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What people are missing in the health care debate

There’s a key point of focus too often absent in debates about federal health care policy. As much as everyone in politics gets worked about policy proposals and their implementation, the thing people aren’t paying enough attention to is how much any policy causes disruption for voters.

The common ingredient with the initial passage and implementation of Obamacare, the resurgence of Obamacare’s popularity as Repeal & Replace was on the table, and now various flavors of Medicare-for-All being discussed on the 2020 trail is problems of public perception arise the degree to which they might disrupt existing health care norms.

  • When Democrats proposed significant changes to federal health care policy in 2009 they faced a massive backlash in town halls and eventually at the ballot box, even though most Americans with coverage would largely be unaffected by Obamacare’s primary focus on the individual market.
  • When the implementation of Obamacare faltered badly in 2013 and stories about disruption for some Americans made news for months, it helped fuel a no good, horribly bad midterm for Democrats in 2014.
  • When Congressional Republicans got serious about Repeal and Replace in 2017 — as much as “serious” applies to actual Replace plans — the public generally revolted because the move was viewed as potentially taking away too much of the known status quo the public now finds acceptable. For example:

Now, even as variations of Medicare-for-All are on the table with the 2020 Democratic primary field and the Democratic House, support for the idea falters when components that disrupt what voters experience today are made clear:

Be that seniors or middle class voters with employer-coverage or other populations (such as beneficiaries of Medicaid expansion), how things might change for the worse is a key issue driving voter behavior on health care.

While government-funded health care via Medicare, Medicaid, the VA, and other government programs increasingly dominates health care in America, Americans themselves are often “small c” conservatives on the issue; preferring what they know rather than risking something that might be worse.

Yes, many in America are unhappy with our current health care system, especially because of costs. Kaiser Family Foundation polling detailed the degree to which even those in employer-sponsored coverage are unhappy with what they have.

The issue often falls on increasing costs to families based on rising deductibles and other forms of cost-sharing as employers seek to spread the impact on the rising cost of coverage, for which they typically pay the lion’s share of the bill.

Reminder, the number of Americans on employer-sponsored coverage is the 800 pound gorilla in health care today.

Image credit: Charles Gaba,

But, politically, the number is more specific. Many of those dissatisfied with their employer-coverage are comparatively lower income and/or working in industries where higher cost-sharing is more common.

The people with employer coverage more likely to be satisfied often hold middle and upper middle class income jobs in white collar industries, often working in knowledge economy or highly compensated service-based industries whose employers choose to offer generous plans to promote employee retention.

Those employers and their families might not truly love their coverage or the insurance company that administers it, but they know what they’re getting and value it, especially if they have children. And those are the very educated, not hyper-partisan, suburbanites who drifted away from the GOP as Donald Trump led the ticket in 2016 pounded Congressional Republicans in 2018 with losses in suburban districts that almost single-handedly made Nancy Pelosi Speaker.

Do Democrats want to retain those votes heading into 2020 and beyond? If so, the smarter move for them is shore up the ACA and offer a Medicare-like public option to those interested rather than disrupting health care for a potentially decisive voting constituency. Even talking about the appearance of disruption was a political albatross for Democrats in 2010 and 2014, and then for Republicans in turn in 2018.

As for the GOP, not only should there be lessons learned about Repeal and Replace, consider even John McCain’s experience in 2008. He proposed addressing one of the most pernicious problems in American health care today: the tax advantage of employer-sponsored coverage versus individual coverage that has now distorted our health care system of decades. The result? Barack Obama pummeled him on the topic. McCain lost for many more reasons, but the same rule applies: proposing disruption to existing health care norms is politically risky.

Thus, as Republicans think about attempting to come up with a cogent alternative to Medicare-for-All, the need to pay attention to potential disruption is real.

Intellectually won of the more solid such right-of-center constructs comes from Avik Roy who argues a model like Switzerland is a logical next step for reforming how we provide health care coverage in America. It’s a strong model, but would involve a lot of disruption.

At the same time, Roy proposes an interesting set of changes to how the federal government deals with the major issue of rising hospital costs (a key factor in the rising cost of coverage). Surprise: it involves more government intervention, at least for now, because government has allowed hospitals to become too concentrated and accrue excessive pricing power. Thus, government needs to correct its own error.

Whether one agrees with that particular solution or not, getting at the issues of costs, including bipartisan approaches to restraining prescription drug costs, rather than continuing to disrupt how many Americans get their coverage appears to be a more politically prudent option for now, even if it leaves some major, distorting problems in the health care system relatively unaddressed in the near future.


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