Tuesday, February 2nd marked a milestone of sorts in the health reform debate: there was no story on health reform in the New York Times (national edition). I haven’t done a study, but as a professional New York Times (NYT) reader, I am virtually certain that this is the first day in over a year without a story in the NYT on health reform.
The day of silence in the NYT is reflective of the astonishing braking power health has shown as an issue since the special election in Massachusetts, going from 100 mph to about 10 mph in just a matter of weeks.
National health reform legislation could still pass in the coming weeks; no one can claim to be able to predict for certain what will happen now. But it is clear that leaders will now focus less on health and much more on jobs and the economy, and media coverage will follow their lead. And as the national conversation shifts, polls are likely to begin to show health slipping as a public priority. But don’t be misled. That will not be because people are less worried about paying for health care or about losing their health coverage if they lose their job; they remain very worried about these things. It will simply be because leaders are talking less about health and health reform and the media is covering health less. When people hear less about an issue, their sense of its importance falls relative to other issues — remember the rise and fall of immigration. And of course, the underlying problems health reform was designed to address have not gone away and will keep the public, employers and government concerned about health care. Just this week we learned from Centers for Medicare and Medicaid Services that health spending has reached 17% of GDP.
On the other hand, if and when leaders rekindle the debate, media coverage will follow and health will rise again as a priority in the polls. Whether national leaders return to comprehensive health reform legislation this month, in a few months, or in several years, there will be an underlying reservoir of public concern for them to tap into. This may surprise you, but polls show quite clearly that the underlying level of public anxiety about health has in fact been largely unchanged since the early 1990’s. Consider these two measures as examples. In 1992, 61% of the American people said they were worried about paying for health care in the future; a similar percentage, 62%, says the same thing today. In 1992, 37% of the American people said “our health care system has so much wrong with it, it needs to be completely rebuilt”; 34% say that now. On both questions (and there are many others), results have moved within a narrow range since the early 90’s. Public concern has been a constant; it’s what leaders do that changes as we have elections and political control shifts, and that in turn drives what is on the media’s radar screen and on the public’s mind when they are asked in polls what the top issues are facing the nation or the president and the congress. (When people are asked about what the top problems are facing them or their families they often give very different answers).
In the middle of the last big health reform debate, the percentage of Americans naming health as one of the top two issues facing the country shot up to more than 50%. Immediately after that debate subsided, the percentage fell into the teens and remained there for 15 years. Generally, only a big unexpected event can change the equation and propel an issue into the forefront, such as a war, a terrorist attack or a natural disaster (and controversial failed response) like Katrina. There are big implications here for strategies to affect policy change. Are top-down or bottom-up strategies more effective? Strategies that target the bottom and the top of the pyramid to influence policy are both important, but my subject today is a more limited one – anticipating the polls.
One big challenge for health is that it has never really broken through as a voting issue even when it ranks fairly highly on the public’s issue priority list. The recent special senate election in Massachusetts was an exception, and even there for Brown voters health was primarily a proxy for broader voter discontent. With very few exceptions, health has not been a decisive issue in elections, either by rewarding or punishing candidates who take strong positions on health reform. The upcoming midterm elections will be the next test of whether that will happen in key races, with key swing voting groups such as seniors or independents, or in the electorate overall. If health reform fails, we will see if the narrower slice of the electorate that tends to vote in midterms will punish Democratic candidates for failing to deliver or reward Republican candidates who run on anti-health reform planks. But if history is a guide, other factors — the qualities of the candidates themselves, local issues, other national issues and especially jobs and the economy – will have a much greater influence on people’s votes. So don’t be surprised if health does not register as a critical voting issue in the midterm election exit polls, it almost never has.
It’s hard to put an overly positive face on the apparent pause in the health reform effort or, at this point, to say with any certainty what will happen next. But there is at least one side benefit if a pause eases public anxiety. The rancorous and fiercely partisan debate has made the public anxious about change and it has made health reform a symbol for many voters of what they don’t like about the policy making process and the political system overall. This is one reason why our polls show that the public is so sharply divided about the legislation overall, but much more positive about the legislation when we tell them what it actually would do. The legislation became a symbol of deeper divisions in America beyond its substance which, with a few notable exceptions, people like. The pause, even a short one lasting a month, could lower temperatures enough so that health reform debate focuses more on the substance and what it does for people and is less of a lightening rod for deeper divisions in our country. Well, maybe.
In any case, don’t make too much of polls showing health dropping as a public priority or of exit polls in the midterm election showing health was not a critical factor if and when they emerge. The public’s underlying concerns about the affordability of health care will not really have changed. And if health does not drop as a priority as national discussion moves on to other issues (or actually rises), or if health registers as a voting issue across the country, that should really send a message to elected officials.