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Reading the Health Care Tea Leaves for 2009

By John Reichard, CQ HealthBeat Editor

May 13, 2008 --With Election Day almost six months away, no one knows the answers, but top health care analysts, pollsters, and advisers offered insights at a Washington, D.C., forum Tuesday—and some surprising answers. They suggested, for example, that the Iraq War might increase rather than decrease the chances of an overhaul, and that while the public looks to Democrats more than Republicans for answers on health care, Sen. John McCain of Arizona, the presumed GOP presidential nominee, may have embraced an unexpectedly strong strategy in focusing on health costs rather than universal coverage.

Democratic pollster Celinda C. Lake conceded at the forum sponsored by the policy journal Health Affairs that McCain is "very audacious and very smart in leading on cost." People come to the health overhaul debate as consumers, not altruists, she said. Their gut concern is "what's it going to do with my coverage."

Worries about unaffordable care cause insured Americans to cling more tightly to their current health care benefits, she suggested, adding that they are likely to resist proposals that water down their current benefits to pay for universal coverage. Lake also noted that insured Americans can bring the greatest political pressure to bear on the health care debate.

"Ironically, one of the strongest predictors of not voting is not having health insurance," she said.

Although Americans see health care as a right, they worry about the cost implications of universal coverage, including longer waits for care and less access to doctors, according to Lake. Women—who Lake sees as key to how the next election will turn out and to the fate of health care proposals in the next few years—worry that instead of having 25 minutes with the doctor they will only have 10 minutes.

Americans also want a uniquely American answer to the problems in the health care system. “"They recognize that the U.S. system is in crisis, but they seek to improve the system instead of adopting a foreign model,”" Lake and her co-authors wrote in an article released Tuesday by Health Affairs. "“The majority of America is not fine with going to government health clinics,"” she told the forum.

But Lake added that because Americans are wary of plunging into the unfamiliar, McCain's plan has significant weaknesses. She appeared to be referring in part to provisions that would provide people with tax credits, allowing those covered by employers to switch to the individual market. Among the cost worries of the public is "losing all that money that employers put into the system," she said.

Democrats, she said, might have a better chance of overhauling health care than they did in the early 1990s if they tried motivating voters out of anger rather than fear. The Democratic message then was that people should support universal coverage because they could suddenly lose their jobs and be "one paycheck away from disaster." That fear caused people to want to stick to what they had, Lake said. Targeting wealthy insurance companies, on the other hand, may be a stronger way to build support for universal coverage.

Despite potential pitfalls, Lake said she sees a "unique" opportunity to move on health care early in the next administration. "Health care for all Americans is a real possibility," she said in the Health Affairs piece. "The coalitions being built in favor of major health reform at the state and national levels are unprecedented in their breadth and influence."

GOP pollster William D. McInturff agreed with Lake that there is a real chance for overhaul, saying public perceptions of the economy are worse now than they were of the recession economy of the early 1990s. The $150 billion to $200 billion yearly cost of the Iraq War has made the public angry about all the money being spent abroad and more open to the idea of spending $110 billion a year on covering the uninsured. "I think Iraq has shifted the dialogue about that kind of price tag," he said.

But Americans aren't willing to accept a little less health care so the uninsured can get more, and they are skeptical that ending lower tax rates for the rich will generate enough money to cover the uninsured, he added.

McCain has certain advantages over Democrats, McInturff asserted. One is that as a Republican, he can go after trial lawyers. The pollster said voters respond strongly to the argument that extra tests and procedures ordered by doctors worried about getting sued drive up the cost of care. But Democrats can't talk about that issue for fear of alienating trial lawyers that account for much of their campaign financing, McInturff said.

As president, McCain would be serving with Democratic majorities in the House and Senate, McInturff predicted, and voters "don't think that is a bad outcome" because it forces compromises around the middle.

Congressional Budget Office Director Peter R. Orszag hammered away at the importance of controlling costs, saying that the rate at which health costs grow is the key to the nation's financial future. Dropping tests, products, and procedures that don't work is the single most important step the United States could take to improve the efficiency of its economy and could produce savings equal to 5 percent of the Gross Domestic Product without harming the outcomes of health care, he said.

But "our political system does not deal well with gradual long-term problems," he added. As a result, it may be wiser for policy makers to focus on areas with both a near-term and long-term payoff. As an example, Orszag cited the finding that end-of-life care costs $50,000 at UCLA Medical Center compared with $25,000 at the Mayo Clinic—with no difference in health outcomes. "That's not about your kids or grandkids, that's about your tax dollars today," he said.

If employers informed workers exactly how much they forego in salaries now because of the cost of care, those employees might become a more potent political force for lower health costs, he added.

Orszag noted that CBO is gearing up for next year's debate by beefing up its staff of health care analysts and by preparing two volumes on policy alternatives for would-be health reformers. The idea is to have a tool kit ready for those assembling health care plans and to avoid unexpected cost estimates that torpedo plans politically. There should be no surprises from CBO in the health care debate this time, he said.

But Orszag hinted that health care won't necessarily be a front-burner issue next year. If the economy is weak, Congress may be preoccupied with that issue. It also faces the expiration of the Bush tax cuts (PL 107-16, PL 108-27) and the issue of global climate change.

However, health care advisers to the top presidential candidates downplayed the idea that health care won't be front and center, and jousted over which campaign would deal best with public anxieties over the cost of care.

Jeanne Lambrew, an adviser to the Clinton campaign, and David Blumenthal, an adviser to the Obama campaign, said the McCain plan can't get costs under control because it doesn't provide for universal coverage. Only when the uninsured are brought into the health system can the nation's entire health costs be addressed, they said. Otherwise, costs are shifted from payer to payer with no comprehensive plan to assure efficiency.

Blumenthal said a reinsurance provision in the Obama health plan would shave $2,500 per person right away off the yearly premium costs of employees in small businesses, in which most uninsured Americans work. But moderator Susan Dentzer, the new editor of Health Affairs, expressed skepticism about the Obama campaign's estimate that its health plan would cost $65 billion a year overall, saying that estimates of the cost of the reinsurance provision alone have run as high as $60 billion per year.

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