs and policies intended to constrain those costs, RA illustrates the dichotomy between the evidence-based thinking of scientists and physicians and the politically driven framing of reform proposals by interest groups seeking to influence voters (Russell et al., 2008).

Analyzing language in health policy communication

Traditional health communication efforts often focus on changing individuals’ unhealthy behaviors using the constructs of societal norms (Prochaska, 2008) and self-efficacy (Bandura, 1977) as key principles in communication campaign design. Such campaigns rarely focus on influencing opinions about imminent changes in health policy, even when those policy changes might affect an individual’s vote in a political campaign. The goals of health promotion campaigns thus tend to focus on agency and the likelihood of individual behavioral change on the part of the target audience, rather than a focus on generating support of greater systemic societal change in the provision of health care for all.

RA focuses on context and meaning-making as well as the specific words and phrases being used to present a position or point of view. ‘One should also consider the positions which are being criticized, or against which a justification is being mounted’ (Billig, as quoted in Watson, 1995: 808). This study analyzes health policy communication to evaluate how structure – in particular, the structure of a debate that is as much political as it is related to public health – influences perceptions of health values, which may affect attitudes and actions of the individuals who consume information online.

Echoing the strategy most often employed in health promotion campaigns, previous analyses of language used in health communication have repeatedly found health issues in media focus more on individual agency and a concept of the ‘will to health’ than on the broader structural impact of social conditions and influence. In an analysis of Australian health magazines, Newman (2007) found writers embraced the healthy values they believed the magazines portrayed, ‘almost entirely related to individual behavior’, rather than social, economic, or political conditions that might impact physical and emotional health. In conducting a discourse analysis about the newer field of gender-specific medicine, Annandale and Hammarstrom (2011) point out the ‘prevailing neoliberal agenda which frames healthcare as a market good and locates health and illness in individual bodies rather than in the wider social arrangements of society’ (p. 583).

Studying websites in Canada and Australia that aim to address the growing problem of childhood obesity, two medical sociologists (Alexander and Coveney, 2013) looked at political trends, specifically neoliberal health policy influences, as constructing a reality that uses moralizing discourse to persuade parents to push their children to exercise more. They determined that governments in the two countries emphasized individual authority (the parents’) rather than social constructs over health outcomes and behavior, in this case their children’s weight. The discourses examined in this study found the website content they examined implied blame, presenting the social problem of childhood obesity as a disease that was ‘epidemic’, caused by its own victims.

The intersection between health care reform and politics

A search of the academic literature found little scholarly research into how media coverage of the ACA might reflect health communication’s intersection with political issues and policy and link that to lessons for health promotion campaigns in the future. Considering the importance of the Act for the nearly 15 million people still uninsured at the end of the first year of the full implementation of the law (Garfield and Young, 2015), examination and analysis of the messages incorporated into media coverage and how their political coloration might obscure messages about the health benefits of its provision, this issue deserves greater attention. A search of the political, health, sociological and communication literature reveals few uses of RA to examine the promotion of the ACA to its potential beneficiaries, by either American political party or the White House itself. A meta-analysis of 40 studies published the year the health exchanges were launched gives reason for pessimism (Kreuter et al., 2014). The authors point out the difficulty of reaching historically underserved populations in predominantly lower income households, the very people most likely to benefit from the new insurance coverage. Using traditional health communications tools would mean finding lower socioeconomic populations ‘where they live’, in neighborhoods and via outlets that focus on underserved populations. But as Kreuter et al. (2014) point out, ‘Economically vulnerable populations often live in information-poor environments, which may limit their exposure to health information’ (p. 52).

To further complicate matters, where the audience may have been difficult to reach, communication was still apparently unclear: in a survey of Americans conducted in the year the law was passed (Kohut et al., 2009), more than two-thirds admitted that they didn’t understand the law. A majority of respondents said they supported individual provisions of the law, but respondents voiced lack of support for the law itself, illustrating their misunderstanding. About 47 percent said they opposed the ‘Affordable Care Act’, but 66 percent favored its requirement of an individual mandate to purchase insurance, and 58 percent said they supported raising taxes on more affluent Americans as a means of paying for better access to health care.

These studies illustrate the difficulty of communicating with diverse publics about a complex issue that encompasses political change and public health. Studies of health communication have focused more often on individual-level behavioral change rather than group-level attitudinal change about public policy. Convincing an audience to support a position or amend a behavior without also earning their belief in the need for the change is likely to be ineffective in achieving the desired result. RA illustrates the social attitudes underlying explicit messages. In the case of politically laden social issues, American conservative viewpoints are commonly expressed as a belief in personal responsibility. This belief encompasses the promotion of business and a capitalistic ‘free market’, whereas more liberal viewpoints emphasize helping the helpless, ensuring administration of social justice, and protection of women, children, and minorities.

This RA supports the paradigm that posits stakeholders direct an audience’s meaning-making through language to support the interests of the group. In a perfect world, those interests would converge on an agreement across partisan divides. This study shows how differing values and attitudes manifest themselves in the political parties’ choices of words and phrases, and how those choices frame arguments for and against health care reform, a change that would radically reshape very large business interests in the United States.

Method

Previous studies of political websites have used both qualitative and quantitative measures to evaluate the potential effectiveness of a given site in communicating to its users and viewers. To narrow the data sample for evaluation, Weare and Lin (2000) ask three basic questions: ‘… what constitutes a Web page, what constitutes a Web site, and how [do] these elements combine to form identifiable messages’. This study defines the sample it examines as the blog entries of each of America’s two political parties and the White House on sites devoted to communication about the ACA. Blog entries were analyzed at a single domain level for each of the organization’s weblogs at the Web addresses listed (Figure 1).

Figure 1.

Domain level of each weblog.

Weblogs, or blogs in the vernacular of those who read and use them, first came to be commonplace as the Internet became more accessible in the late 1990s. The term originally referred to an online personal diary and is believed to have been coined in 1999; earlier uses appear in references to computer database systems (Kogan et al., 1998). Blogs are studied for their potential in health care applications (Nguyen et al., 2014), journalism (Matheson, 2004), and for their use in political campaigns (Trammell, 2006). Their application in promoting political beliefs about health care reform is the focus of this analysis.

As Weare and Lin mentioned in 2000, ‘few studies have delved into what messages are specifically trying to convey and how they convey it’, an idea this research will attempt to address in regard to health care reform and its political presentation. Thompson (2012) examined a website focused on communicating with users interested in mental health issues using the concept of synthetic personalization (Fairclough, 1989), wherein a message is ‘contrived for a mass audience so individuals feel as if they are being spoken to personally’ (p. 397). Such emotional appeals constitute a powerful mode of communication that can bypass the skepticism and guardedness an individual may feel toward institutional entities or groupspeak.

RA as a qualitative method has a great deal to offer the evaluation of how health care reform has been communicated to political audiences. This study analyzed the textual content of three online sources of information about a key health and political issue of the presidential administration of Barack Obama. Each entry is considered a unit of analysis for the purposes of this examination.

To preserve and facilitate examination of the content of the three blog sites, the text of all blog entries from January 2010 to December 2014 was entered into three Word documents, one for each of the three blogs. Defining the sample, in this case, means examining and analyzing all blog posts within the three specific parent URLs: http://www.democrats.org/issues/health_care (Figure 2), https://gop.com/the-case-against-obamacare/(Figure 3), and https://www.whitehouse.gov/blog/issues/Health-Care (Figure 4). The initial sample included all content listed at these URLs because the named URLs linked specifically to weblogs primarily concerned with the ACA and included entries pertaining to its debate and passage. Hyperlinks beyond these pages were not followed for the purposes of this study; links to other pages were not followed nor their content included in analysis in order to maintain consistency of data. As Weare and Lin (2000) proposed, ‘researchers can and should employ individual pages as the recording unit whenever possible’ in conducting content analysis.

Figure 2.

Democratic Party weblog as of February 2015.

Figure 3.

Republican Party weblog as of April 2015.

Figure 4.

White House weblog as of April 2015.

A simple count of words and repeated phrases was initially used to determine prevalent concepts in the text. That count provided points of comparison among the sites as well as determination within a given site of its prevalent themes. Inductive and computational methods were used to initially code the content, including spreadsheet software and conversion of dynamic Web pages into static Microsoft Word documents. Qualitative inductive analysis was applied after initial quantitative analysis to examine the prevalent concepts within the texts, and RA used to evaluate specific language constructs used to win audience support in communication about health care reform. For example, references to one political party’s dominance over another or to health care industries’ control of access to care qualify as instances of attempts at persuasion – words and phrases specifically chosen for the meaning they already carry within specific social groups, in this case political parties.

Examination then focused, after the initial quantitative analysis, on language that indicated politically and socially significant context, including phraseology used to disclaim ideas, such as ‘supposedly’ and ‘claimed’; where passive voice was used as opposed to active voice, illustrating the concept of ‘agentless passive construction’ (Fairclough, 1992); and how the text constructed actors it portrayed, including who was acting, how they were constructed or depicted, the themes used in constructing the identity of those actors, and their goals and intentions.

Where authors were identified, analysis was included of the importance of unnamed institutional authors versus named authors of blog entry text. Where authors were named, any background or traits accorded them are included in the analysis, such as whether they were presented as experts on a specific aspect of the issue or stakeholders in an element of the new law. Direct quotes versus paraphrasing and attribution were noted as well as framing of specific prevalent messages, and those qualities will be compared within and across the three organizations’ entries.

Weblogs analyzed for this study

At analysis, the Democratic Party website included blog entries dating to 29 June 2012, as well as a subsite on ‘The GOP Health Plan’ that was undated. The Democratic National Committee (DNC) also had a completely separate site, linked to from its health care blog, entitled ‘This Is Obamacare’. That blog included a simple home page with complex animated graphics and a pull-down menu at the bottom giving users the option to click on a given state in order to find location-specific information. The North Carolina site, for instance, included information on how many formerly uninsured people had access to care as well as statistics on children’s coverage and Medicare benefits to North Carolinians under the ACA.

Similarly, the Republican Party’s website attacking ‘Obamacare’ included a blog, with entries dating to 8 June 2011. The overall Obamacare blog listed 520 items about the law, including 315 entries categorized under the word ‘research’, 57 entries listed as press releases, 97 blog posts, 3 petitions, and 48 videos. Links from the top paragraph on the home webpage – rather than the blog itself – included items also hosted on the GOP (Grand Old Party or The Republican) web domain that discuss the President’s ‘Lie of the Year’, a URL link to a ‘Broken Promises’ page; a link to a subsite titled ‘Obamacosts’; and a broken link to a page on how the law’s regulations and rules reduce competition. The Republican website included a customized error page for this dead link, showing a photograph of Hillary Clinton and the message, ‘What do Hillary Clinton and this link have in common? They’re both “dead broke”’. (https://gop.com/obamacare-regulations-and-rules/, accessed 27 January 2015.)

The Whitehouse.gov website included a blog as well, though not a separate blog specific to the ACA. The White House blog did include a tag for ‘health care’, which included primarily news about the ACA. For this analysis, entries using the tag ‘health care’ were screened to determine whether their subject was the law or another health care topic. Hallahan (2000) describes the motivation, ability, and opportunity (M-A-O) model of public relations as positing that communication difficulties are exacerbated in a world ‘compounded by the clutter of messages and the competition for attention’ as exists in online media. Many potential enrollees came to news about the ACA already confused about the law and its tenets (DiJulio et al., 2014), therefore assuming that a mainstream audience would understand that a new health care regulation or provision should be credited to the law could result in research results that inaccurately reflect those audiences’ likely comprehension of the ACA. The tendency of American media audiences to support its specific provisions while voicing opposition to the law itself has been documented by Pew and by academic research published as this study was conducted (Bergeron et al., 2016; Pasek et al., 2015). Thus, the study’s author made the decision to narrow the data for this research to only blog entries that explicitly mentioned the ACA either by the law’s official title or by its nickname Obamacare.

The first mention of health care was in a post about the President’s inaugural speech, indicating the importance of the issue for President Obama. The first post specifically about the ACA on the White House blog was dated 5 March 2009, prior to introduction of the law in the House. That post is entitled ‘Live-blogging the White House Forum on Health Reform’. (http://www.whitehouse.gov/blog/2009/03/05/live-blogging-white-house-forum-health-reform, accessed 26 January 2015.)

An earlier quantitative analysis of the issue of presentation of the ACA using framing as a measure of news media content (Marshall, 2014) determined that three primary themes were repeated in mainstream media coverage of the law during Congressional debate in 2009–2010: fight or conflict, economic impact, and patient care quality. Whether those themes recur in current online presentation of the law’s benefits and faults will be determined in preliminary qualitative analysis, and initial examination will allow for the possibility (if not likelihood) that other themes and presuppositions will emerge. Since the law passed Congress in 2010, debate over its provisions has focused on several issues, including the impact of passage on overall health care costs, requirements for states to expand Medicaid, and court challenges to the law’s subsidies for people of middle income.

Results

Democrats: A fight for protection of the vulnerable

The blog kept by the Democratic Party, titled simply ‘Health Care’, consisted of 269 posts. Its tenor overall maintained a tone of protectiveness, of aiding ‘all Americans’, and by implication particularly those citizens who need assistance. Its home page begins with description of a century-old ‘promise’ to make health care easily accessible for all:

… seven Democratic presidents pushed for health reform over the years, each one moving the ball forward – from Medicare to children’s health insurance. Today, we finally are able to make real the principle that every American should have access to affordable health care, and no one should go bankrupt just because they get sick.

That opening paragraph, which is visible on every page when a reader clicks through archived posts, sets a tone maintained throughout. Its initial post, on 11 January 2010, promotes President Obama’s weekly address ‘and how reform will help build a new foundation for American families’. Families, women, and children are the focus of the ‘help’ the blog refers to often; the word ‘help’, in verb and noun forms, occurs 40 times in the blog entries dated from the first post to the last, on 16 May 2014. The historic nature of the health reform law repeats often in the entries as well, in references to ‘historic health reform’ and ‘historic proportion’ of the Administration’s signature achievement. The word ‘historic’ occurs 22 times in the nearly 300 posts that constitute the weblog.

In early entries, the blog sets a tone of defiance, of challenge and gauntlet-tossing. On 2 March 2010, the headline reads ‘Kaine to Republicans: I Dare You’. The chairman of the party, Tim Kaine, is featured as a guest on a popular news show. Kaine’s comments are paraphrased as taunts directed at the opposing party and their opposition to health care reform, saying, ‘he hoped Republicans would campaign on protecting insurance companies and their ability to discriminate against patients with pre-existing conditions, on re-imposing higher prescription drug costs on seniors and on kicking kids off their parent’s insurance at an earlier age’. The comments came in the month the ACA would finally pass, a year after the President introduced the bill. The tone of fighting for the rights of the downtrodden – of protecting average Americans – continues as the debate over the bill heats up in Congress. Posts and their headlines talk about the ‘desperate’ need for reform as Democrats ‘march’ for ‘swift action’. The protection reform offers will be ‘immediate’, and the hegemonic nature of the alignment between the Republican Party and the for-profit health insurers is characterized as ‘jaw-dropping’ discrimination against helpless women and children. Defeat and struggle recur throughout the posts in the days leading up to the Congressional vote, evoking images of war and persistence. In one headline appearing a year after the law was passed, the content exemplifies the message of heroic action: ‘The President came to my rescue’. The post describes a woman with ‘a big problem that was really starting to wear on her’ as she feared ‘something sudden and dire’ – the loss of her health insurance:

Desperation shows up as a characteristic of the opposition, as well, as a March 19, 2010 post titled ‘Fight the Fear’.

“Want any more proof that Republicans are in the throes of desperation? They are forging counterfeit memos intended to scare Americans about Medicare.”

The theme of desperation is echoed in an entry headline on a particular provision of the law that allowed parents to maintain coverage of their adult children up to the age of 26 years. The day that provision took effect, 3 May 2001, an entry headline reads in part ‘Young adults rush to join their parents’ health care plans’.

The day the law passed – 22 March 2010 – the tone of the blog posts is not triumphant, but measured. Reference is made to Organizing for America, the Party’s ‘grassroots arm’, and its work to achieve health reform. Describing the victory, a post simply says, ‘we achieved the desired result last night’. This may be an example of multiple authorship – the style of this particular entry varies noticeably from the abrupt, succinct language of previous posts – but the blog does not credit most of its authors, so it is difficult in most cases to know which party supporters contributed to the content.

Within a week of its passage, Republicans in Congress had signaled their intentions to repeal the law, and a post title on 29 March returns to the tone of defiance, as the President tells his opponents to ‘Go For It’ in attempting to roll back reform. The blog notifies supporters that representatives will return to their districts to ‘trumpet hard-won health care’ and their ‘legislative victories’ as ‘the Party of Action’ works to inform its constituents.

The theme of predatory insurance companies and their mercenary supporters in the Republican Party runs throughout the Democrats’ blog. Posts repeatedly characterize Democratic members of Congress as protecting average Americans from the ‘worst abuses of the health insurance industry’. Insurers are presented as heartless, greedy profit-seekers, waging ‘discrimination against sick people’, while Democrats fight to shelter the helpless and infirm. The party ‘protects consumers so that families have the peace of mind to know that the health of their loved ones is not subject to the whims of insurance companies’.

When midterm elections shift the balance of power in both legislative houses, the entries resume a more dispassionate tone, reporting upon the GOP’s effort to repeal the law and reassuring readers that passage of a call for repeal will not result in suspension of the law’s benefits. Fear-mongering language does appear as the days change, so that by 6 January 2011, the blog’s author(s) warn of a ‘devastating impact on individuals, families, small businesses and the economy’ if the law were repealed.

The theme of caring for families recurs frequently in the 4 years of blog posts analyzed for this study. Families, children, women, and senior citizens are represented as requiring and deserving protection against the powerful financial interests of insurers and Republicans. Other profitable health care industries are not mentioned; no posts refer to pharmaceutical firms or physicians’ investments in hospitals and for-profit clinics, for instance. Families, particularly, are presented as in need of ‘control’ of stagnant or dwindling household income.

Women are the predominant representatives of the law’s beneficiaries in individual stories, frequently as helpless victims of illness or injury, further victimized by a bureaucratic insurance system intent upon denying their medical care. The words ‘woman’ and ‘women’ show up 130 times in 269 posts, while the words ‘man’ and ‘men’ show up 10 times – as afterthoughts, as in a post describing supporters of the ACA as ‘men and women alike’, or in the phrase ‘working men and women’. At one point, men become a secondary opponent, 2 years after the passage of the law when an entry points out that ‘women pay more than men do for the same health insurance coverage’.

Women as victims appear frequently in the Democratic Party’s site entries. The President is depicted as their protector, ensuring access to contraceptives and reproductive health care. Low-income women are especially sympathetic in posts such as that on 22 June, as the blog writes of Republicans’ successful efforts to stop funding of Planned Parenthood clinics in Indiana. ‘… roughly 9,300 low-income women will no longer have the same access to health care’ as the new state law ‘takes away medical treatment’ for women who have used the clinics. Women as mothers struggling to provide for their families appear in many posts, including one headlined ‘A Mother’s Support’, ostensibly written by a working-class mother who writes ‘… no American should be among the working poor or lose everything they have worked for due to an illness in their families’. As the Presidential re-election campaign gathered strength, posts focused particularly on women – a constituency generally perceived as sympathetic to the Democrats’ party platform. One post vilified the Republican candidate, Mitt Romney, as supporting a culture in which ‘… being a woman would continue to be a pre-existing condition’, referring to GOP desires to repeal the health reform law, reinstating health insurance practices in which higher premiums were charged to women than to men. ‘The President cares about women’, proclaims one entry headline, while Republicans ‘attack’ women and seek to undermine their rights.

The White House Blog: Paternalism overlaid with credibility and expertise

The White House blog, with no specific title, includes posts about all health care issues – though the majority refers to the ACA either directly or obliquely – and presents the President as caring and concerned about those for whom the system has not worked, whether lack of access to health care has meant financial burdens or physical ill health. About 494 posts dating from the ACA’s passage specifically refer to the ACA, using the criteria that the law’s name is mentioned either by its official title or the term ‘Obamacare’, or that the law is indirectly named as ‘health care reform’ or ‘health insurance reform’. There are 519 remaining posts on the blog, many of which refer to the law without defining or naming it, or to the website on which health care plans are sold, Healthcare.gov. The exclusion of these posts for this analysis is deliberate, and to this author indicates one of the essential issues in communication from the administration about the new law: a lack of clarity as to its specific provisions, which are many, and a lack of messaging consistency about the law. Brand consistency is a marketing concept considered key to successful advertising and public relations campaigns (van Riel et al., 2003), and it appears to be lacking in this effort to effectively publicize a controversial measure. That communication inconsistency may reflect wavering reluctance to identify the President with a law that proved immensely unpopular at some points in its twisting path through Congress, or it may be indicative of the bureaucratic obstacles to clear communication often inherent in governmental public relations campaigns.

The first entry to refer to the ACA by name is dated a month after it became law, on 30 April 2010. To that point, the law is referenced simply as ‘health reform’. The post is clear, and includes specific references to popular tenets of the law in simple language. The author, Todd Park, is not credited with any other posts on the site:

The Affordable Care Act has a number of important measures to promote more consumer choice and control when it comes to health insurance options. A big part of that will be a web portal that offers American consumers and small businesses the ability to find health coverage options in their states through a clear, easy-to-understand process.

While the party-specific blogs engage in hyperbolic rhetoric and fear appeals, the White House site takes a more measured, academic tone. Its ‘speakers’ are experts in their subject matter, such as Health and Human Services Secretary Kathleen Sebelius, Director of the White House Office of Health Reform Nancy-Ann DeParle, and Director of the Office of Management and Budget Peter Orszag. Posts are credited to specific authors, often guest authors who are also subject matter experts (Secretary Sebelius authors many of the entries). Where the other blogs use conversational language and short, sharp sentences, the White House frequently projects an intellectual tone. A post calling claims that covered individuals will lose their existing health care plans ‘false’ names the falsehood an ‘old canard’, a word from the Middle French that dates to the 1850s. At the same time, in a post a week later, the language shifts abruptly to ‘Debunking another bogus chain email about health reform, this one about your taxes’. The abrupt change in tone – from intellectual subject matter expert to folksy, conversational brevity – may reflect an accusation made about the President at the time (March 2010) by vice-presidential candidate Sarah Palin: that he was a ‘law professor’, not a commander in chief (Ruckert and Gerhart, 2010). In some cases, the entries here appear to make an effort to counter that image.

Still, the posts revert far more often to dispassionate fact-dissemination, focusing on issues of health care access (43 mentions), quality of care (40 posts), and gratitude (‘thanks’ appears 38 times in the entries).

As with the Democratic Party’s blog, the White House blog appears to target women, an audience highly attuned to health issues and generally recognized as the frequent buyers of health care and insurance. Women are mentioned 50 times in the 494 posts analyzed for this study, men once, and the word ‘man’ shows up twice. ‘Mother’ or ‘mom’ is used 17 times, with reassuring language such as ‘peace of mind’, a phrase that appears 10 times:

Happy Mother’s Day, from the ACA. (Posted 11 May 2014)

More than 8 million Americans have signed up for coverage through HealthCare.gov. And for families across America, that’s making a difference – providing peace of mind for parents and kids alike.

Patriotic appeals appear with regularity in all of the blogs examined in this analysis. In the case of the Administration’s communication on its health care blog, Americans feature prominently – but often as individuals in need of protection from insurance companies, or assistance from the government in the form of the new law. A concerted effort to present specific individuals as examples of those who will benefit – or are benefiting – from the new law is apparent on the site; themes recur as ‘voices of health reform’ and as community leaders ‘empowering’ and fighting for the needs of those who require ‘protection’ as offered by the ACA. ‘The Faces of Health Care’ as a headline repeats 24 times, including first names and last initials with brief descriptions of each individual – ‘an emergency physician in Pembroke Pines’, ‘Connie W. from Los Angeles’.

Protectiveness may be the most subtly recurring theme in the White House blog. Some language makes it obvious; the word ‘help’ appears 74 times among the entries analyzed here. Explicit language also includes, for instance, ‘Getting the Information Out to the Most Vulnerable’, a post about one community leader who acts to help ‘the ones most in need of [the law’s] resources, services and benefits’ and another example of a specific individual, ‘Nathan’, ‘whose son Thomas has a chronic illness’ and who will ‘no longer [be] haunted by worries like, what’s going to happen if I lose my job? … How will we survive?’ Other entries are more subtly protective, evoking images of helpless children coupled with fear appeals:

Robyn-Care: Providing Extensive Care for a Sick Baby

Complications at birth are usually hard to deal with, and more than usually they are hard to pay for. Robyn’s son Jax, who was born with serious genetic disorders, accumulated a $150,000 bill in his first day in the NICU, and if it weren’t for the Affordable Care Act’s prohibition on lifetime dollar limits for coverage, they might have been denied assistance.

Unlike either of the two political parties’ blogs, the WhiteHouse.gov blog addresses minority audiences directly, in several cases in Spanish (‘Una Simplísima Explicación de Obamacare’ in August 2013) and offers resources to other language users off-site, as in a post offering access to information in Korean. Asian Americans were targeted six times in this blog’s entries, while the other two never mentioned or addressed the demographic category as a group or individually.

Finally, cost – a recurrent theme in all three blogs analyzed here – appears in the Administration’s online communication as the concern primarily of individual ‘Americans’, for whom the ACA changes and saves lives, grants control, and bestows ‘the freedom to pursue their dreams’, and the ‘ability to stay healthy’ upon middle-class, working Americans.

The nearly 500 White House blog posts analyzed for this study overwhelmingly convey a paternalistic power relationship between the Presidential administration and the ‘working class, middle-income Americans’ that will benefit from expanded access to health insurance and care. Repeated references to safety, protection, and help – reminders to ‘take advantage’ of the new program, encouraging language, heart-lifting stories of ‘families, seniors, businesses, and taxpayers’ no longer oppressed by ‘insurance company abuses’ – populate the content.

Republicans: The case against Obamacare

Where the Democrats and the White House repeat a discourse promising assistance to the women, families, and minorities disenfranchised by a predatory for-profit health care industry, the Republicans use their weblog to point out the ‘broken promises’ of a Democratic administration and Congress. Beginning on 8 June 2011, the GOP ‘Obamacare’ blog, ‘The Case Against Obamacare’, takes a different tone entirely. The blog’s contents use sarcasm, hyperbole, and euphemisms for death (‘flat-line’, for instance) in overwhelmingly negative yet frequently humorous posts.

A frequent theme featured in the entries is unfulfilled ‘promises’, as in the President’s ‘Healthcare Promise He Can’t Keep’. That and other posts use a ‘broken promises’ hyperlink to connect to posts with similar themes, an online content tool called ‘tagging’. Tagging is not used by the Democratic bloggers or on the White House blog. As described by Kamel Boulos and Wheeler (2007), tags can ‘surface individual perspectives’ in a website or page. Tags are used in blogs and on the other Internet sites to aggregate entries under certain themes or messages, an informal form of discourse categorization determined by the authors of the posts and the users of the site.

The ‘broken promises’ tag appears in 21 blog posts on the GOP blog; 29 posts link to the tag ‘Obamacosts’, all 97 posts analyzed here were tagged ‘Obamacare’. Broken promises is used frequently to refer to provisions of the law or its implementation that when enacted resulted in unanticipated outcomes, such as the ‘promise’ made before passage of the ACA that Americans could keep the health care plan they were enrolled in at the time the law was created. One Republican blog entry in June 2011 cites the reality of that promise as ‘Health Care Doubletalk’ that causes ‘Lingering Pain’ as it lengthily quotes the President’s original words reassuring citizens of that promise. The reality that some plans would not survive reform is characterized in the Republican posts as ‘plan elimination’ or ‘termination’, words suggestive of death.

The writers of the Republican blog entries show some efforts at humor in references to medical terminology, humor not evident in either the Democratic or White House blogs. A headline criticizing the lack of progress on technology adoption under the President is headlined ‘Hard Pill To Swallow’, and one of many posts about the loss of catastrophic health care plans cites a study of the change as offering a ‘Dire Prognosis’. ‘Another Poor Diagnosis of ObamaCare’ begins a post claiming costs will rise under the plan. A reference to contemporary culture appears in a post dated 14 October 2011, calling a failed long-term care insurance plan ‘an ObamaCare Zombie’.

Desperation, a theme repeatedly appearing in the Democratic weblog, appears in the opposing party’s entries as well. In January 2011, a writer describes public relations efforts to reach supporters by e-mail: ‘In the Obama campaign’s second e-mail of the day to supporters, campaign officials once again are caught scrambling to try to defend Obama’s record of failed promises’. The new law is criticized as likely to bring on dire financial consequences for the nation. As opponents awaited a Supreme Court decision on a requirement in the law that mandated coverage for all who could afford to pay, business owners are cited as opposing the law because of its potential harm:

When I ask them, what does ObamaCare do for you? They just say well, nothing we hope because the Supreme Court has got to say no to it. I mean, this is at the front and center of what could derail the economy.

Small business will ‘flat-line’, claims another post, an oblique medical reference to heart monitors used on hospital patients.

The potential economic impact of the new law is featured on the Republican weblog, where mention is rare on that of its opponents. The word ‘cost’ shows up 60 times in the 97 entries on the blog. Cost estimates of the law’s implementation are said to be ‘ballooning’ by billions of dollars, and the impact upon ‘taxpayers’ a ‘burden’. Citing one of many attempts to repeal the law, a July 2012 post touts the party’s ‘fiscal responsibility’ in the face of, presumably, irresponsible Democrats:

In a measure which will continue to show the commitment of House Republicans to display sound fiscal responsibility and repeal a health care law fraught with reckless tax increases, the House will vote on repeal. This vote will be interesting because unlike the passage which took place on a strictly party line vote, a number of Democrats will join their Republican colleagues in voting to repeal Obamacare.

The costs discussed on the site include both overall costs to the national budget and individual impacts, such as increased insurance premiums:

The truth the White House doesn’t want to admit is people will face higher costs, smaller healthcare networks and an actual comparison of premiums from states around the country shows why the administration wanted to cherry pick the numbers.

The language becomes hyperbolic after Healthcare.gov, the White House website intended to make enrollment in new insurance marketplace plans a simple online process, goes live with much ceremony and many technical problems:

Millions of Americans are being told they can’t keep their health insurance policies or their doctors as a result of ObamaCare. This comes on top of the massive layoffs, skyrocketing premium increases, and website ‘glitches’ that have already resulted from this government-run ‘debacle’.

The widely publicized trouble-plagued launch of Healthcare.gov receives much attention on the GOP blog; the word ‘glitch’, unused on the other two weblogs analyzed for this study, appears 13 times and merits its own hyperlink tag. The writer’s sense of humor appears in a particularly vitriolic post about the failure of Healthcare.gov:

Does the White House win worst Monday in Washington? After President Obama failed to give the American people any concrete information on how he was going to fix ObamaCare besides a 1-800 number, Jay Carney had a particularly rough press briefing where he was asked about penalizing individuals when they can’t access ObamaCare, why HHS hired a firm the Canadian government fired and who misled the president that ObamaCare would be like booking a hotel or plane ticket on Kayak, among other things.

Sarcasm is used frequently in GOP blog entries, a genre that, like humor, does not appear on the blog entries of the Democratic supporters of the ACA. A headline about the second anniversary of the implementation of health care reform asks ‘Obama Won’t Be Highlighting Obamacare This Week … Wonder Why?’ and refers to White House staffers and a news poll about the law: ‘Guessing they are seeing the same numbers we saw in today’s ABC/WaPo poll showing two-thirds of the country wants to ditch some or all of Obamacare’. Several entries on the site taunt the President, characterizing his supporters as ‘vexed’ and Obama himself as ‘ObamaScared’, one of many plays on the derisive term for the law coined by opponents of the ACA. Taunting language and sarcasm are evidenced by posts titled ‘It Doesn’t Look Like Obama Will Deliver On Those Health Care Promises’ and ‘Hard To Imagine How Things Could Be Going Worse For Obama Administration’. A March 2014 post discusses the ‘disaster’ of state-run enrollment websites, or exchanges, citing Oregon as a particularly fraught example. The headline uses sarcasm, humor, and taunting language in just four words: ‘The Beaver State Exemption’. A later post about the same situation in Oregon, after the state has opted to discontinue its own exchange in favor of the national Healthcare.gov site, mentions US$200 million in ‘wasted’ taxpayer funds and a Democratic legislator who ‘… was so proud of the legislation, that he compared the state exchanges to getting lunch in a food court’.

Discussion

We use words to create meaning to inform, influence, and persuade others. Heath challenged public relations academics and practitioners to ‘engage in ongoing dialogues in ways that make society more fully functional by fostering effective processes of enlightened choice’. (Heath and Frandsen, 2008). The depth, breadth, and complexity of the 906-page law that is the Patient Protection and Affordable Care Act do not translate easily to the brevity required in online messages and social media. Engagement in ongoing dialogue, especially via today’s dominant online media channels, may increase dysfunction in society by fostering miscommunication rather than enabling effective, enlightened choices. Heath’s (2006) ‘zones of meaning’ are difficult to create when there are opposing zones and each side’s goal is to craft its own persuasive message. Transcending partisanship to create programs to benefit millions of human beings is made more difficult by the medium itself.

In the case of the partisan public relations efforts examined here, the main parties in American politics had divergent goals for health care reform: the Republicans, to quash the Administration’s efforts at reform and appeal to small and large businesses and their older, more conservative voter base; the Democrats, to support the new law, and thus demonstrate concern for social justice and a desire to help women and families. While the GOP’s dire language, references to death, and cost to taxpayers may not resonate with the young adults insurers ardently seek, its humor and snark may be more successful tools with that audience than the more serious social justice messages of the Democratic Party. Sarcasm is used as a tool of discourse to confirm relationship status (Seckman, Couch, 1989), and within the context of online communication its presence confirms power status. Heath’s zones of meaning may also translate to unintended feelings of exclusion generated by these blog posts; the professorial tenor of the White House blog entries could well alienate a less-educated audience already confused by a complex law.

After 2 years into its full implementation, the ACA and the increased insurance coverage it provides still fall short of the law’s ultimate goal: to insure all Americans who cannot otherwise afford health care. In particular, younger adults continue to choose to go without coverage. This group – often called the ‘young invincibles’ (Hogberg, 2013) – is important because its lower use of medical care can help insurers balance the costs of the care needed by older adults. Reaching that group, and persuading its low-risk, low-cost members to sign up for the insurance coverage required of them by the tenets of the law, is crucial to the success of the ACA. Yet, little guidance has been offered on how to communicate with these and other publics to enable informed decision-making or ‘enlightened choice’.

As a step toward that goal, this study contributes knowledge about current communication practices of partisan organizations, hoping to influence behavior of their constituents. RA was chosen to enable the study of the meanings created by discourse (Heath, 1993: 142). The results of that analysis reveal images of defenseless women; greedy, villainous insurers; cheated taxpayers; and struggling small business owners as victims of a sometimes fickle Presidential administration.

These messages have proven persistent even as the ACA has provided health care to millions of previously uninsured Americans, and the images leave blameless other stakeholders in the free-market system that prizes profit above social justice. The broken promises and dire consequences portrayed by opponents of the law contrast sharply with the protective paternalism of the content of supporters. This analysis shows that the messages communicated online by the two parties, as well as messages from the sponsor of the bill – the President – have often conflated increased health care access with villainy and victimization of specific groups rather than presenting audiences objective information about the law to inform their decisions. Zones of meaning may have been created, but they are not shared across groups.

In addition to revealing specific messages, RA looks at the underlying motives of the present arguments as well as the language they choose to use. Whether opposed to the concept of health care reform or supportive of it, leaders of the two dominant political parties in the United States must answer influential lobbies in the pharmaceutical, physician, insurance, and hospital industries and have chosen to use specific messages about the law in order to demonize only certain stakeholders they see as threats. While portraying the beneficiaries of their positions as in need of protection, political leaders use rhetoric to inflame emotion and influence debate. Even the more measured tone of the Administration’s blog posts presents a persuasive argument for protection of vulnerable Americans, presupposing an ability on the part of the producer of the messages to provide that protection to victimized women and children.

Limitations

Dozens of posts to the White House weblog studied for this analysis were eliminated because they did not directly reference the ACA, though the content of the post’s message clearly referenced benefits conferred by the new law, such as insurance enrollment deadlines. I excluded such posts for the purposes of this study to ensure validity of the data, while the unlabeled content likely was intended to promote the law, no such allowance was made for either the Democratic or Republican parties’ blogs.

Many of the excluded White House blog entries used the hashtag ‘#GetCovered’, referring not to the ACA but to a provision of the law requiring annual renewal of insurance coverage. The use of the hashtag #GetCovered without a concurrent mention of the Act itself illustrates the lack of branding consistency in the blog’s communication about the new law; the implicit appeal to young adults in the use of social media without the added repetition of the brand ‘Affordable Care Act’ likely leads to confusion about whether the new availability of health insurance for younger, healthy Americans is a result of the new law or simply a coincidence of timing for a yearly insurance renewal.

The content of these three blogs cannot be considered quantitatively equivalent – the number of posts on each differs considerably, there is an unaccountable gap in the Republican blog entries from 16 July 2012 to 27 March 2013, and use of graphics and external hyperlinks, as well as blog devices like tagging, varies from site to site. This analysis serves to highlight the themes, messages, and genres of the entries on the three sites and results cannot be generalized to political writings about health care reform in general.

The need for clarity of information on health care reform

Searching academic databases including Web of Science, PubMed, and EBSCO host for scholarly articles on health communication and the ACA turned up little research examining how public relations efforts to communicate about the new law accurately described its provisions to potential enrollees. Most results directly pertaining to communication about the new law came from trade publications and public relations presswires, generated by or for the insurers most likely to benefit from enrolling young, healthy Americans in the new plans.

When Barack Obama became President of the United States, he began efforts to implement a federal program that would help provide access to health care to more than 40 million Americans, who were then uninsured. To many, this accomplishment made sense, not just as a liberal issue of social justice but as a logical step for an affluent country that, unlike its global peers, had not previously provided for the health of those who could not afford to pay for care themselves. Informing those individuals who could benefit from the new law – and communicating with the corporate stakeholders in the for-profit system in ways that would also accurately inform their efforts – could, ultimately, have achieved an enlightened choice. This analysis illustrates that political partisanship also creates meaning, but that the meaning can skew accuracy using emotionally laden language to influence opinion without apparent regard for enlightenment.

Citing a workshop held to share ideas about communicating with the millions of potential new insurance enrollees, Parker (2012) quoted participant Lynn Quincy, Senior Health Policy Analyst for the Consumers Union, as saying that ‘studies conducted by the Consumers Union show that consumers do not know how to shop for insurance, nor do they understand cost-sharing terms (e.g., deductible, co-insurance, benefit maximum), medical coverage terms, or how to compare policy options’.

Scholars who have studied communication about the new health reform law and availability of coverage for eligible audiences repeatedly mention the importance of communicating in language its beneficiaries can understand – simple, clear terms unencumbered by judgment or politics (Brandon and Carnes, 2014; Parker, 2012; Shue et al., 2014). Again, the studies about these issues address enrollment in health plans. While some research has been performed about the influence political debates have had on understanding of the law, the implications are clear: Messages about the complex issue of health insurance intended for a general audience must communicate with those affected ‘in a manner that they can understand, with information they can use, to make informed choices about which policies best suit their needs’ (Parker, 2012).

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author biography

Laura H. Marshall is a Doctoral Candidate in Strategic Communications at the School of Media and Journalism at the University of North Carolina (UNC) at Chapel Hill. Her research focuses on messaging in online media about health care and health policy. She comes from a professional background in healthcare public relations and broadcast journalism.

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