John Carroll

As we enter a year with a congressional election, candidates are unlikely to stir things up with imaginative, comprehensive proposals

John Carroll

Late last year, Emily's List, a group of "pro-choice" Democrats, unveiled the results of a survey it feels clearly lays out a simple strategy on how that party's candidates around the country can benefit from the way independent women voters view health care in the run-up to the mid-term elections.

If candidates promoted their commitment to affordable health care as an example of their respect for family values, the group asserted, they would be likely to hit a chord not only with independent women voters, but with Republican women with weak ties to their party. And this was no marginal change: Health care and prescription drug affordability combined ranked number one on the survey's list of concerns for women — ahead of Iraq, education, and the economy.

"Women need to hear it not just from the prism of economic issues, but the prism of family values," says Karen M. White, national political director of Emily's List. Sure, affordability of drugs and insurance coverage are both basic pocketbook issues, she adds, "but you have to talk about it. Say, 'We value families enough. I have a plan to make sure this is a part of my values platform.'"

What Emily's List (there never was an Emily; it's an acronym for "early money is like yeast," meaning that candidates who start off with a lot of dough are to be envied) didn't suggest, though, was any idea of what that plan should be. That, says White, is up to individual candidates. "Every candidate, I think, will focus on what she believes is best for her campaign."

For years now, the conventional wisdom in Washington has held that health care affordability is one of the biggest, if not the biggest, issue that would collar voters for the Democrats. (A recent Wall Street Journal/NBC News poll placed health care behind the war but ahead of the economy among voters' key concerns.)

But ever since the Republicans won the political trifecta and gained control of the House, the Senate, and the presidency, there's been little solid evidence that the Democrats have been able to capitalize on that connection to their advantage — at least not in big enough numbers to alter the balance of power in Washington, D.C.

"When you ask people what they're worried about, health care costs almost always tops the list these days," says Larry Levitt, Kaiser Family Foundation vice president. But even though they're worried about it and rate it high, "That hasn't translated into making it a voting issue."

"I think it does seem that issues of affordability are at the top of the heap in terms of the policy agenda," agrees Glen Mays, PhD, associate professor and director of health policy research at the University of Arkansas for Medical Sciences. Methods of determining how best to cut Medicaid and Medicare costs will continue to demand congressional attention, he says. And the most likely outcome of the election will be a slight shift in the political mosaic that will leave Congress looking for incremental improvements that can achieve bipartisan support — such as pushing for an expansion of disease management programs to save money for federal health programs.

"Hodgepodge of ideas"

Aside from that, adds Mays, Congress after the 2006 elections is unlikely to settle for whatever marginal advances President George W. Bush is likely to gain for his primary strategy of using tax reform to push health savings accounts and enhance affordability. But don't look to Democrats to push anything comprehensive that demands a confrontation over major changes.

"It's kind of a hodgepodge of ideas floating around," says Mays about the Democrats. "Most of the energy is focused at the state level, such as Maine with its new health insurance plan, Dirigo Health. Democrats are likely to support state-based solutions aimed at expanding coverage, reducing costs."

Incremental changes

He continues, "There's not a lot of new ideas floating around in this cycle and for that reason, incremental strategies — building on existing policy options that are on the table" — are the most likely ones to gain acceptance.

Aside from a shared emphasis on health care affordability by both parties, these analysts don't expect candidates to advance bold new ideas or dramatic solutions. Therefore, it's unlikely that voters will be moved by political talking points that don't come tied to specific proposals.

"On the one hand, it's a bit perplexing," adds Levitt. But it's also hard to deny. In 2004, exit polls put health care far down the list of voting issues. "There's a lot of agreement on the problem," he adds, "but not a lot of agreement over what to do about it, which makes it harder to translate into a voting issue."

President Bush has signaled his intention to hew to a theme that he has stuck to throughout his term in office: fine-tuning the tax benefits to make insurance more attractive and rejecting any effort to raise tax barriers. And should anyone question his willingness to help out the elderly, there's the new Medicare Part D to point to.

Al Hubbard, the president's economic adviser, told reporters recently that you can forget about taxing health benefits worth more than $11,500 a year for families, as the president's own tax advisory panel on so-called "Cadillac" health care policies urged.

That's a clear win for America's Health Insurance Plans, which wants to see the administration help make plans more affordable and has championed HSAs as one way to do that.

Bush has already called on Congress to expand the tax benefits available to health savings accounts, making the tax-sheltered health savings, tied to high-deductible health plans, more attractive. In the lead-up to releasing his administration's new budget this year, Bush has reportedly also decided to push to make it easier for individuals to deduct health care expenses and to prod Congress to make it easier for people to move from job to job without changing their insurance plans. And he's also likely to push to make providers' pricing and quality data more accessible as well, something that Medicare Administrator Mark McClellan has been promoting through a variety of new programs. That policy approach is likely to earn swift support from Republicans in Congress.

But some are openly skeptical that Bush and his political allies will manage to significantly broaden Republican support on that kind of agenda. "There are rumors that the president is going to make health care a more visible priority," says Ron Pollack, executive director of Families USA and a frequent critic of Bush's health care policies. "But based on past performance, that would be quite a trick. Making health care more affordable and accessible has received scant attention."

Airing grievances

Just maybe, though, enough candidates who back substantial changes in Medicare Part D or who back the CHIP program will get elected this year, Pollack adds. But other independent observers say it's unlikely to see much good come out of this — or any other — political season.

"Campaigns are rarely the place where good policy gets made," says Levitt. "They're more a forum for airing grievances."

But don't expect either party to point any political barbs at managed care organizations. Once the whipping boy for various interests, there's no one out beating the bushes for voters angry at managed care organizations.

"The concerns about the restrictions imposed by health plans and managed care really have fallen off the radar," says Levitt. "In part that's because plans have loosened up, and in part that's because patients' rights is no longer a live issue in Congress."

John Carroll, a freelance writer living near Austin, Texas, has been a contributing editor of Managed Care for four years.

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