Public Health Communications: Lessons Learned From the Affordable Care Act

During my tenure serving under four Assistant Secretaries of Health at the US Department of Health and Human Services, one of the most important pieces of advice I received was to remember that the term “public health” was made up of two words. For public health practitioners, the “health” part is rather straightforward; remaining up to date on evidence-based and scientifically sound health practices is critical. It is the “public” part that is often more difficult for practitioners to continuously gauge and requires both astute listening skills and empathy. For without the public being on board with specific public health practices or policies, it is quite difficult for any public health program to achieve its maximum health impact.

This task of communicating public health practices and ensuring bidirectional information flow is not new to public health practitioners. However, it can be even more challenging when one is dealing with politically charged issues such as climate change and needle exchange programs. Vaccination policy is another subject that requires health practitioners to engage segments of the population—in this case, vaccine skeptics—in a way that presents the clear science but with empathy.

EXPERIENCE WITH THE AFFORDABLE CARE ACT

Perhaps the most recent case study with respect to communicating a politically charged public health program involves the Affordable Care Act (ACA). Although designed with noble intentions to improve the accessibility, affordability, and quality of health care, the law was ultimately passed in 2009 on a party-line vote with the added benefit of a budget reconciliation process. Since then, the uninsured rate has declined by 43%, from 16.0% in 2010 to 9.1% in 2015, and there is evidence of improvement with respect to both financial security and health status.¹

In spite of this progress, public opinion of the ACA, according to Kaiser Family Foundation health tracking polls, was unfazed between 2010 and 2016, with roughly 40% of the public having a favorable view of the ACA and 40% having an unfavorable view (Figure 1; http://kaiserf.am/2m3qjYp). In this issue of AJPH, Gollust et al. make the case that local media messaging about the ACA emphasized political over substantive reporting and reinforced a political polarization in public views of the ACA.² Overall, there are likely numerous reasons for the enthusiasm gap in the ACA including significant partisanship, misinformation, an imperfect law, affordability issues with respect to cost sharing, plan cancellations, and the troubled rollout of the health insurance exchanges, just to name a few.

FIGURE 1—

Favorability of the Affordable Care Act: United States, 2010–2016

Source. The Henry J. Kaiser Family Foundation, January 2017. Altered by Anand Parekh, with permission.

COMMUNICATION FAILURE

One possible factor that deserves additional research is whether public officials and other public health and health care leaders failed to communicate the merits and the challenges of the ACA in a clear and consistent way. Optimal communications generally require an appropriate messenger providing a compelling message to the right audience at the most opportune time.

There is a range of intriguing questions. With respect to the messenger, should public officials such as the US president and the Secretary of Health and Human Services have been more visible discussing the law with the public given that this was the administration’s signature domestic policy achievement? With respect to the message, in spite of the law’s focus on covering the uninsured through private health insurance exchanges and Medicaid expansion, should there have been much more attention given to the broader insurance benefits in the law that have an impact on a larger constituency? Polling has indicated that specific provisions of the law, such as the receipt of preventive services without cost-sharing, keeping adults younger than 26 years on their parents’ insurance plans, and prohibiting insurance companies from denying coverage because of a person’s medical history, were favored by a majority of Republicans and Democrats (http://kaiserf.am/2m3vZSp).

Finally, could supporters of the law have better capitalized on critical events over the course of the past few years? One could hypothesize that the months following (1) the June 2012 Supreme Court decision that the individual mandate was authorized by Congress’s power to levy taxes, (2) the 2012 re-election of the president, (3) the June 2015 Supreme Court decision that federal health insurance subsidies were available to eligible Americans in state and federal marketplaces, and (4) the March 2016 announcement of 20 million Americans newly covered because of the law should have all led to significant bumps in public approval of the law. Yet, as seen in Figure 1, none of these seminal events led to a sustained increase in favorability for the law.

LESSONS LEARNED FOR PUBLIC HEALTH PRACTITIONERS

For front-line public health practitioners who have tried to ably translate the ACA to millions of Americans over the past many years, there are several lessons learned.

Health Literacy

First, health literacy remains a major public health challenge. Nearly nine out of 10 adults have difficulty using health information that is routinely available in our health care facilities, retail outlets, media, and communities.³ Beyond this, the concepts of insurance, premiums, and deductibles central to the ACA are not ones familiar to most Americans. Public health leaders have an important role to play in improving health literacy in this country, and the Department of Health and Human Services’ National Action Plan to Improve Health Literacy offers specific solutions.

Multilevel Communication

Second, public health leaders must remember that optimal public health communication involves a multilevel approach that includes not only general messages for the mass audience but also targeted messages at the group level and tailored messages at the individual level.⁴ Matching the most appropriate messages to specific audiences is critical to maximize impact. Although tailored messages often require additional cost and effort, their ability to help individuals process information and to lead to changes in attitudes followed by behavior are significant.⁵ Increasingly important to this point is assessing health communication strategies for an increasingly diverse population with respect to race, ethnicity, socioeconomic status, age, and gender (http://bit.ly/2kDfjhj). For example, it is estimated that more than 60 million Americans aged five years and older speak a language other than English at home (http://bit.ly/1Q4mqeW).

Steady, Incremental Communication

Finally, effective public health communication strategies require exposing individuals to appropriate messages multiple times over an extended period as opposed to one-time communication efforts. Changing attitudes, behaviors, and social norms are often slow and, thus, a commitment to a steady, incremental process of communication over time is necessary. In this regard, building positive relationships with local reporters by providing not only evidence-based information but also real-life stories can help shape media coverage (http://bit.ly/2kD3oAa).

In summary, the ACA is a complex law that has affected Americans in different ways over the past seven years. Translating health policy issues to the American public is an important responsibility of public officials. For this very reason, public health communications continues to be a core leadership skill for public health practitioners.