1 THE RHETORIC OF REFORM: EXAMINING THE ROLE OF POLITICAL LANGUAGE IN RHODE ISLAND’S HEALTH CARE DEBATE A dissertation presented by Kevin P. Donnelly to The Department of Political Science In partial fulfillment of the requirements for the degree of Doctor of Philosophy in the field of Public and International Affairs Northeastern University Boston, Massachusetts August 2009 2 THE RHETORIC OF REFORM: EXAMINING THE ROLE OF POLITICAL LANGUAGE IN RHODE ISLAND’S HEALTH CARE DEBATE by Kevin P. Donnelly ABSTRACT OF DISSERTATION Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Public and International Affairs in the Graduate School of Arts and Sciences of Northeastern University, August 2009 3 ABSTRACT Political language refers to the way in which public policy issues are portrayed, discussed, and ultimately perceived by the community at large. Focusing specifically on two case studies in Rhode Island—the efforts of two policy entrepreneurs to enact comprehensive health care reform, and Governor Donald Carcieri’s successful pursuit of a Medicaid “Global Waiver”—this thesis begins with a description of the social, political, and economic contexts in which these debates took root. Using a “framework of analysis” developed for this thesis, attention then centers on the language employed by the political actors involved in advancing health care reform, along with the response of lawmakers, organized interests, and the public. A major finding is that the use of rhetoric has been crucial to the framing of policy alternatives, constituency building, and political strategy within Rhode Island’s consideration of health care reform. In addition, statistical analysis of original survey data shows that political language orientations are related to the public’s policy preferences, a fact that has long been assumed but seldom investigated empirically. 4 ACKNOWLEDGEMENTS This dissertation would not have been written were it not for the guidance, support, and tremendous amount of time given to me by Professor David A. Rochefort. Throughout my time at Northeastern University, Professor Rochefort has served as an advisor, mentor, and close friend, offering encouragement and advice to steer me through the highs and lows that come with pursuing a doctoral degree. I will always be grateful for the role Professor Rochefort has played in shaping me as a scholar. I also want to extend my sincere appreciation to Governor Michael Dukakis and Professor John Portz, both of whom gave generously of their time as part of my dissertation committee. Their contributions and insight have been invaluable in developing and advancing my dissertation work. I want to express a special note of gratitude to my wife, Meghan, whose unflinching support extends far beyond this dissertation. Throughout my graduate career Meg has made substantial personal sacrifices, read and edited every paper I ever wrote, and endured countless hours of my absence. More importantly, it is her thoughtful perspective and loving reassurance that enabled me to go confidently in the direction of my dreams. I also want to thank my Mom and Dad, who instilled in me the belief that I could accomplish anything I set my mind to. The support and encouragement they have given me throughout my life made the completion of this dissertation possible. 5 Finally, I would like to recognize the generous financial support provided by Learn and Serve America, Neighborhood Health Plan of Rhode Island, Northeastern University’s Community-Based Research Initiative, and Northeastern University’s Department of Political Science, without which the administration of a public opinion poll that was vital to my dissertation research would not have been possible. 6 TABLE OF CONTENTS Abstract 2 Acknowledgements 4 Table of Contents 6 Chapter 1: Political Language: A Framework of Analysis 9 I. Developing a Model of Political Language 9 II. Political Messengers 11 A. Political Leaders 12 B. Policy Entrepreneurs 15 C. Organized Interests 17 D. The Media 20 III. Political Messages 22 A. Issue Framing 23 B. Problem Definition 25 C. Symbolism 29 D. Storytelling 31 IV. Political Response 34 A. Public Opinion 38 V. Political Language and Health Care Policymaking 40 VI. Thesis Methodology 46 VII. Conclusion 49 Chapter 2: Rhode Island Politics and the Emergence of Two Health Care Reform Initiatives 54 I. Rhode Island Politics: A Primer 55 II. Rhode Island’s Health Care Landscape 62 III. The Emergence of Comprehensive Health Care Reform 71 A. Background 72 B. Application of Kingdon’s Agenda Access Model 79 The Problem Stream 79 The Politics Stream 83 The Policy Stream 85 IV. The Emergence of Medicaid Reform 86 A. Background 87 7 B. Application of Kingdon’s Agenda Access Model 90 The Problem Stream 90 The Politics Stream 91 The Policy Stream 93 V. Conclusion 95 Chapter 3: Policy Entrepreneurs and the Language of Comprehensive Health Care Reform 101 I. Methodology 103 II. An Introduction to Rhode Island’s Health Care Reform Policy Entrepreneurs 105 Lieutenant Governor Elizabeth Roberts 105 Dr. Nick Tsiongas 107 III. Diverging Approaches to Reform 109 Lieutenant Governor Roberts 109 Dr. Nick Tsiongas 115 IV. The Political Messages of Rhode Island’s Policy Entrepreneurs 120 Lieutenant Governor Roberts 120 Dr. Nick Tsiongas 129 V. Conclusion 134 Chapter 4: Rhode Island’s Medicaid Waiver Debate 141 I. Methodology 144 II. A Review of the Governor’s Waiver Proposal 145 III. Political Messengers 149 A. The Carcieri Administration 150 B. Opponents of the Waiver 152 IV. Political Messages 154 A. The Carcieri Administration 155 B. Opponents of the Waiver 165 V. Coverage of the Waiver Debate in The Providence Journal 175 VI. Political Response 185 VII. Conclusion 189 Chapter 5: Political Language and Public Opinion in Rhode Island 196 I. Methodology 198 II. An Overview of Public Opinion on Health Care 8 Reform in Rhode Island 200 III. Review of Political Language Items 215 IV. Exploring the Link between Political Language and Policy Preferences 227 V. Conclusion 234 Chapter 6: Orwell and Beyond 239 I. Principal Findings 240 II. Future Research Directions 247 III. Orwell Revisited 251 Appendix A 260 Appendix B 266 Appendix C 268 9 —Chapter 1— Political Language: A Framework of Analysis Language is integral to the human experience. The words we speak enable us to communicate ideas, relate to one another, express emotions, persuade and dissuade each other, and even process thoughts. Language touches every aspect of our lives, and the words we choose—whether deliberate or not—shape our laws, institutions, policies, and politics. Political language refers to the way in which public policy issues are portrayed, discussed, and ultimately perceived by the community at large (see Beard, 2000, among others). The study of language in the political realm rests on the assumption that the dynamics of public discourse play a powerful—and often overlooked—role in shaping the public policy process (see Elder and Cobb, 1983; Edelman, 1988; Rochefort and Cobb, 1994; Stone, 2002). Research in this area is very much an interdisciplinary field of study, drawing on concepts from sociology, linguistics, cognitive psychology, political science, and other fields. As a result, the political language literature is highly compartmentalized and rather difficult to apply in a systematic fashion. In this study, a holistic “framework of analysis,” integrating the conceptual tools developed in a range of disciplines, will be used to explore several questions related to how political language has shaped health care reform policy in the state of Rhode Island. I. Developing a Model of Political Language Scholarly literature related to the use of political language can be categorized into three broad topics of interest: the messenger, message, and response. The “messenger” refers to individuals and/or groups who are communicating, as well as their resources, 10 motivations, and the intended purpose of their use of language. The “message” represents the content of the language itself. Lastly, the “response” refers to the influence of language on political thought and public policy. Despite a proliferation of research related to each of these core components of political language, and the fact that they are vitally interconnected, there has never before been an integrated analytical framework that ties together the conceptual tools that have been developed in these research areas. The need for this type of holistic framework of analysis is great. While much can be gained by simply studying the language used in the political sphere, without taking into consideration the motivations, goals, and resources of those who are communicating, as well as the ultimate impact of those words, it is not possible to capture the full scope of political language. Figure 1 represents not only the three critical elements of the study of political language, but also—and perhaps more importantly—their overlapping nature, the details of which will be elaborated on in the pages that follow. Messenger Message Response Figure 1: A Holistic Model of Political Language 11 II. Political Messengers Political messengers are those groups and Messenger individuals who create and advance political messages for public consumption. These drivers of political language Message Response come in a number of forms, but can be broken down into four main categories: political leaders, policy entrepreneurs, organized interests, and the media. Sometimes the messages delivered by