After 28 Years, a “Totally New Deal” for Healthcare and the Economy?

Two seasoned political strategists, Paul Begala, and Stan Greenberg, spoke at “Health Action 2008,” a conference that Families USA sponsored in Washington last week.  There, they argued that the U.S. may be on the threshold of what Begala, a political contributor on CNN’s “The Situation Room,” called “a totally new deal.”  Greenberg, chairman and CEO of Greenberg, Quinlan Rosner, went a little further: “It is very possible that the whole conservative complex crashes.”

In an interview later that afternoon, Greenberg explained what he meant: “I think this election is going to mark an extraordinary defeat for conservatives.” Greenberg isn’t talking about the number of Congressional seats that the conservatives may lose: he is not forecasting a sweep for Democrats that equals the LBJ landslide. Instead, he’s predicting something more fundamental: that the right wing of the Republican party will be shattered. “There may be a fragmentation on the conservative side that changes what’s possible after the election.”

For many who came of age in the 1980s and the 1990s, this must seem unimaginable. For the past 28 years, the U.S. government has been held captive by the conservatives. Ronald Reagan sowed the seeds and George W. Bush harvested the fruit of a political movement bent on deregulation and smaller government while consolidating and preserving the wealth of the country’s richest citizens.

At the beginning of Bill Clinton’s first term, it seemed that the nation might be ready for deep changes, in large part because we had entered a recession that was threatening not just blue collar but white collar workers.  Middle-class and upper-middle class employees were afraid that they were going to lose not only their jobs, but their health insurance.  But as that recession eased, Bill Clinton’s first major initiative went down in flames.  A health care reform plan that would have signaled the beginning of progressive economic reform failed, in  part because Americans were no longer as anxious as they had been when Clinton captured the White House.  (Ezra Klein recently did a superb job of putting the death of the Clinton healthcare plan in context, explaining how a combination of “bad timing, political misjudgment and human error” conspired to kill what had been a “courageous effort” to pass health reform.)

But now, Begala and Greenberg say, the time is ripe for radical reform. They make their argument based both on the fact that the conservatives are in disarray and on what Americans now say when they talk to pollsters about healthcare reform.  In September, 62 percent of those polled said that “rising health care costs are a very serious problem in the economy”—up from 50 percent a year earlier. And, as the recession deepens, that number is likely to climb.

Paul Begala began his speech by pointing out how different this election is from past elections. As others have noted: there is no incumbent. “We Have to go back to 1928 to find an election without an incumbent president or vice-president on the ballot,” observed Begala, whose consulting firm, Carville & Begala, helped elect Bill Clinton.

And George W. Bush has no coattails. “Usually, after a two-term presidency a vice-president or someone from his cabinet would be running. But our president’s popularity rating is down to 33 percent—it has been below 50 percent his entire second term,” Begala added.

During his eight years in office, Bill Clinton saw his popularity fall as low as 33 percent “just once, in one survey,” Begala noted.  “In the past, the public has been extremely loyal to sitting presidents, even when they do incredibly foolish things.

“Ronald Reagan sold weapons to the Ayatollah of Iran, Begala says, his voice cracking at the unbelievable absurdity of the transaction.  “No One thought that was a good idea. (Well, okay, except perhaps Ollie North, who as Begala recalled, later testified that he thought raising money from the Ayatollah to support Nicaraguan freedom fighters was “a neat idea.”)

As for Bill Clinton, “he had a girlfriend,” Begala pointed out. “And he lied about it. No One approves of having an affair and lying about it.”

Still, Clinton’s popularity never sank like Bush’s. What is the moral of this story, Begala asked--“that George Bush needs a girlfriend?”

“No, what this tells us is that we have given up on Bush,” said Begala, wiping his hands.  “We’re done with him.

It’s a new game, and rather than feuding over the mistakes of the past, progressives should  be seizing the moment—especially when it comes economy and health care reform, Begala declared. “The hardest thing for people working on healthcare to understand is that this is not 1994.  This is a completely different country. On healthcare, the progressives are too cautious.” 

Everyone talks about how badly would-be reformers were “burned” the last time around.  And it’s true, he acknowledged, “a cat that sits on a hot stove never sits on a hot stove again.  But it won’t sit on a cold stove either. We need to be smarter than Mark Twain’s cat.”

“I think progressives need to remember that on the other side—they have nothing to sell but fear,” Begala added. He then channeled a fear-mongering conservative: “Oooo, Single Payer; Oooo, Socialized Medicine,” he cried, crossing his arms over his eyes, and shaking his hands over his head as if warding off  ghosts of the Cold War Past.

Stan Greenberg, who has been reading public opinion since the 1970s and served as pollster both for President Bill Clinton and Vice-president Al Gore, spoke next.  “What I do is, I try to help elections matter, to help them have meaning,” said Greenberg, who, together with James Carville, founded Democracy Corps in 1999.  “If I do anything in life, I understand the dynamic of an election and the opportunity to create mandates.”

He offered an example: “When the 1992 election was over, people understood what it was about: ‘It’s the economy, stupid!’  This time around, Greenberg is certain “there will be a mandate on healthcare.” Moreover, he insists that “healthcare and the economy are one and the same issue. Health care costs are a central economic issue.”

Just as in 1994, voters will be voting their pocketbooks. And this time, it’s not likely that the recession will end quickly, or that the public’s anxiety about losing health insurance will suddenly disappear. Health care costs continue to levitate, and employers are backing off. Meanwhile, the price of oil climbs and the war in Iraq goes on and on.

The voters are angry, Greenberg continued. “They won’t elect someone without taking them through all sorts of tests. The candidate who wins will win on three linked issues: reducing the number of troops in Iraq, making healthcare affordable for all, and energy independence.

“I believe that when we wake up after election day we will know that these are the issues that matter,” he added, “though not necessarily in that order. “

And when it comes to healthcare, “the public is open to fairly complex plans for reform,” says Greenberg.  But the candidates are going to have to take responsibility for explaining their plans, And then explaining them again. And again.

“Among the mistakes we made in 1994,” Greenberg explains, “is that we thought the media would do it. They won’t. They’ll write one story, and then move on, looking for ‘new’ news. So the candidates have to find ways to repeat, repeat, repeat.” And, Greenberg stressed, “They must allay anxieties with facts.

“They also need to be aware that the conservatives’ proposals also sound good,” he cautioned. Rather than reforming the health care system, most conservatives would give people tax credits or tax cuts so that they can “be in the driver’s seat” and fund their own health care.  “We know the consequences of these health care policies,” Greenberg observed, referring to the fact that most of the middle-class doesn’t have enough discretionary income to fund a health savings account, and that tax cuts tend to be most valuable to those in the highest tax brackets.

The conservatives’ plan will not broaden access by putting a brake on healthcare inflation. It would simply reinforce a three-tier health care system in which some Americans receive what they believe is good health care, a second tier receives what they know is insufficient care, and a third tier receives no care at all until they are very, very sick. 

This is what progressives need to explain to voters. They also need to show how their plans dovetail with what the public values most. Here Greenberg produced polls revealing what voters say they want.  (The numbers come from a series of 14 surveys in eight battleground House districts and six competitive Senate states that Greenberg Quinlan Rosner conducted in November. The presentation also incorporates data from a Democracy Corps National Survey that was done in May 2007. The below charts are pulled from this presentation.) 

First, Greenberg noted that there is strong support for reform.  Even when asked “Would you support or oppose reforming our current health care system to provide affordable health coverage for all Americans . . . if it meant government taking a much larger role in our health care system—and if it meant that you would have to pay more in taxes?” 44 percent  said they would support reform. The chart below refers to this group as “firm supporters.”

“Conditional supporters” by contrast, initially said “yes” to reform, but dropped their support in the face of greater either government involvement OR higher taxes, while “firm opponents” opposed any reforms to our current health care system.

Clearly, there are still fears of a “government takeover” and progressives need to explain that their plans would let families keep their private sector insurance if they choose. The majority of voters also are still unwilling to pay higher taxes to ensure coverage for all.  Nevertheless, Greenberg points out “44% support reform—even if it means more taxes and more government involvement. Other voters just need to be reassured that the government role will work for them and that costs will be contained.” Here, I would add that money will be the central, recurring problem in the fight for health care reform. As we have seen both in California and in Massachusetts, the question of how we will pay for reform—especially as the economy heads south—cannot be ignored. I will be talking about this in my next post.

Greenberg’s polls also looked at the degree to which Democrats, Independents and Republicans agree on the issues. When asked about the biggest problem in our health care system, “costs are too high” ranked first with all three groups.  By contrast, as the chart below shows, only 34 percent of Independents and 24 percent of Republicans saw the fact that  “there are too many people without coverage”  as “one of the biggest problems.”

Instead, both Independents and Republicans were significantly more worried about insurance companies.  Here, the polls showed that voters were primarily concerned that insurers will refuse to cover them if they are sick.  As Greenberg points out, progressives must allay fears with facts, making it very clear that under their plans, insurers would no longer be allowed to refuse coverage or raise rates if a customer is sick. They could not “cherry-pick” healthy patients or shun the sick.

Pollsters also asked “Which Values Should Guide Reform,” giving those polled a choice among:

• Fundamental Right: Healthcare is a fundamental right – every American should be guaranteed coverage that can never be taken away
• Choice of Doctors: Every American should have a choice of doctors and hospitals
• Shared Responsibility: Individuals, businesses and government have a shared responsibility for covering health care costs
• Should be Private: America’s health care system should be private and market-driven, not government run
• Business Not Hurt: American businesses should not be hurt by health care costs

As the chart below reveals, more than half of all Republicans, Independents and Democrats ranked having a “choice of doctors and hospitals” either first or second among the values that should guide reform.  “This is key, key, key,” says Greenberg.

Voters also believe that individuals, government and business should share in the cost of care. But the majority of Independents and Republicans are not convinced that health care is a “fundamental right”—which explains why so many are not willing to pay higher taxes to make sure that everyone is covered. Progressives will have to find other ways to finance reform.

Greenberg then revealed what percentage of voters strongly support (left-hand number in each row) or totally support (second number) elements of progressive and conservative plans for health care reform.

PERCENTAGE WHO STRONGLY SUPPORT/TOTALLY SUPPORT ELEMENTS OF PROGRESSIVE PLAN                                                      

PERCENTAGE WHO STRONGLY SUPPORT/TOTALLY SUPPORT ELEMENTS OF CONSERVATIVE PLAN

Finally, Greenberg ranked the key elements that voters favor, showing that the progressive messages generally outperformed the conservative messages. As the chart below shows, the progressive promises (in blue) meant more to voters than the conservative ones (in red). The lighter shade in each bar represents respondents who valued a promise "somewhat," the darker shade are those who place "much" value in the promise.

As you can see, promises of Security (you cannot lose your insurance,) No Discrimination (insurers are prohibited from discriminating and denying coverage), Universal Coverage and Choice ( if they choose, families can keep the private insurance they now have) meant more to voters than conservative promises of tort reform, affordability (with a tax cut making healthcare more affordable) individual choice (as to whether or not you have to purchase insurance) and markets (letting free market competition continue to try to solve the problems of our health care system.)

Greenberg believes that when you look at voters values, fears and priorities, it becomes clear that “the conservatives are out of touch. Social conservatives are being devalued and de-linked. We can win this debate,” he adds. “I’m not worried about the debate. I’m worried about the programs.”

I’m not quite as confident as either Begala or Greenberg that the conservative wing of the Republican Party will be pushed off the political stage—though it is true that American political history is a history of pendulum swings. And after years of conservative dominance, it is time for a “New Deal”—a “totally new deal.” Perhaps we are entering a new era, where we will be able to do things that we haven’t been able to do in the last 28 years.

The question is, how are we going to fund health care reform? I talked to Don Berwick, head of the Institute for Healthcare Improvement about that in Washington last week. In my next post, I’ll talk about how we might persuade hospitals to put fewer heads in hospital beds.

Comments

[cheap cialis]

On cost, however, I agree with you. " Ensuring that no one pays more than 5 to 7 percent of their income on health insurance" would be very difficult when health care takes 15% or so of GDP--unless the rich paid very high extra taxes (say 5 to 7 percent of every dollar a multi-millionaire earns) to subsidize middle-class and low-income workers.

[maggie mahar]

Med Students and Ann--

Med students-- glad you're agitating. I do think that doctors--and perhaps particularly young doctors--need to be in the vanguard of health care reform.

Anne-- Always good to hear from you. I agree about RN's-- you'll be interested in what Don Berwick has go say about making greater and better use of them in the piece I just put up on paying for healthcare reform.

[Med Student AMSA member]

Yes, there are certainly many moving parts to this issue, but let's not overlook one of the most fundamental and ferocious obstacles to overcome. And let's face up to what it's gonna take to get there.

Are you ready? AMSA is!

Med Students Take a Stand for Health Care at
http://youtube.com/watch?v=pYoe6hJAXaw

[Ann Malone, RN]

Re: "There needs to be a lot of feedback between the people developing guidelines at the top, and the hospital/doctor groups working to continuously improve quality."
Posted by: maggie mahar |

Maggie - One of many good points, but compels me to say "please, don't overlook the nurses!" After all, we're the most numerous of health professionals providing care in "the system". (And I dare say that things would be a lot better if we wielded the influence and power that our skilled caregiving roles deserve)

[maggie mahar]

Kathleen, Marc and jd--
Thank you for your comments-

Kathleen- thank you for your support

jd--you make a number of good points
First, yes, you are right, even if patients have the choice to choose their doctor, their doctors might not choose them.
If Medicare goes ahead with the 10% average across the board cuts in the fees it pays doctors this summer (as it is scheduled to do) many doctors might begin to refuse to take Medicare patients.
But I doubt that Congress will go ahead with the cuts. The political fallout would be too great.
As to whether patients have to be linked into a network, I'm not sure I'm following your argument.
Even if Medicare's fees are lower, it still has a huge customer base. Most doctors need those patients.
So Medicare doesn't neet to set up a separate network of doctors who have agreed to its fees. Most doctors will accept Medicare's fees (unless it does the across-the-board cuts, which I very much doubt) because Medicare represents so many patients.

Most doctors need the business--and as you say, they prefer dealing with Medicare which doesn't try to micro-manage treament, and pays promptly.

So Medicare doesn't need to guarantee doctors a capitve audience of patients (locked into a network).The know that Medicare will offers a huge number of patients.

And under national health reform, patient would have a free choice of doctors.

Marc--
You are right-- I completely agree that a group of doctors and hopsitals have to work toether to create "continuous quality improvment"
At the top, I think that the NIH (or whoever) only needs to work on evidence-based research which can great guidelines for best practice--not rules, just guidelines.
Then, hospital/doctor groups need to apply those guidelines to individual paitients--who are always unique.
There needs to be a lot of feedback between the people developing guidelines at the top, and the hospital/doctor groups working to continuously improve quality.

[Marc B Stone]

Maggie-

There is every reason to "lock" patients into networks under health care reform - the need for managerial controls that are necessary to improve the process of care, both cost and quality. Having a public institution that decides what works (and, therefore, what should be covered) is only a small part of what's needed - clinical decision-making is too complex to prescribe exactly what should be done in most situations. It's the fallacy of central planning. The managerial controls I'm referring to are not top-down pronouncements; they are based on the collaborative principles of continuous quality improvement. To accomplish this, health care providers have to work closely together and be accountable to each other and management requires information systems on what everyone in the system is doing. allowing patients to obtain services "a la carte" from different systems of providers makes this effort nearly impossible.

[Kathleen O'Connor]

Great information! Thank you for those interviews. We at CodeBlueNow! have also done some research on voters regarding health care. We did surveys, so far, in two states. Iowa and Washington. Our findings mirror those Greenburgs findings. It will be interesting to see if the candidates can reach across the aisle to get to health care reform.

Our research can be accessed on our home page: www.codebluenow.org

We will have some more reports coming out later this week.

Keep up the good work. Best regards, Kathleen O'Connor
CodeBlueNow!

[jd]

Maggie,

As always, fantastic work. You are one of the best-researched writers on health care policy and I continually learn from your tireless work.

But as usual I'm writing to take issue with something. I'm not entirely clear what you meant in speaking about private insurance networks vs. Medicare, but I think I disagree.

You say that Medicare will pay for you to see any doctor, whereas private insurers will only pay for a limited set of in-network providers, because these are the ones they've struck deals with on price, and that there is no reason to permit this to continue under a universal coverage scheme.

But how much difference is there really? There are physicians who will not accept Medicare, and this number is slowly growing. You might say that it is the physician who is rejecting Medicare, rather than the other way around. But again, is this any different than private health plans? In both cases, the insurer (Medicare or private plan) offers the provider a rate. The provider chooses to accept that rate or not. When providers don't accept it, it's for the same basic reasons: they think the rate is too low, or they don't want to deal with the administrative hassle of insurance (this latter reason is more common with private plans than Medicare, but there are physicians who prefer a cash-only business).

So why is it that more physicians accept Medicare than any private plan? It isn't that Medicare pays a higher fee schedule, because it rarely does. The main reason is that Medicare is bigger than any private plan, and by a large margin. You are forgoing a larger portion of your potential revenues if you don't accept Medicare. There are other reasons as I'm sure you know: Medicare tends to engage in less utilization review and pays more quickly. But the main reason is just size. It is not a coincidence that United and WellPoint have huge networks that begin to rival Medicare's.

My point is that there is far less difference here than suggested. Though there are differences in how Medicare and private plans set the rates, they both offer physicians rates based on a process that takes cost and local averages into account, but which is not a true negotiation. Private plans only negotiate with very large providers, such as hospital systems. Private plans, in fact, generally peg their rates to Medicare (say, Medicare plus 5%, or something). How much more a private plan pays than Medicare depends on (a) how big it is in members and (b) how small it is willing to let its network get in order to pay less. But those lower payments have to translate into lower premiums, or no one will buy the smaller network plan. That's a major reason why HMOs are 5%-20% less expensive than PPOs. The savings are largely passed on to the member.

So I guess I just don't get the distinction you were drawing. If we don't get rid of private insurers in a UHC system, why not let them continue to offer different prices to providers?

To give one possibility out of many: In the French system the government offers a universal base rate that every physician accepts, but not necessarily as full payment for services. A physician could charge twice as much as the base, meaning the national plan covers half. If we were to adopt a system like this, private insurers could then offer to cover the other half, and the larger ones could presumably get discounts on the rate. There are many other systems in which insurers could offer supplemental plans or richer-benefit plans for which they would negotiate rates.

Or am I missing your point?

[Maggie Mahar]

Rick and Marc-
Rick--thanks for the encouragement.
Marc--Your point about cost is a good one. The point about "choice" isn't necessarily true.
I agree that if we're going to improve quality and efficiency, doctors need to be organized into capitated groups where they are paid for caring for a certain number of patients rather than paying them fee-for-service.
But there is no reason that these need to be closed networks.
If my primary doc is in group A he could still refer me to a specialist in group B. And in fact, it's more likely that both doctors would be part of one huge multi-specialty group (think Kaiser or Cleveland Clinic.)
The reason private insurers now set up networks and refuse to let patients go out of network (unless they pay extra) is because the insurers have struck a deal with the doctors: you'll accept the fees we're paying you (even if they seem low) because we're guaranteeing you business. The patients are "locked in" to the network.
Under health care reform there is no reason to allow insurers to strike such deals.

Also remember, the Democrats' plans all talk about creating a public sector "Medicare for all" type plan that would compete with private insurers.
Medicare doesn't lock people into networks--you can go to any doctor you choose. I suspect that insurers that tried to force patients to stay in networks would have a hard time competing with the public sector "Medicare-for-all" plan.

On cost, however, I agree with you. " Ensuring that no one pays more than 5 to 7 percent of their income on health insurance" would be very difficult when health care takes 15% or so of GDP--unless the rich paid very high extra taxes (say 5 to 7 percent of every dollar a multi-millionaire earns) to subsidize middle-class and low-income workers.

Under health care reform, the rich will subsidize lower-income families (just as they now do under Medicare) but not to that extent.

The only answer is to wring the waste out of our health care system so that it isn't so expensive. The $2.1 trillion that we now spend is more than enough to provide high quality care for everyone in the nation. But the dollars need to be redistributed.

We have to stop covering unproven procedures, unncessary often redundant tests, unncessary hospitalizatoins and over-priced drugs and devices that are no better than the older, cheaper products they replaced. We need to funnel that money into more preventive care for everyone.

Countries like Switzerland offer excellent healthcare to everyone while spending only 60% as much per capita as we do.

[Marc B Stone]

Looking beyond the cheerleading and taking off the rose-colored glasses, the presentation shows why any health care "reform" that truly fixes the system will fail.
1) The importance of choice of doctor. Any effort to improve the quality, efficiency and cost of health care will involve organizing doctors into capitated group practices. If your primary care doctor is in practice A and you want to see a specialist affiliated with group practice B you're out of luck or out of pocket or the organizational controls become so weakened that nothing can be accomplished. Attempts to significantly limit choice will kill the plan.
2) Ensuring that no one pays more than 5 to 7 percent of their income on health insurance is impossible when health care takes 15% or so of GDP. To meet this premise it would be necessary to hide the rest of the cost by subsidizing everyone and imposing very substantial taxes that would somehow need to be seen as fair and reasonable but not part of health insurance costs.

[Dr.Rick Lippin]

Maggie-

Thanks for a very informative post! We are in your debt for your onsite reporting.

Yes politics is all cyclical in my opionion. The Reagan/Gingrich revolution is at long last dead.

Regarding health care reform - it is coming soon.
We will pay for it by emphasizing individual and insitutional prevention and by facing the reality of compassionate and ethics based rationing. And on the treatment side we will pay for "what works"= efficacy.

It will be tough but we will grow up at long last.

Dr. Rick Lippin
http://medicalcrises.blogspot.com