Health Politics

POLITICS: What's The Matter With Kansas and Every Place Else?

Joanne Kenen — Wed, 14 May 2008 16:15:00 -0400

Health Affairs, as you know if you've read us or any other health policy blog this week, devoted its May/June issue to health reform, and held a forum on health politics in DC this week. (Merrill Goozner did a nice summary including an update of what the Congressional Budget Office is doing to gear up for health reform.) They also did a conference call recently summing up the political landscape with Bob Blendon of Harvard's Kennedy School and School of Public Health, Julie Rovner of NPR and Robert Laszewski, of Health Policy and Strategy Associates Inc. and the Health Care Policy and Marketplace Review blog. Here's a recap from the Health Affairs blog, and here's the transcript.

Blendon pointed out that most voters are not college-educated and will not be voting based on the minutiae of policy plans; they want a debate about the big picture on topics like health care, trade etc. Laszewski thought that John McCain was vulnerable because people wouldn't have much faith in his approach to covering the sickest, hardest to insure people; Democrats, he said, would be able to depict it as another health care "train wreck."

An interesting tidbit from Rovner who found a surprising level of support for single-payer in Kansas of all places. “It’s not just a matter of people wanting the security of what they have now. People, if anything, want to go more towards the government and less towards the market.” Rovner was “not suggesting that there is a groundswell of a majority for a single-payer system. But I am suggesting that as people see costs go up, I think they are looking more towards the government and less towards the private market as a way to protect themselves.”

(I should disclose that Bob Blendon has answered approximately one zillion questions from me over the past 15 years and taught me a great deal of what I know about health politics and Julie is my pal.)

POLITICS: Sometimes Health Reform Bills Do Pass...

Joanne Kenen — Tue, 13 May 2008 13:51:00 -0400

We've all done a lot of looking back to the lessons of 1993-94, and the long list of reasons the highly complex, ill-timed and politically-polarizing Clinton health care plan failed. But today the journal Health Affairs published an essay looking back not just at the failures of the Clinton plan but at the successful passage of two major health reform initiatives--the truly bipartisan State Children's Health Insurance Program (SCHIP) and the Medicare Modernization Act, which added prescription drug coverage for seniors.

The article, written by New America's Len Nichols, and Hill veterans Elizabeth Fowler and Christine Ferguson, acknowledges that the drug law remains controversial--a lot of Democrats don't like the basic structure of the drug benefit, and parties are still fighting about payments and changes the law makes to the overall Medicare program. But enough Democrats did back the legislation to see it enacted (barely), and some of them today acknowledge that even if it isn't the bill they would have written, even if they want to change some of it, it is helping seniors get their medication. The authors cite several reasons for its passage. Among them: President Bush took a hands-off approach to the details, letting Congress do its job of legislating. Republican Congressional leaders enforced party discipline so they held together to pass legislation that would help them politically. And, in the several years that lawmakers worked on the issue the two parties' models for delivering the drug benefit evolved to have at least some common ground.

The children's health program has been widely perceived as a bipartisan success from the outset. Clinton backed it, but Congress led the initiatve from the start. "The episode illustrates exemplary congressional leadership, a lack of partisanship, and a president leaving details to Congress while championing the basic goal and message of expanding coverage for low-income children."

Not so, however, for the second chapter of SCHIP, last year's reauthorization battle and Bush's veto. In that case, Bush rejected a bipartisan Congressional initiative and Republicans split among themselves, with the more conservative ones winning the day.

The authors conclude with three lessons (or wishes?) for next year.

Make health reform the top priority.
Be leaders, not partisans.
Develop a broad consensus, but leave the details to Congress.

Hope the folks on both ends of Pennsylvania Avenue next year, whoever they may be, are listening.

POLITICS: But Will Voters Still Love Health Policy Reform in the Morning?

Joanne Kenen — Mon, 12 May 2008 19:24:00 -0400

We hear lots of talk about health care reform and the presidential campaign, and certainly it registers in the polls. But is it resonating enough to make a difference in November—and will the next president, whoever that is, put the issue front and center if voters don't demand it?

As John Whitesides of Reuters wrote the other day:

"The sharply contrasting health care visions of Republican John McCain and his Democratic presidential rivals offer the promise of a grand campaign debate—if the candidates find room on a crowded agenda.

While health care reform ranks as the second-biggest domestic issue after the economy in most national opinion polls, it will compete with the Iraq war, taxes, high gas prices, and other topics for a prime-time spot in the campaign."

The history of public opinion and health care reform is worth recalling. It's only a slight oversimplification to say that "the public" identifies problems in the health system and demands change in the abstract. But then after hearing politicians argue about reform proposals for months, and being bombarded with critiques from interest groups, the public can end up quite change-averse. That support for abstract ideas about change becomes fear or opposition to concrete proposals. And the public tends to worry more about what health insurance means to them—can they afford it, can they count on it—than what it means to society as a whole and the uninsured. As Mollyann Brodie, the Kaiser Family Foundation's public opinion expert, told a gathering of health policy veterans recently (a few slides from her presentation below):

Goals are easy to agree upon
Solutions are hard
Change is scary

Health care is further complicated because people hold rather contradictory views—they don't trust government meddling in their heath care, but they want government to fix it. With a free lunch on the side. As Larry Jacobsen, a political scientist who studies health politics at the University of Minnesota and its Humphrey Institute of Public Affairs wrote recently in the New England Journal of Medicine:

"Health care reform efforts have been undermined not only by Americans' ambivalence toward government but also by the split between public dissatisfaction with the overall system's performance and patients' satisfaction with personal health care. Whereas more than 70% of Americans are quite negative about the country's coverage and costs, less than 40% are disappointed with their own circumstances. A mere 15% complain about the quality of care they receive."

All this suggests that public is more likely to follow if leaders have some kind of consensus among themselves on where to lead. Heated, divisive, partisan debates about complex topics tend to push voters back into a cocoon of the status quo. Only the status quo doesn't really exist anymore. Our system is hurt, and inaction will only make it worse.

Of course heated presidential campaigns aren't the best venue for working out consensus on complex social and economic policy. But on the morning after November 4th, we'd like to see the next president, whover that may be, articulating a vision and starting to build the coalitions that will give Americans the health care they need and deserve.

POLITICS: The Big Picture in Health Care

Joanne Kenen — Mon, 05 May 2008 17:17:00 -0400

With John McCain making health care a campaign theme during the past week, there's obviously been a ton of coverage in new media and old about both the proposed changes to the system and the politics of reform. The L.A. Times today has one of the clearest overviews, outlining the big picture differences between the Republicans and Democrats. It also tries to capture how the two approaches would evolve over the long-haul—not just what health care could look like if/when reform is passed but what is likely to occur in the ensuing years. It points out that the McCain plan in particular creates what New America's health policy director Len Nichols is quoted in the article as calling a "Wild West of competition." The fear is that McCain's approach and the amount of his tax credits would leave many people with only bare bones insurance policies. Not much use if you get sick—as The New York Times reminded us this Sunday in a piece on the medical costs insured families can still face when they are underinsured (which they often don't know until the bills pile up). And of course the critics of the Barack Obama/Hillary Clinton approach say it is too "Big Government."

Of course, the LA Times article by pointing out the ways in which the two parties are at polar opposites on health care comes back to the point we make frequently: reform won't happen without more bipartisan conversation, trade-offs, and middle ground. (Which exists—even McCain and the two Democrats have some points of agreement on how we should move away from the fragmented way in which we deliver care.)

P.S. The LA Times piece was by Ricardo Alonso-Zaldivar who wrote a great article last fall on how several Republicans, then still seeking their party's presidential nomination, wouldn't be able to get insurance under their own health proposals because of their cancer history. He wrote that long before we began this blog, but here's a belated link in case you missed it.

POLITICS: Mandate Confusion

Joanne Kenen — Mon, 28 Apr 2008 21:41:00 -0400

The very first day we started this blog, in March, we wrote about the mandate war between Hillary Clinton and Barack Obama, and how it was obscuring their many areas of agreement on health care. With the two Democratic candidates again beating each other up about health policy it's worth checking out Jacob Hacker's piece on The New York Times web site today (it's also available on NewAmerica.net). Hacker, a Yale political scientist and New America fellow, urges the two candidates to cool it because their health care rhetoric is only confusing voters. Hacker writes:

"So what's the main story: (1) a basic Democratic consensus about what should be done, or (2) a widening policy divide fueled by presidential ambitions? The answer is (1), but unfortunately, the reality of (2) is increasingly upstaging this welcome development. And, unfortunately, this unnecessary and self-defeating conflict could ultimately derail efforts at reform, confusing and turning off the very voters Democrats need to woo."

Clinton and Obama (and John Edwards, who was the first of his Democratic rivals to propose a health care plan) agree on an awful lot. The big difference: Clinton wants an individual mandate that everyone must have insurance. She argues that you have to get everyone into the insurance system, the healthy and the sick alike, if you are going to reform insurance markets and control costs. Obama mandates coverage only for children, although he said he wanted to take other steps that would lead to much higher rates of adult coverage. Hacker writes, "His decision seem[s] to have reflected fear of the potential backlash against an individual mandate, as well as a belief that few people would shun coverage if it were affordable and available." He also concludes that both plans would cover "all or virtually all" Americans for a relatively modest cost.

John McCain is making health care his campaign theme this week. He stresses cost containment more than coverage, and his coverage proposals are market-based. We can't have a national debate about health reform unless both sides are participating so we welcome his voice.

VOICES OF REFORM: Hospital Industry's Chip Kahn Ready to "Shake the Policy Tree"

Joanne Kenen — Mon, 28 Apr 2008 15:04:00 -0400

In 1994, he was one of the masterminds of the infamous Harry and Louise ad campaign that helped kill the Clinton health care initiative. Now Chip Kahn is trying to prepare the ground for comprehensive national reform after the 2008 elections. No more baby steps and incremental reform. Kahn wants to cover everyone. Economically, he says, we have no choice.

Kahn, currently the president of the Federation of American Hospitals, has been around Washington long enough to know that big change doesn't come easily, and that no matter how inclusive the message from whoever occupies the White House next year, partisanship is not going to dissipate like the morning dew. Far from it, he told us the other day in a friendly if not always 100 percent encouraging conversation that included words like "bludgeoning" to describe the national legislative process.

But if the political parties are as deeply, or more deeply, divided than in the early 1990s, some of the interest groups that were once metaphorically clawing each other's eyes out about health have found common ground. That's powerful, Kahn said. And it's different.

"I've been involved in some pretty strange bedfellow alliances in my time. But this is one of the strangest," said Kahn, who has been a Republican heavy-weight player on Capitol Hill and a top trade official for both insurers and hospitals.

He was referring to the Divided We Fail coalition, which has brought together big business, small business, labor and the AARP. For many of the participating groups, comprehensive health reform and coverage for all Americans has become a simple matter of economic survival, Kahn said.

Fifteen years after President Clinton unveiled his health plan, "we are at the other end of a long cycle," Kahn said. The costs trends in health care are affecting the insured and the uninsured alike, business and labor, employer and worker, both through the bills they pay directly and the costs that are shifted. "Major parts of the American economy are saying enough already... Let's have action and organize our health care system so that coverage is universal." Some of these groups voiced similar sentiments in the early 1990s, but "they are coming together in ways they didn't before, and there seems to be a certain will to carry it through." Both big and small business groups are increasingly seeking comprehensive reform to end the inefficiency and the "hidden tolls and taxes" in the system.

No details are on the table yet, and it's the details, Kahn said, "that tend to scatter people asunder in healthcare reform." But for the moment, they are "willing to get together and shake the policy tree and get some reaction." Besides, the details are Congress's job. And the next president, whoever he or she may be, will have to provide leadership on health policy from the outset: political honeymoons don't last long nowadays, and the new president will also have an agenda crowded with the Iraq war, the housing crisis, and the economy.

"We're only at the beginning of this process," Kahn said, surveying the long road from happy coalitions to a White House bill signing ceremony. "Hope springs eternal."

POLITICS: Senate Veterans Say Now is the Moment for Bipartisan Health Care Reform

Joanne Kenen — Wed, 16 Apr 2008 20:22:00 -0400

One thing all former Senate Majority Leaders have in common: they didn't fix U.S. health care. One thing at least four former Senate Majority Leaders have in common: they want to try again and they believe now is the moment.

Two Democrats, George Mitchell and Tom Daschle, and two Republicans, Bob Dole and Howard Baker, teamed up several months ago at the Bipartisan Policy Center and they have made health their signature issue. They cited both a moral and economic imperative to address the intertwined issues of cost, coverage and quality.

"There are no easy fixes or they would have been done already," Dole said during a joint appearance with Mitchell at the National Press Club. Mitchell was only half-joking when he said that fixing health care is more difficult than bringing peace to Northern Ireland.

The four leaders, working with an experienced bipartisan team of policy analysts, plan on holding four forums during the next several months, before submitting to the next president and Congress policy recommendations that they said would be less detailed than a piece of legislation but more targeted and meatier than vague statements of principles. They won't make the recommendations public until after the elections, to avoid injecting themselves into politics. But then the next president, they said, needs to act fast before the window of opportunity closes.

The words they used were carefully selected, leaving them plenty of bipartisan wiggle room. For instance they didn't specifically come out and call for covering all Americans (although that sure felt like the subtext). Instead they said they wanted to provide "affordable accessable coverage choices in a reformed insurance market." They stopped short of calling for an individual mandate that would mean everyone had to have insurance, instead saying the goal was "ensuring and promoting a strong individual role in health care coverage and costs." They want to open a conversation, not end it.

Given that all four of them have been political brawlers in their time, it was striking to hear how emphatically they endorsed a bipartisan solution (which is what we tell anyone who will listen—and some who won't.). Sixty votes -- at a minimum -- will be needed to get legislation through the Senate, they said. And if there's one thing that these four men know better than anyone, it's what it takes to get, or not get, legislation through the U. S. Senate.

"I'm optimistic now that there is a now a real will to act," said Mitchell, who since retiring from the Senate in 1995 has not taken on a project unless he meant business, whether seeking peace in Northern Ireland or rooting out steroids in baseball. He said he believes that this country has reached the point on health care where "there's a hunger for change." He described a near-unanimous consensus that the system has "deficiencies and failures" and he said that feeling is getting so powerful that it's poised to create a second consensus around how to repair it. We can't wait.

VOICES FOR REFORM: Dispel the Myths, Seek the Center

Joanne Kenen — Thu, 03 Apr 2008 15:56:00 -0400

Everyone's talking about health reform after the elections. How do we get there?

Drew Altman, CEO of the Kaiser Family Foundation, outlines four steps to make it happen.

First, health care has to figure big in the November election. If Iraq, the economy or other issues eclipse health in the mind of voters, the odds of progress are diminished. (Yes health care and economic anxiety are related, but it's too soon to know how they will be linked in voters' minds come November )

Second, we'll need presidential leadership. For health reform to stand a chance "a new president will have to make it an early and top priority and exercise real leadership," Altman writes. The temptation might be to focus on unfinished business, such as the State Children's Health Insurance Program. That would be a step (or two or three) forward, but it isn't comprehensive national reform.

Third, we'll need compromise. Genuine, bipartisan, centrist, give-and-get compromise. "No matter who is in the White House or what the margins are in the Senate, it is very unlikely that the deep divisions about how to reform our health care system between left and right will have been transformed enough to support passage of legislation that will entirely satisfy either liberals or conservatives. Health care's ideological divide is too deep." A Democrat in the White House would mean tilting a bit leftward, and a Republican would mean going a bit rightward, but the center has to hold through the ideological fights as well as the clashes over financial winners and losers in a transformed $2 billion health care system.

Finally, from now through at least November, we've got to talk (not shout), educate, learn and listen. Our task is to "establish the facts and dispel myths." And for policymakers, that means not only listening to each other but to the public. What do ordinary people experience when they get sick? What do they worry about? How do they see health care costs and care tying into their growing economic anxieties? We'll have plenty of time to fight about the details next year. But let's do the groundwork now.

(Quick disclosure: I was a media fellow at the Kaiser Family Foundation last year.)