Healthcare Technology Featured Article

July 31, 2017

Understanding the Narratives Behind the US Healthcare Battle



The Affordable Care Act has been one of the most contentious topics in recent American politics. As President Trump and the Republican Party gear up for a renewed push to repeal and replace the ACA following an initial defeat this year, a legislative battle is brewing. Before any new vote takes place, however, Republican and Democratic stakeholders have fought to win a Narrative Battle across news and social media to shape the public’s perceptions about any repeal.

Understanding the Narratives about the ACA, their volume, and how they resonate with the public is critical to gauging the future of “Obamacare”—or what could soon be called “Trumpcare.” Utilizing the Protagonist engine, we pulled a data set from over 80,000 pieces of content on the Narrative Landscape around the ACA and its potential replacement the American Healthcare Act. Deconstructing the data with Narrative Analytics, we found an ideological battle waged through Narratives lead by by Republican and Democratic leaders, their influencers in media, and everyday Americans. We used data from thousands of sources to see precisely who is set to win the Narrative Battle and why.

If we look deeper within the text of a Narrative, we can break it down into the lens of a traditional four-part story with heroes, villains, and a call to action. This helps us understand the deep-rooted beliefs and values that make up an argument or action. While a Narrative might not always catch every individual nuance, we’ve seen Narratives successfully capture the core beliefs and values about issues, topics, people, and even companies. Let’s break down the components of the Narratives we’ve surfaced in the data that are being pushed by Republican and Democratic leaders and unpack them through this four-part structure. We’ll start with the primary Republican Narrative, Skyrocketing Costs:

“The Republican Party always opposed the Affordable Care Act, but it was forced through Congress without their support. When the Obama administration tried to implement the flawed policy across the country, it was bound for failure. As a result, premiums for millions have skyrocketed, our national deficit has increased, and insurance providers have pulled out of state markets because they’re losing money and are unsustainable in the long-term. The ACA is broken and must be repealed and replaced with a fiscally responsible alternative.”

Cost is the central theme of the Narrative, with an emphasis on the fundamentals of the Affordable Care Act being broken and financially untenable. This comes together with real-world costs of implementation impacting a broad array of heroes: individuals, companies, and even the government itself. The concept of excessive cost and the ACA itself seem to be the critical villains, rather than a person or group. Here’s an example of President Trump pushing this narrative in the Washington Post:

“The best thing politically is to let Obamacare explode.” The president said that the law remains “totally the property of the Democrats” and that “when people get a 200 percent increase next year or a 100 percent or 70 percent, that’s their fault.”

While the President was quoted after the Republican replacement for the ACA first failed to pass in the House, the President attaches the Democratic Party to the Skyrocketing Costs narrative as an additional villain. Now let’s examine the main Democratic narrative Playing Politics over Patients:

“Before the Affordable Care Act, millions were denied healthcare due to cost or pre-existing conditions. The system needed to be changed and passing the ACA not only created opportunity for those people, but it saved lives. Now despite Republican opposition, the ACA is more popular than ever as millions of Americans today rely on it for affordable and lifesaving healthcare. The ACA must be protected from President Trump and Republicans who want to repeal it for shortsighted political gain.”

People who need healthcare are the primary hero in this Narrative. While patient outcomes are central in its call to action, the Democratic Narrative also frames President Trump and the Republican Party as the villains, attaching them to outcomes related to the ACA’s repeal. Here’s an example of Democrat House Minority Leader Nancy Pelosi amplifying this narrative to CNN:

“Instead of focusing on jobs and wages, Republicans have decided to launch an all-out assault on affordable healthcare in America. Their plan is to repeal the Affordable Care Act, slash Medicaid, and destroy the sacred Medicare guarantee that has protected generations of Americans. The Republicans' plan won't make America great again. It will make America sick again.”

It’s clear in the quote from House Minority Leader Pelosi that there is an emphasis on patient outcomes in the Narrative, alongside the characterization of the Republican Party as a villain. As we’ll discuss later, the ultimate buy-in and amplification of this Narrative by non-Democratic stakeholders are key to its impact and resonance.

Leveraging a machine learning model, we classified every story within our data set to capture and calculate Narrative Impact, a measure of the overall influence of a Narrative in a landscape based on its share of volume and engagement. With this measure alone, it’s evident that the Democratic narrative, Playing Politics with Patients, is winning the narrative battle capturing most the conversation at 56 percent compared to Skyrocketing Costs which only holds two percent of impact. The Narrative Take ACA Even Further, which focuses on replacing the ACA with a single payer system, has a larger share of impact at three percent, again also larger than the sole Republican Narrative. 

While politics is central to this landscape, conversation about the adverse effects of the ongoing battle over the ACA repeal also has a large share of impact. These neutral Narratives, which aren’t pushed by either political party, examine the other aspects the battle over the Affordable Care Act has on American society from direct impacts on the healthcare industry itself to broader knowledge disconnects about the ACA from American voters. 

Despite the differences in focus, the Narratives are driven by both events and party messaging. The starkest indicator of this is the spikes in both the Republican and Democratic share of Narrative Impact just before the anticipated House vote to repeal the Affordable Care Act and replace it with the Republican designed American Healthcare Act. In both Republican and Democratic Narratives, consistent volume of the message over time is key, while we can see this over the course of the last three months, it’s evident that Democratic messaging is consistently higher in volume and impact.

A final critical key distinction between Democratic and Republican messaging is who amplified the Narrative. The primary speakers pushing the Republican Narrative were President Trump and House Speaker Paul Ryan. While Democratic leadership like House Minority leader Nancy Pelosi and Senator Chuck Schumer amplified the Democratic message, their overall Narrative footprint was low compared with Republican leadership. 

President Trump has the highest individual Narrative footprint, which is expected, but what is critical to note is that alongside Speaker Ryan, Republican leaders have a greater overall impression within their own Narratives compared to the Democratic leaders. Nancy Pelosi and Chuck Schumer have a significantly smaller Narrative footprint across all conversations. Rather than Democratic leadership, American protestors further amplified the Playing Politics with Patients Narrative in interviews across the country, representing some of the highest impact stories in the data set. This quote from the New York Daily News captures a perfect example of this:

“Protester Gabriel Cohen, 55, a freelancer and part-time professor, said he would have been dead if not for Obamacare. “The ACA saved my life. Because of the ACA I was finally able to afford health insurance,” he said. “Shortly after that a swollen lymph node was found in my neck. It was stage III Hodgkin's lymphoma."

This key party difference in who delivered the message is perhaps part of what dictated the success of the Democratic Narratives over the Republican Narrative. Yet while volume and impact are absolutely critical for winning a Narrative Battle, message resonance--particularly how real people react to a Narrative--is the true indicator of Narrative success. While it’s clear the volume of people amplifying the Democratic Narrative is higher, it’s crucial to examine message resonance as well.

Often, high-volume Narratives still don’t hit the mark with their audiences. In this case, however, we didn’t see that. We broke down total social sharing of content within each Narrative category: Democratic, Neutral, and Republican, to assess just how well these Narratives connect to their audience. If we use this measure as a barometer for who is winning this Narrative Battle, it’s largely apparent that Democratic Narratives are easily dominant with more than a million total shares across social media. Republican Narratives performed significantly weaker with roughly forty-five thousand total shares.

While the repeal of the ACA was halted at the onset, it’s clear that for President Trump and the Republican Party removing and replacing the Affordable Care Act is top priority. This political battle will continue, but the ability of the President to garner legislative success hinges on whether the Republican Party can amplify their Narrative about the ACA and whether it will resonate with everyday Americans.




Edited by Alicia Young
By Special Guest
Reinhard Cate, Content Marketing Manager at Protagonist ,




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