Health Care Still Vital Issue in 2008 Campaign

The Kaiser Family Foundation has been issuing quarterly tracking polls on the issues voters want presidential candidates to address. Health care has been the top domestic issue voters are focused on (Iraq has been the top issue). But now that the mortgage crisis, gas prices and a faltering stock market has had more time to impact family’s sense of financial security, the economy has taken on greater importance to voters.

In the March 2008 Kaiser Health Tracking Poll 45 percent of the voters listed the economy as one of the two issues they would most like to hear presidential candidates talk about. 32 percent of the voters listed Iraq and 28 percent mentioned health care. Immigration followed with 14 percent, education with seven percent and terrorism six percent.

The economy topped the list for Democrats, Republicans and Independents alike. For Democrats, however, health care was the second most mentioned issue followed by Iraq.

In the Kaiser poll published in December 2007, Iraq was the top issue, mentioned by 35 percent of those surveyed, followed by health care mentioned by 30 percent and then the economy, cited by 21 percent of the participants. Democrats, Republicans and Independents all ranked the top three issue in this order.

When asked what single issue will most drive their choice for the next president, the economy was at the top of the list for all voters, Democrats, Republicans and Independents. For Democrats and Independents, the next two issues were Iraq and health care; for GOP voters it was terrorism and Iraq.

In March, the top issue for all voters was Iraq, followed by the economy and health care for Republicans and Independents, while Democrats selected health care and the economy as their next two most important issues.

While the economy has supplanted health care as the top domestic issue among voters, health care is still a powerful issue. However, health care costs are a factor in how people feel about the economy. 10 percent of voters cited health care costs as the single most important economic issue facing you and your family. This trailed inflation (26 percent), high taxes (13 percent), and the price of gasoline (11 percent), but it was higher than items like problems getting a good-paying job or a raise in pay (nine percent) and the cost of housing (six percent).

Health care reform remains a critical issue, especially among Democrats and Independents. When evaluating health care reform proposals, 58 percent of what the Kaiser Foundation calls “health-focused voters” want to provide health insurance for nearly all of the uninsured, even if it involves a substantial increase in spending. 30 percent support a more limited plan that would cover only some of the uninsured, but involve less spending.

In 1992, the sign in the Clinton campaign war room read “It’s the economy, stupid.” What’s less well known is the addendum to the sign that read, “And it’s health care, too.” History looks like it’s repeating itself (although this time it may not be a Clinton war room). While Iraq will remain a critical issue, the economy and health care are even more relevant to voters’ decisions. That could change, but barring a terrorist attack on American soil, the voters are increasingly focused on the economy and remain strongly interested in the candidate’s positions on health care.

In other words, future debates will sound a lot like the recent debates. 

Congressional Health Care Reform Plan Waiting for New President

During their Ohio debate Tuesday night, Senator Hillary Clinton and Senator Barack Obama spent the opening 16 minutes diving deep into the minutia of their health care reform plans. The public has heard the debate many times before. One might be forgiven for believing the differences actually matter. They don’t.

The reality is that health care reform will be a top priority for either of these candidates should they gain the White House. What plan eventually emerges will be negotiated, compromised and updated so much and so often, it may bear little resemblance to the proposals Senators Clinton and Obama have put on the table. And that’s fine. No one has the secret formula. Crafting the best health care platform for America should involve a great many people not yet heard from.

Then there’s the health care reform proposal already waiting for the new president. Sponsored by Democratic Senator Ron Wyden and Republican Senator Bob Bennett, the Healthy Americans Act is the most bi-partisan and prominent bill stewing in the current Congress — or any recent one, for that matter.  Supported by a dozen senators, six from each party, in many ways it goes much further than the plans being promoted by the Democratic presidential candidates. And compared to Senator John McCain’s market-based reform plan, it’s downright radical.

Twelve percent of the Senate is a long way from a majority. But it’s a start. Even Senators Wyden and Bennett don’t agree with every aspect of their bill. The plan requires all Americans to buy coverage. It does away with the preferential tax treatment of employer-based coverage, forcing individuals to purchase their own coverage through regional purchasing pools. While it’s not a single-payer system, those pools do mean multiple governmental agencies will be running the show.

The Healthy Americans Act is, as it stands, seriously flawed. But that’s not the point. The details of this legislation don’t matter any more than the specifics of the candidate’s proposals. What matters is the existence of a bi-partisan coalition of Senators waiting for a president who is serious about building a consensus to appear on the scene. That’s fertile ground for a serious debate and equally serious negotiations about a complex and vital issue. And that’s good news.

Seeds of 1993 Health Care Plan Defeat Planted by Clinton

At the Democratic debate in Austin last week, Senator Hillary Clinton declared her experience in the 1990s in developing and promoting health care reform would serve her well if elected president. She claimed it would help her stand up to the special interests. Senator Barack Obama responded it was her approach to health care reform that doomed the effort. He is right. She is wrong.

Senator Clinton blames special interests, especially the insurance companies, for defeating the health care reform package she developed for her husband’s administration in 1993-94. There’s some merit to the claim. Tens of millions of dollars went to lobbying, advertising and organizing against the proposal. But while that level of spending would have made passage more difficult, if the plan had been well conceived and well promoted it would not have been enough. With Democrats in the White House and controlling Congress, the right plan, developed and sold in the right way should have been successful. And that was the problem. Under now-Senator Clinton’s leadership, the plan was developed in secrecy and presented to the public and decision makers with unforgivable ineptitude.

Senator Clinton talks a lot about reaching out to all points of view to fashion consensus policies and programs. Now. Then, however, it was her way or the highway. In late-1992 she began assembling a large group of very smart people to develop her health care reform package. They sequestered themselves in Washington and talked among themselves. Occasionally they’d seek input from outsiders. But like Ken Kesey’s Merry Pranksters, you were either on the bus or off the bus. And if you were off the bus, your opinions didn’t matter.

This created two problems. First, developing policy in an echo chamber rarely works. The results may look good when considered in a vacumn, but when exposed to the real world, one flaw cascades through the interwoven assumptions, reducing the whole to dust. The Clinton health care plan of 1993 and 1994 was beautiful to behold, an exquisite example of theoretical policy. It was also fragile. Because the Clinton administration was unwilling to accept advice or input or, heaven forbid, changes, from the outside, it lacked a foundation to withstand deep scrutiny. Much to the surprise of the Clinton health care working group, their plan was flawed. And those flaws led to the unravelling of the whole.

Second, excluding members of Congress from the process was just stupid. By ignoring even Democrats in Congress, there was no one at the other end of Pennsylvania Avenue who had any stake in the outcome. In fact, it merely engendered hostility. I participated in three Congressional hearings, representing the National Association of Health Underwriters (NAHU is an association for health insurance agents and other professionals). None of the questioning dived deeply into the Clinton health care plan. There was plenty of questions concerning other reform proposals, but our criticism of the Administration’s plan was pretty well accepted by the Congressional panels.

The lack of an open process is one of the reasons Assembly Bill X1-1 failed in the California legislature. To their credit, the staff of Governor Arnold Schwarzenegger consulted with far more “outsiders” than the Clinton health care task force. But these were seriel discussions held in private. No one really knew what the entire package looked like until months into the Year of Health Care Reform. As a result, when the legislation reached the State Senate, there were few there who had a stake in its passage. When faced with the state’s budget crisis, it was easier for them to let health care reform slide away.

The lesson is clear: developing health care reform requires an open, inclusive process. Every opinion and perspective needs to be represented. Senator Obama gets this. Unlike Senator John Edwards, who claimed he wouldn’t let the insurance industry participate in developing his health care reform legislation, Senator Obama said they’d have a seat at the table, they just wouldn’t be able to buy them all.

It’s this approach to openness and collaboration that holds the greatest promise of success. Senator Clinton tried the old way. It didn’t work. Her continuing the blame the special interests instead of her own mistakes for the defeat of the Clinton Administration’s health care plan shows she may not have learned the right lesson. And that’s another reason she’s no longer the frontrunner for the Democratic nomination.

Candidates Need to Address the Real Health Care Reform Issue: Cost

Senators Hillary Clinton and Barack Obama have agreed to two debates before the critical Ohio and Texas presidential primaries. They’ll face off on February 21st in Austin, Texas and then meet again, just five days later on the 26th, in Cleveland. At both sessions Senator Clinton will go after her rival’s health care plan for failing to seek universal coverage. After all, she’ll remind viewers yet again, universal coverage is a moral obligation of society and a litmus test for real Democrats. Been there. Done that. Now it’s time for a new discussion on health care reform.

Health care reform is complicated, complex and challenging, but at its core it boils down to two issues: access and affordability. Access is actually the easier of the two for politicians to address. Just promise voteres they’ll be covered and, if at all possible, avoid talking about what that coverage will look like. If you must address the benefit package, say it will be similar to”fill in the blank” — Medicare, Medicaid, Congress’ health plan, Canada’s. Everyone will assume it covers what they want it to cover. (How many people know prescription coverage is not covered in most Canadian provinces?)

Controlling skyrocketing health care costs is a lot tougher. But as Congressional Budget Director Peter Orszag has made clear, it’s absolutely critical to the country’s financial wellbeing. Yet the topic makes politicians uncomfortable. They have to talk about voters getting the coverage they need, not everything they want. It means tough choices about what’s the responsibility of the coverage provider (whether it’s a private insurance company or a government agency) and what’s the responsibility of individual Americans. It requires explaining what is driving the costs — not only an aging population and new technologies, but consumer expectations, as well. There was a time when a drug addiction was dealt with by the criminal justice system; now it’s a medical issue. It means addressing America’s life style and pointing out that America’s obesity rate is 30 percent higher than Canada’s. That’s a harsh statement to make when you’re going after the couch potato vote. 

During previous debates, the candidates have gotten a free pass on addressing the issue. They’ve made vague references to how they’d reduce medical costs, but I don’t think there’s been a single follow-up question on the topic.

That should change — and it might. The Austin debate is hosted by CNN. On the channel’s Anderson Cooper 360 Degrees on Tuesday night, the pundits actually acknowledged the importance of addressing health care costs, lamenting the candidates’ failure to address the issue.

Was anyone at CNN watching CNN at the time? It’s a 24-hour news channel. CNN and its competitors have to put something between all those commercial breaks. If getting the candidates to talk about controlling medical costs, make them talk about it. Devote a 30 minute segment to the cost control provisions in the both the Democratic and Republican candidates’ health care reform packages. Ask them what ideas they are they pushing and which ones they won’t even consider. Ask them to discuss rationing. Make them describe the sacrifices they’d ask of Americans.

And those debates? CNN is hosting the one on February 21st. Maybe CNN could bring up this issue then?

There’s no need for CNN’s talking heads to lament the candidates’ failure to address an issue: they have the power to force them to discuss it. And they should.

Obama’s Health Care Reform Plan Out of Balance

Senator Barack Obama has been on the defensive concerning his health care reform proposal for much of the past several months. Senator Hillary Clinton and, while he was in the race, former Senator John Edwards pounded Senator Obama for failing to seek universal coverage by mandating Americans to obtain health insurance. If you don’t start off with a plan for universal coverage, Senator Clinton claims in nearly every speech she gives, you won’t get it. She goes further, claiming universal coverage is a moral obligation of the nation and a litmus test Democrats.

Senator Obama counters that Senator Clinton would have to garnish wages to force people to buy coverage. He notes that Senator Ted Kennedy, the dean of Congressional health care reformers, is comfortable enough with the Obama approach to endorse the Senator. Finally, Senator Obama claims his reform package, by lowering  the cost of coverage, will result in Americans getting covered because they will finally be able to afford it.

Unfortunately for Senator Obama, his logic doesn’t hold up to any meaningful scrutiny. Virtually every study done shows Senator Obama’s approach resulting in fewer insured Americans than does Senator Clinton’s. Arguing that they’re equal in terms of “universal coverage” defies logic and experience.

But there’s a worse gap in in Senator Obama’s health care reform plan: his refusal to consider a mandate to buy coverage, coupled with his plan’s inclusion of requirement that carriers sell policies to all applicants, undermines his claim to making coverage more affordable. The carrier mandate (often called “guarantee issue”) raises the cost of insurance unless all residents are required to buy. That’s how New York and New Jersey approached health care reform — carriers there have to sell to all comers, but the purchase of coverage is voluntary. The result: premiums are twice as high in those states than in California.

This shouldn’t come as a surprise. Imagine a system in which homeowners could wait to buy fire insurance until after their house burned down. Or one in which drivers could wait until after their accidents to buy car insurance. The cost of these policies would be astronomical. After all, if consumers can avoid paying a premium until they need the coverage, they’ll wait. That’s not being irresponsible, that’s human nature.

There’s no reason to think introducing this imbalance nationally will produce any other result when it comes to health insurance. Without including both, a mandate for carriers to sell and for consumers to buy coverage, Senator Obama’s plan will increase health insurance costs in spite of other provisions in his reform package.

Senator Obama no doubt is aware of this reality. He may be in denial about it, but he’s bright and so are the people around him. In an ideal world he’d address the imbalance in his health care reform plan now, during the primaries. But doing so would open him to charges of flip-flopping. It would demonstrate that Senator Clinton’s experience dealing with health care reform led her to a more responsible conclusion (at least on this aspect of their plans). Senator Obama might be interested in bringing a new approach to politics, but even he’s not ready to hand his opponent a cudgel on an issue as important to voters as health care reform.

My guess is he’ll wait until after he’s secured the nomination — if he does, indeed, secure it. Then, sometime in the summer he’ll introduce a willingness to consider guarantee issue in combination with an “affordability exemption” to assure it doesn’t bankrupt consumers. And if it doesn’t happen during the campaign, guarantee issue is certain to find its way into his Administration’s reform package.

If Senator Obama is lucky, Senator Clinton will continue to level only the “lack of universal coverage charge” against him. That line of attack is getting old, but she seems unwilling to abandon it, even though she’d be far better served by forcing Senator Obama to defend an indefensible imbalance in his plan.  

Clinton and Obama on Health Care Reform: 95% the Same

Health care reform was one of the few issues on which Senators Hillary Clinton and Barack Obama tried to differentiate themselves during their debate tonight. They acknowledged substantial similarities in their plans. Senator Obama went so far as to describe them as being “95 percent” the same. Both candidates call for the government to offer consumers an alternative to the private market, for example.

When compared to the health care reform packages offered by the Republican candidates  (which rely more on market reforms and avoids extensive government intervention) the Democratic Senators’ proposals are virtually indistinguishable. But campaigns are about choices, so they emphasized the five percent.

Senator Clinton’s proposal seeks to provide universal coverage by requiring health plans to accept all applicants and all residents to buy coverage. Senator Obama focuses on reducing the cost of health care coverage. As I’ve written before, this tension between access and affordability mirrors California’s recent health care reform debate.

The candidates described their differences in stark terms, as a seemingly irreconcilable chasm between them. In reality, while differing in emphasis, these two approaches are not really either-or propositions. They’re complimentary. Don’t take my word for it — ask my son.

He turned 13 a few weeks ago. Health care reform is not high on his list of interests. However, he’s recently gotten interested in the primary so he joined me tonight to watch the debate. As Senators Clinton and Obama went back and forth on their reform packages, he asked me what the argument was about. Thanks to the miracle of DVRs I was able to pause the debate and explain. We resumed watching and, after another couple minutes of the candidate’s throwing health care statistics around he grabs the remote, presses pause and exclaims, “This is so stupid. First you make it affordable and then you make sure everyone buys it.”

So, now that we’ve got that resolved, I’m going to have him start work on creating the Democratic party’s position on immigration. 

Pre-Super Duper Tuesday Presidential Survey Now Open

With the presidential crowd thinning and Super Tuesday on the horizon, I thought it was time for another unscientific presidential survey. And this time you get to vote in some hypothetical general election match-ups.

It only takes a minute to complete and it’s anonymous. The survey is over on the Alan Katz Politics blog, but if you want a short cut, just click here. The survey will remain available until 5:00 pst on Tuesday, February 5th.

Presidential Survey Results are In

The survey results are in and statistically –there’s a lot of ties. You can take a look over at the Alan Katz Politics Blog. 
Added January 29th, 9:00 pm.

Not That Obama Needs My Advice

Senator Barack Obama got hammered by Senator Hillary Clinton and former Senator John Edwards on his health care reform proposal at their debate earlier this week in South Carolina. Senator Obama’s focus is on making coverage affordable; Senators Clinton and Edwards emphasize universal coverage. If he continues to let his opponents define the debate this way they win and he loses.

For those who might find it interesting, I discuss how what happened in California provides a way for Senator Obama to reframe the Democratic debate on health care reform over at the political blog.

Democrats Debate Access versus Affordability in South Carolina

Health care reform was a hot topic during the presidential candidate’s debate in South Carolina on Tuesday. Senator Hillary Clinton and former Senator John Edwards claimed universal coverage was the most important priority while Senator Barack Obama put affordability at the top of his list. This dichotomy mirrors the debate California experienced with Governor Arnold Schwarzenegger insisting on coverage for all and the legislature’s Democratic leadership questioning the fairness of requiring individuals to buy coverage they couldn’t afford.

I’ve written more about this somewhat strange, but probably not surprising, echo of California’s health care reform debate on the political blog.