In the Shadow of 9/11: Health Care Reform in the 2004 Presidential Election

Abstract

The real-world problems of providing affordable medical care for seniors and the non-elderly have intensified and, yet, the range of what policy makers and reform advocates see as responsible or even conceivable remedies is narrower in the 2004 presidential campaign than what it was during Bill Clinton's campaign in 1992. This article explains this paradox by studying what is on the minds of voters and how the candidates are responding. It suggests that the political response to comparable real-world conditions in health care have been diminished by the new found attention to national security, changing public perceptions toward health care, and the political calculations of politicians as they react to well-organized interest groups and the demands of new national and international issues.

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SYMPOSIUM
In the Shadow
of
9/11:
Health
Care Reform
in
the
2004
Presidential
Election
Lawrence
R.
Jacobs
Michael
Illuzzi
ealth care reform is
an
important issue in the
2004
presi-
dential elections and is receiving serious attention from the
H
Democratic and Republican candidates. Changes in the
economy that fuelled increased productivity and depressed job
growth have also shifted more of the costs of medical care and in-
surance onto employees. The rising costs of insurance premiums and
health care are far outpacing the general inflation rate and workers’
wages. Meanwhile, state governments reacted to widening budget
deficits from
2001
to
2003
by reducing Medicaid eligibility and ben-
efits. These changes in employer-based health insurance and gov-
ernment policy have contributed to the largest rise in the share of
Americans without health insurance in a decade. In
2002,
the unin-
sured numbered
43.6
million and, according to the Congressional
Budget Office,
57
to
59
million non-elderly people are uninsured at
some point over the course of a year.’
When lack of access to medical care and soaring costs reached or
exceeded today’s levels a dozen
or
so
years ago, Washington policy
makers and candidates for president, the
U.S.
Senate, and other
elected offices rushed forward with a range of proposals to tackle the
problems facing both seniors and the non-elderly. Today, proposals
for health care reform are narrower and more limited even though the
magnitude and seriousness of the challenges approach
or
surpass
those faced in the early
1990s.
Although Democratic Party nominee
John Kerry is proposing to expand access to health insurance to mil-
lions of Americans, he has not proposed the kind of comprehensive
change in the health care system that candidate Bill Clinton proposed
in the
1992
presidential campaign. President George
W.
Bush touts
the
2003
expansion of Medicare to include drug benefits, but his pro-
posals to expand access to health insurance to the tens of millions of
non-elderly are modest and are more limited than Kerry’s.
Interest groups and other political players have adjusted to the new
caution. Promoters of health reform express a renewed appreciation
of incremental reforms in place of Clinton-like ambitions to remake
the country’s financing and delivery of health care: the piecemeal ap-
proach is embraced
as
less disruptive of the existing health care sys-
tem,
as
more readily explainable to voters, and
as
less susceptible to
provoking intense interest group opposition and distortion.
For
their
part, reform critics aim their fire at slowing down even incremental
efforts rather than engaging in the life and death struggle to defeat
comprehensive change.
Why are the political responses to health care in
2004
more mod-
est than those proposed in the early
199Os,
even though the severity
of the problems is comparable? The important but moderated pro-
file of health care in the
2004
election compared to its headliner sta-
tus in
1992
stems from three factors.
First and foremost, the perception of increased external threats fol-
lowing the terrorist attacks on September
11,2001
has partially over-
shadowed health care on the policy making agenda.
A
dozen years ago
tiilk
of the “peace dividend was rampant
as
the Soviet Union’s collapse
Lawrence
R.
Jacobs
is McKnight Land Grant Professor at the
Uni-
versity of Minnesota and directs the
2004
Elections Project at the
Humphrey Institute. He edited “Healthy, Wealthy, and Fair”(Oxford,
2004)
and authored “Politicians Don’t Pander”(Chicago,
2000)
and
“The
Health 0fNations”as well
as
numerous articles
on
health policy
andAmerican politics in HeaEthAffairs; Journal of Health Policy, Pol-
itics, and Law; American Political Science Review and elsewhere.
He
received an Investigator Award in Health Policy Research fiom the
Robert
Wood
Johnson Foundation and has served
on
its NationalAd-
visory
Committee. He
is
chairing the
Task
Force
on
Inequality and
American Democracy for the Amm’can Political Science Association,
which recently released its report.
Michael
Illuzzi
is
an advanced
graduate student in the Department
of
Political Science at the Uni-
versity
of
Minnesota.
__~
~ ~ ~~~ ~ ~~~~
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Lawrence
R.
Jacobs
brought the Cold War to an end and national security receded
as
an
issue, widening the space for domestic issues. The
9/11
attacks
com-
bined with the wars in Afghanistan and Iraq have revived national se-
curity
as
a principal concern, elbowing aside some domestic issues in
policy debates and in the public’s mind.2 Convincing Republican wins
in the
2002
mid-term elections on national security themes cemented
their hold on the policy agenda in the eyes of politicians.
Second, the Republican Party controls the lawmaking branches. It
enjoys majorities in the House of Representatives and the
U.S.
Sen-
ate while President Bush sits in the White House. This kind of uni-
fied party control of Congress and the White House is unusual and
especially potent in the hands of a political party that is
as
unified
as
the GOP. Republican dominance of Washington debate has tamped
down ambitious efforts to expand health care access. By contrast, the
early
1990s
saw the Democrats in control of the House and Senate
and Republican President George H.W. Bush breaking from Ronald
Reagan’s anti-tax message by raising taxes to
both reinforced existing suspicions of the GOP on health care, while
also signaling the
Party‘s
willingness and effectiveness in enactingleg-
islation. The net effect has been to maintain the Democratic advan-
tage on the issue and, at the same time, to protect President Bush
from the kind of strong public disapproval of his handling of health
care that confronted his father in
1991
and
1992.
The
Publick
Congested
Policy
Agenda
On the eve ofthe
1992
election, Americans ranked health care
as
one
of the top
2
or
3
issues demanding attention.3
lko
surveys conducted on November
3,1992
reported that Amer-
icans ranked health
are
as
the third most important issue facing the
country, behind the economy and the budget deficit?
Health care remains a touchstone issue in the
2004
battle for the
Democratic nomination and the general election campaign. Health
care and Medicare were consistently listed
bv oarticiuants in
the
Democratic orimaries
..
fund government operations and control the
budget deficit.
Third, domestic initiatives in
zoo4
sail
under the heavy clouds of large and growing
government budget deficits and a strong
headwind against
tax
increases. Ronald Rea-
of
higher government deficits has been res-
urrected, restricting the fiscal and adminis-
trative capacity of government. Congressio-
Today, proposals for health
care reform
are
narrower
and more limited even
though the magnitude
and
approach or surpass those
faced in the early
1990s.
and caucuses
as
one of the top three issues
that “mattered in deciding whom you sup-
portCed,r5
The
economyand
jobs
alongwith
the War in Iraq were the other top issues
among
Democraticvoters. Participants in the
Democratic nomination process are, how-
country and harbor stronger feelings about
the issue.
The
9/11
attacks have knocked health care
gan’s platform to slash taxes even at the cost
seriousness of the challenges
ever,
far
liberal than the
rest
of the
nal Democrats and Kerry are boxed into a
corner in which calls for higher taxes (even on
the wealthiest) face a drumbeat of criticism and promises to bring
budgetary discipline have invited scrutiny of their plans to finance
health reform. By contrast, in the early
199Os,
the sting of Reagan’s
anti-tax charges had been dulled, and Harris Wofford’s surprise Sen-
ate election in Pennsylvania on a platform calling for national health
insurance brought media and public attention to the issue and
demonstrated its political potency. Candidate Clinton capitalized
on
this political environment to frame health care reform
as
a strategy
for controlling (rather than
growing)
the government’s budget deficit.
The renewed concern about national security combined with the
changed domestic political context has created an odd paradox: the
real-world problems of providing affordable medical care for seniors
and the non-elderly have intensified and, yet, the range ofwhat policy
makers and reform advocates see
as
responsible or even conceivable
remedies is narrower than what it was in the early
1990s.
This
article
explains this paradox by studying what is on the minds of voters and
how the candidates are responding.
In
particular, it explores the chang-
ing public perceptions toward health care and the political calculations
of
politicians
as
they react to the public, well-organized
interest
groups,
and the demands
of
new national and international issues.
A
Distracted
and
Ambivalent Public
in
a
Post
9/11
World
Public opinion surveys are a kind of Geiger counter. Today, they are
picking up the anxieties and deprivations OfAmericans
as
they watch
the steady rise in uninsurance rates and in medical care expenses.
Even
as
health care remains a concern ofhericans, it is not the only
worry on the minds of Americans. The terrorist attacks on
9/11
have
helped to supplant health care from the very top of the public’s agenda
and to modulate the relative intensity
of
the public’s fears about the
issue. In addition, the Democratic “ownership” of the health care
issue has been challenged. Clinton’s failure in the early
1990s
some-
what attenuated Democratic dominance over the decade; but Re-
publicans’ reform of Medicare in December
2003
appears to have
out of the top echelon of issues that most
trouble the country
as
a whole, though it still remains important.
Just
days before September
11,2001,
a
Gallup poll found that traditional
domestic social policy issues (including health care and Medicare)
dominated the list of issues that respondents offered in response to
its standard open-ended question on the most important problems
facing the country.
A
handful of issues received the most attention:
the economy
(22
percent) and unemployment/jobs
(10
percent);
health care
(5
percent) and Medicare/Social security
(5
percent); ed-
ucation
(11
percent); ethics/dishonesty
(9
percent); and dissatisfac-
tion with government
(6
percent).
The September 11th attacks propelled national defense and the
im-
plications of fighting terrorism to the top of the public’s concerns,
pushing aside traditional domestic policy issues. Gallup’s October
2001
“most important problem” question recorded the high water
mark in the sea change in public perceptions: Americans were un-
derstandably preoccupied with terrorism
(46
percent of respondents
identified it
as
the country’s most important problem), followed by
fear ofwar
(10
percent), national security
(8
percent), and the loss of
personal freedoms because ofwar
(6
percent). Issues that had dom-
inated public anxieties only a month earlier lost their urgency in this
period of national shock
-
the ranking of the economy slid dramati-
cally (only
13
percent identified it)
as
did unemployment/jobs
(4
per-
cent) and, to a lesser extent, ethics
(6
percent). Health care and
Medicare fell off the public’s agenda; education, unemployment, and
poverty also fell far below national defense.
In theyears since
9/11,
fears about national defense have subsided
(though they remain far above their levels before September
2001)
and traditional domestic concerns have revived. Even
as
the public
reassessed the importance of national defense in the context of a
range of problems facing the country, health care issues have yet to
re-
gain the top
billing
they had duringthe
1992
elections or in the period
before
9/11.
Recent polls of
all
Americans consistently
rank
health
care
as
trailing the economy and unemployment and the
war
in Iraq and
terrorism
as
critical national problems. Figure
1
shows the slide of
health
care
in the public’s
ranking
of
most important problems. In May
NATIONAL.
HEALTH
REFORM
AND
AMERICA’S
UNINSURED
FALL
2004
455

SYMPOSIUM
2001,
health care was ranked
as
the third most important national
problem behind education and the economy. Almost half a year after
lenges facing the
count'3'
in
the
minds
Of
Americans*
By
9/11,
with the economy now ranked
as
the country's top concern.
9/l1,
terrorism
and
the
Iraq war remained
the
most Pressing chal-
national
defense
had subsided from the perid just
aRer
What remains significant is that terrorism and the Iraq War con-
occupied by health care and other domestic issues. Indeed,
six
fold
more Americans identify war and terrorism
as
the nation's most im-
portant problems
as
point to health care.
veys'
An
ABCmashin@on
survey found
that
the
inate the public's list of most important national problems:
26
percent
identified the economy and jobs; the Iraq
tinue
to
draw
Public
attention
and
to
take
agenda previously
The
displayed
in
ape
in
additional
economy
and
jobs
and
the
Iraq
war
and
terrorism
continued
to
dam-
The
Health CareAgenda: Lower Concern aboutdccess,
AfloTdability, and Radical Change
tition for agenda space, public concern about critical aspects of health
tial portion of Americans continue to struggle to pay for medical
care
and to keep health
insurance. Thirty-four
percent
ofAmericans
ily
had difficulty
the
cost
of
necessary
medical
in
the
past
year
as
percent stayed at a disliked job to keep health insurance coverage
(as
affordability of medical treatment do remain concerns ofAmericans.
icy issues has not reached the levels of
intensity found a dozen years ago. In the
the issue ofhealth
care
has lost out
to
other issues in the compe-
has also become
On
a
personal level, a substan-
reported in a pew survey in
June
and July
2003
that they ortheirfam-
to
29
percent
in
March
1994.
compared to
21
percent
in
March
1994).
Access to health care and the
Nonetheless, their concern about &dressing them
as
public pol-
1994,
between
30
and over
50
percent of
Americans identified health care
as
one of
the two most important issues
for
the government to address. After
2001,
health care failed to exceed
20
percent and
was
often quite a
bit lower. During
2004,
it reached
16
percent in February and fell to
9
percent in April (not shown in Figure
2).
In short, polls consistently show that Americans remain concerned
about health care but their relative ranking of issues places a higher
priority on economic concerns and terrorism than health care com-
pared to the early
1990s.
Over the past decade, health care has lost
agenda space to other issues that are seen
as
more pressing. Although
Democratic contenders
for
their Party's nomination quite rationally
highlighted health reform to their partisans, the incentives for Dem-
ocratic candidate John Kerry
to
repeatedly single it out
as
the nation's
top problem in his campaign against President Bush are not
as
strong
as
the incentives facing Democratic candidates in
1992.
Fig~e
I
Most
Important
Problems
Facing
the
Countryloday?
May
01
Warwar in
Iraq
0%
Economy 6.5%
Dissatisfaction
wlgovt
2%
Health Care 5.5%
Terrorism
2%
Unernployrnentljobs 5%
Education 7.5%
Feb
03
34%
21%
5%
2%
I
6%
6%
I
.5%
Jan
04
16%
20%
5%
5%
14%
I
2%
4%
Note:The question was worded as fol1ows:"What
do
you
think
is
the most impor-
tant problem facing the country today? [Record verbatim response, Probe for clarity
Do
not probe for addrtional mentions. If more than one mention, record all in order
of
mention.]"
Source: Pew Research Center for the People and the Press. January
2004.
News
Interest Index."Economy and Anti-TerrorismTop Public's Policy Agenda."
three quarters (77 percent) said they were not too satisfied
or
not at
all
satisfied with the availability and affordability of health care in Jan-
uary
1993.'
The combination of moderated concern about affordability and ac-
cess and intense anxieties over national defense appears to have con-
tributed to a noticeable decline in support for completely rebuilding
the health care system. Figure
3
shows that Clinton's proposal to
comprehensively reform health care financing and delivery during the
heady days of the
1992
campaign and his first year in office reflected
something approaching a "negative consensus" among Americans. In
1991
and
1992,
polls reported that about
9
out of
10
Americans con-
sidered the country's health care system in crisis. Forty percent
or
more of Americans believed our health care system had
so
much
wrongwith it that it needed to be completely rebuilt. Bycontrast,just
30
percent favored completely rebuilding the health care system in
the summer of
2003.~
Americans do not agree to the extent they did
in the early
1990s
that the status quo is sufficiently flawed that the
health care system needs to be rebuilt.
Health Policies that the Public Prefers
The diminution of the "negative consensus" to rebuild the health
care system coincides with only mixed support for specific reforms.
A
HSPH/ICR survey from May
30
to June
3,2003
asked respondents
to choose among four distinct policy changes to widen health insur-
ance
-
a
single payer system, a requirement that employers offer
health insurance to their employees, tax credits to buy private health
insurance, and expansion of state programs for low-income people.
None of the four approaches enjoyed particularly strong support; be-
tween
21
and "percent backed each
reform.
The authors of this
sur-
vey concluded that there
is
a
"lack
of
consensus on any single ap-
proach to helping the uninsured
[that]
has persisted now for a
number ofyears."g Although no single proposal
stands
out for
unusual
public support, this survey did find that about three-quarters
of
Americans agreed that it was extremely
or
very important to "provide
health insurance
for
most uninsured Americans"
(74
percent) and
456
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8r
ETHICS

Lawrence R. Jacobs
supported policies to guarantee health insurance for more Americans
by “expanding state government programs for low-income people”
(80
percent), “requiring businesses to offer private health insurance
for employees”
(77
percent), and “offering uninsured
tax
deductions,
credits, [and] other assistance”
(73
percent).
The lack of a “positive consensus“
-
namely, the coalescing of the
public behind one reform approach
-
reflects ambivalence among
Americans, intense opposition from stakeholders, and the inability of
even
advocates
Of
health
reform
to
‘Onverge
on specific proposals. The failure to find a “positive consensus,” how-
ever, is the rule rather than exception in the history of American
health care reform. Even on the eve of Medicare enactment in
1965,
lic ambivalence and intense opposition depressed SUPPOrt. A
March
and
only
a
plural%
Of
the Public supported
this
landmark reform; Pub-
Medicare over a private scheme by a
46
to
36
percent rnargin.lo Put
simply, intense public interest and support for specific reforms are
im-
portant but not sufficient conditions for successful reform; persistent
convergence of policy experts and government officials on a particu-
lar reform approach is also indispensable.
Stubborn
Resurgence
of
Health
Care
a
Campaign
Tool
with
the
polarization
ofthe
Democratic
and Republican
parties
and
their supporters,
80
percent
or
more of voters have already reached
a
decision
to
vote
for
I(erry
or
Bush.
The
critical
&allenges
for
each
sure
that his base
ofparty
supporters
turns
out
to
vote
and that he
wins
over
a
majority
ofthe
2o
percent
or
less
of
treat policy issues
as
a potent tool to rally the base and win over the
are
to
voters who have not yet reached a decision. Campaign strategists
v
the Democratic Party
or
“lean” in the Re-
publican direction.
1/93 1/94 1/95 1/96 1/97 1/98 1/99
1/00
1/01
1/01 1/03
Note:The data series used
to
generate this exhibit did not include an observatlon for every month.
Dots
on the
trend line indicate points where actual data were used.We assume a linear trend between actual observations.
“Don’t know” responses were included in the base when percentages were calculated.The question was worded
as fol1ows:”What do
you
think are the two most important issues for government to address?’
Sources: Harris Interactive polls, various years (Blendon et al,
2003).
Figure
3
Perceptions
of
Health Care Systems
Percent
I00
Crisis
in health care
I
L
____
~
~____
80
Need
to
40
completely
rebuild health
care system
20
President George
W.
Bush tried to take
a page from Bill Clinton’s political playbook
by promoting health care reform in order to
neutralize the substantial advantage that
Democrats have consistently enjoyed on the
issue in the country and among the high-
turnout seniors. In the fall of
2003,
the Bush
White House and its supporters promoted
the passage of Medicare reform to Republi-
can
skeptics in Congress on the grounds that
it would secure the President’s reelection
by
demonstrating the Party’s resolve to help se-
niors. Figure
4
indicates that the President’s
strategy initially worked during the summer
of
2003
as
Congress worked to pass legisla-
tion, which was enacted in November and
signed into law by Bush on December
8,
2003.
Polls of the public’s evaluations of which
major political party
will
“do
a
better job of
reformingthe
U.S.
health care system” show
that Democrats generally outpaced Republi-
cans
by more than
20
percentage points from
the
1990s
into
2002
(Figure
4).
The major
exception immediately followed the devas-
tating defeat of the Clinton plan in late
1994
when the Democratic advantage shrank to
7
01
I
I
I
I
I I
I
I
I
I
I I
points, though it rebounded back to the
20
point range within the year and generally
1/82
I
1/83
I
1/84
1
1/85
I
1/86
I
1/87
I
1/88
I
1/89
I
1/90
1
1/91
I
1/92
I
1/93
I
1/94
I
7/82 7/83 7/84 7/85 7/86 7/87 7/88 7/89 7/90 7/9
I
7/92 7/93 7/94
held steady over the next eight years.
Source: Jacobs and Shapim,
2000,
p.
224.
By summer and fall of
2003,
however,
NATIONAL HEALTH
REFORM
AND
AMERICA’S UNINSURED
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457

SYMPOSIUM
President Bush’s promotion of health reform helped to slash the
Democratic advantage. Republicans closed within
7
points in July and
the rating of Democrats slid to its lowest recorded level in October.
Future erosion seemed imminent in the aftermath of the Medicare
drug
benefit. Indeed, a December
15-17 2003
Princeton Survey Re-
search Associates poll found that a solid majority
(55
to
27
percent)
approved of the new Medicare legislation that “includes some cover-
age of prescription drug costs and changes the way Medicare covers
other medical expenses for senior citizens.”
A
December Gallup
sur-
vey similarly found a strong majority
(50
to
30
percent) in favor of
a “new Medicare law that deals with prescription drug benefits for
senior citizens and changes the way Medicare will cover the medical
expenses of some senior citizens.” Gallup also discovered that a plu-
rality of seniors
(65
and older)
also
favored the new Medicare legisla-
tion, though by a slimmer margin
(46
to
39
percent).
By
early
2004,
though, the criticism took root that the Medicare
reforms offered too little coverage of
drug
and other medical costs and
at avery high financial price. Gallup reported in March
2004
that the
majority that had favored the new Medicare legislation in December
had been replaced by ambivalence among all adults (who were split
41-35,
with
24
offering no opinion) and that seniors opposed it
-
only
36
percent backed it compared to
48
who opposed it
(16
percent of-
fered no opinion).
In addition, Americans began to doubt Republican stewardship of
health care policy.
A
January
2004
Hart/Teeter poll found that the
Democratic advantage had returned to
26
points (Figure
4).
A
Feb-
ruary
2004
poll by Opinion Dynamics survey for Fox News found a
similar Democratic advantage
(21
point gap), even though it
sur-
veyed registered voters rather than
all
adults.
The negative slant of public evaluation hurt Bush.
A
mid-January
ABC/Washington Post poll found that
51
percent disapproved of
Bush’s handling of Medicare compared to
36
percent who approved
of it
(13
percent “don’t know”).
A
survey by Gallup from January
29
to February
1,2004
found even stronger negativism:
57
percent dis-
approved of Bush’s handling of health care policy and
35
percent ap-
proved
(8
percent “don’t know”).
Polls
also
showed that Americans believed that Kerry would do
a “better job” than Bush on health care by
10
to
15
point margins.
A
March
2004
Princeton Survey poll found that
Kerry
enjoyed a
16
point advantage over Bush on health care even
as
a closely divided
electorate faced ferocious campaigning by Kerry, Bush, and their
allies.”
The silver lining for Republicans is that disapproval of President
Bush‘s handling of health care has not collapsed to the low levels ex-
perienced by his father. In
1991
and
1992, 60
to
69
percent disap-
proved of H.W. Bush’s handling of health care;
only
24
to
29
percent
approved.12 In
2004,
the Republicans’ Medicare reform has not
succeeded in stealing a Democratic issue
as
the White House hoped,
but it appears
to
have helped prevent the kind of crisis of credibility
that befell
H.W.
Bush.
Figure
4
Perceptions
of
Health Care Systems
Percent
10
01
I
I
1
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
I I I
1
I
I
I
1
I
May Jan Dec
Oct
Dec
Oct
Sep Sep Mar Mar Jun Jun
Jul
Oct
Jan
90 92 93 94 95 96
97
98 99
00 01
02
03
03
04
Note: Number above the Democratic plot
is
the number of percentage points by which Americans trust the Democratic
Party more than the Republican Party to handle heaith care.
May 1990,)an 1992. Dec 1993,
Oct
1994, Sept 1998,July
2003,
Pew Research Center for the People &the Press.”Which
political party the Republican party or the Democratic party do
you
think could do a better job
of
refoming the
US
health care system!”
Oct
1996, Gallup,”Do you think the Republican Party or the Democratic Party would do a better job of dealing with
each
of
the following issues and problems?.
. .
Health care policy”
Dec 1995. Sep 1997, Hart &Teeter.”(Let me read you some specific issues) When
it
comes to.,
,
dealing with the prob-
lem of health care..
.
which party do you think would do a better job-Democratic Party, the Republican Party, both
about the same, or neither?’
Mar 1999, March
20W,
July
200
I,
June 2002, January 2004, Hart &Teetec”When
it
comes to., .dealing
with
health care
...
which party
do
you think would do a better job-the Democratic Party, the Repubkcan Party, both about the same, or
neither?”
Oct
2003, Harris Interactive.”Which party do you think
is
more likely to do what
you
want about the heakh care issues
that are important to you?’
But the key concern of campaign
strategists in health care is not simply
how it is playing among all voters but its
particular traction among critical sub-
groups
-
especially, seniors who turn out
on Election Day at particularly high
rates. If the Democrats maintain
or
ex-
pand their advantage
as
the party trusted
to do the betterjob
on
health care reform
and President Bush continues to get
mixed reviews for his handling of the
issue, it will be avaluable tool to win sup-
port from seniors. Generational replace-
ment and other factors have contributed
to recent erosion in the tilt of seniors to-
ward Democrats; the negative reaction of
seniors toward the Medicare drug reform
may bring seniors back to the Demo-
cratic Party.
Indeed, the boost that the White
House expected from passing Medicare
failed to materialize and, in fact, appears
to be hurting the President. By
2004,
Keny
had
a
double digit advantage among
seniors.
For
instance, a March survey by
Princeton Research Associates found
that Bush held a slender
2
point advan-
tage among all registered voters but that
Kerry enjoyed an
18
point bulge in the
65
and older group
(53
to
35,
with Ralph
Nader drawing
4
percent).
The critical question is whether se-
niors and other voters will have health
care and Medicare foremost in their
minds
as
they enter the voting booth in
November. President Bush‘s emphasis on
fighting terrorism in the
post-9/11
world
along with the Democratic focus on the
economy and unemployment may well
diminish the prominence of health care
458
THE
JOURNAL
OF
LAW,
MEDICINE
&
ETHICS

Lawrence
R.
Jacobs
and prevent it from assumingthe top tier
Although Kew does not follow in
Balancing Public Opinion
status it enjoyed in
1992.
Government officials and other political
Comprehensive Health Care
comprehensive
Of
health
elites rarely comply with public opinion
Reform:
High Political
Risks
care financing and delivery,
his
in
a
mechanical fashion. Policy makers
and candidates weigh the views of voters
proposals will be far more
alongside the intense preferences of
and
Low
Benefits
The political payoffs of promoting health
care reform
as
the principal campaign
expensive and expand insurance
vocal, well-organized, and well-financed
theme in
2004
has been somewhat di-
Coverage to far Illore non-elderly
interest
groups*
minished by the arrival of national de-
Americans than the
Presidentk.
Strong public support for tax-financed
national health insurance is one of the
fense and economic renewal
as
the top
Clinton’s footsteps by proposing
and’nterest
concerns of voters. In addition to lacking
the kind of intense head-liner status it
enjoyed in
1992,
proposals for more than incremental reform face in-
tense opposition from well-organized groups. Not surprisingly, health
reform proposals from Democrats and Republicans have been tai-
lored to reflect the objectives of traditional interest group allies and
to avoid provoking intense opposition from the major health care in-
terest groups such
as
the
AARP,
the American Medical Association
(AMA),
the AFL-CIO, America’s Health Insurance
Plans
(AHIP),
Pharmaceutical Research and Manufacturers ofAmerica (PhRMA),
and business groups like the
U.S.
Chamber of Commerce.
John Kerry has ducked the kind of comprehensive reform that can-
didate Clinton proposed in favor of proposals that appeal to the mid-
dle class and to longtime Democratic Party constituents without
alarming business. Rather than calling for universal health insurance,
he is speaking to middle America’s concern about affording health
care by calling for incremental expansions of coverage through a
combination of tax credits and
an
expansion of existing government
programs including Child Health Insurance Programs and Medicaid
as
well
as
opening opportunities to enroll in group health plans like
the Federal Employee Health Benefits Program. Keny’s call to sub-
sidize employers to lower employee health insurance premiums and
to
stabilize and expand employment-based coverage simultaneously
supports one of the AFL-CIOs major objectives of inducing =ern-
ployers to pay their fair share” without intensely antagonizing busi-
ness groups like the
U.S.
Chamber of Commerce and America’s
Health Insurance Plans. Kerry’s focus on making children the prior-
ity
for health insurance coverage is also a priority of the AFL-CIO and
other Democratic activists. Although the
AARP
continues to support
the Medicare reform that President Bush and congressional Repub-
licans passed, Kerry appeals to seniors by promising to extend its
drug
benefits and
to
support other reforms backed by the
AARP.
Finally,
Kerry’s support for limiting medical malpractice by establishing an
independent review
of
claims and eliminating damages in
all
but
egregious cases is generally consistent with the
AMA,
though it does
not
go
as
far.
In these positions and others, Kerry is responding to the genuine
concerns ofvoters and critical Democratic Party constituents without
provoking a firestorm of opposition from traditional opponents of
health reform. Although Keny does not follow in Clinton’s footsteps
by proposing comprehensive reform of health care financing and de-
livery, his proposals will be far more expensive and expand insurance
coverage to far more non-elderly Americans than the President’s.
Bush’s proposals echo the views of critical interest groups
as
well
-
notably, the America’s Health Insurance Plans, Pharmaceutical
Research and Manufacturers of America (PhRMA),
AMA
and the
US.
Chamber of Commerce. Bush‘s plans to limit the damages a
plaintiff could receive for medical liability and tax credits for pur-
chasing private health insurance are supported by business groups
and the
AMA.
His Medicare drug legislation was aimed
at
luring se-
niors into Republican ranks, winning the support of
AARP
and ap-
peasing the PhRMA, even though it rankled some Republicans who
saw it
as
an inappropriate and unaffordable expansion of government.
--
most consistent findings in surveys for
most of the past three decades
or
longer.
About two-thirds of Americans in the late
1980s
and early
1990s
supported national health insurance, financed by tax money and pay-
ing for most forms of health care. Indeed, Bill Clinton’s pollster
(Stan
Greenberg) reported in
1993
that there was greater support for a
broad-based payroll
tax
than agovernment mandate that employers
provide health in~urance.’~ Support for tax-financed NHI dipped to
53
percent in
1994
after the Clinton administration failed to get even
avote
in
a Democratically-controlled Congress
on
its reform plan, but
rebounded to
61
percent by February
2003
in a HSPH/ICR survey.
The holdup on health care reform does not simply reflect, then, con-
fusion among Americans; political elites
rule
out some policies
or
dis-
agree over policies that enjoy strong and sustained public support.
Indeed, a growing body of research questions the influence of the
public’s policy preferences and suggests instead that government of-
ficials appear (particularly in recent times) to be disproportionately
responsive
to
the
intense preferences of business, the wealthy, and the
~rganized.’~
The
votes of
U.S.
senators have been found to corre-
spond far more closely with the policy preferences of each senator’s
rich constituents than with the preferences ofthe senator’s less-priv-
ileged c~nstituents.’~ In addition, national government policy more
generally also appears more than twice
as
responsive to the prefer-
ences of the rich
as
to the preferences of the least affluent.’6 Business
and other elites
also
exert far more influence than the general public
on
U.S.
foreign policy, which not only guides the country‘s diplo-
matic and defense
affairs
but also
has
powerfd consequences for do-
mestic economic conditions through decisions
on
trade and the pro-
tection and promotion of American jobs and businesses.’7
The strongest supporters and opponents of health care reform
-
from insurers, hospitals, and the medical profession
to
seniors and
or-
ganized labor
-
give generously to political campaigns and are among
the most active lobbyists in Washington.18Although contributors and
lobbyists rarely get away with literally bribing government officials,
their money and connections do buy them privileged access and the
opportunity
to
present selective information and make their case.’g
In short, the connection of public opinion to government policy is
complicated. Strong and sustained public support for health care re-
form
can
be
a
catalyst for reform but
this
kind of public focus is rare
and public views can be offset by the well organized and affluent.
Finessing
Health
Care Reform in
2004
In the context of public concern about health care that has not risen
to the level of strongly supporting a fundamental rebuilding of the
status
quo,
Bush and Keny are playing it relatively safe politically.
In-
stead of the stark contrast in
1992
between Clinton’s call for funda-
mental change and Bush senior’s tacit endorsement of the status
quo, incrementalism is back. President Bush has offered proposds
that partially insulate him from the “do nothing” charges that
hounded his father. Kerry has avoided comprehensive reforms that
are unpalatable to interest groups with the money and organization
to mount
a
politically damaging offensive and that credibly fuel
charges from Republicans of being too liberal.
NATIONAL
HEALTH
REFORM
AND
AMERICA’S UNINSURED FALL
2004
459

SYMPOSIUM
The cost of political rationality, however, is that the proposals
of
candidates Kerry and Bush may well seem opaque to the average voter
and difficult to differentiate. The legacy of
9/11
circles back around:
the heightened attention to national security has helped
to
bump
health care off the top of the agenda and to discourage candidates
from
proposing
bold
new reforms, which may in turn complicate the
efforts of the average voters to differentiate the positions of the can-
didates.
The
candidates appear to be largely to other issues
to
set
themselves apart from each other.
References
1.
R
Adams, “Health Care a Defining Issue for Democratic Candidates,”
CQ
Weekly, May
24, 2003,
at
1255;
US. Census Bureau,
Health Inxurance
Coverage
in
the Unitedstates:
2002
(Washington, D.C.:
U.S.
Department
of Commerce,
2003).
2.
M.M. Bouton and B.I. Page, eds.,with
L.R
Jacobs, RC. Longsworth,
S.
W,
C. Hug, and C. Whitney,
World~ews2002: American Public
Opinion
and
Foreign
Policy
(Chicago: Chicago Council on Foreign Relations,
2002).
3.
L.R
Jacobs,
RY.
Shapiro, and E.C. Schulman, “Poll llends: Medical Care
in the United States
-
an Update,”
Public
Opinion
Qmrterlg
57,
no.
3
(1993): 394-427;
L.R. Jacobs, “Health
Reform
Impasse: The Politics of
American Ambivalence Toward Government,”
Journal of Health Politics,
Policy, andLaw
18
(Fall
1993): 629-55.
4.
The Harris poll
(Louis
Harris andhsociates
1992)
found that the economy
and candidate
character were the top
two
issues while the Roper poll
(Roper
Center
1992)
reported the economy and budget deficit received top billing.
5.
L.R
Jacobs,
Policy Dumps Politic8
in
the
Choicea
of
Voters
in
Democratic
Primaries and CauctLses,
A Study by the
2004
Elections
Project, Humphrey
Institute, University of Minnesota Website,
at
<
http://www.hhh.umn.edu/
centers/csp/elections/policy-trumps.pdf>
(last visited July
22, 2004).
6.
The question read, “Next I’dlike you to rate your satisfaction with
the
state
of
the nation in some different areas. For each of the following
areas,
please
tell me whether you are very satisfied, somewhat satisfied, not
too
satisfied,
or not at
all
satisfied. How about the availability and affordability of health
care?”
The
sources
were a Gallup/CNN/USA Today poll
(1993):
Harvard
School of Public Health/Robert Wood Johnson
Foundation/International
Communications Research poll
(2003).
7.
Jacobs, “Health Reform Impasse: The Politics
of
American Ambivalence
Toward Government,” supra note
3.
8.
The
question wording was
the
following: Which ofthe following statement
comes closest to expressing your overall view of the health
care
system in
this country?
(1)
On the whole, the health
care
system works
pretty
well and
only minor changes are necessary
to
make it work (better),
(2)
There are
some
good
things in
our
health
care
system, but fundamental
changes
are
needed to make it work
better,
(3)
Our
health
care
system has so much
wrong with it that we need to completely rebuild it,
(4)
Not sure/don’t
know.n
The
1991
polling results were found in both a CBS/NW
poll
from
August
1991
and a Harris poll in November
1991
(see
Jacobs, Shapiro, and
Schulman, supra note
3).
The
2003
polling
results
were found by a
13-27
July
2003
CBS/NYT poll.
9. R.J. Blendon, J.M. Benson, and C.M. DesRoche, “Americans’ Views of the
Uninsured: An Era for Hybrid Proposals,”
Health Affairs
Web Exclusive
(August
27, 2003):
w3-409, at
c
http://content.healthaffairs.org/cgi/
reprint/hlthaff.w3.405~1>.
10.
L.R
Jacobs,
The
Health
of
Nations: Public
Opinion
and the Malcing
of
American
andBritish Health Policy
(Ithaca,
Ny:
Cornell University Press,
1993): 192;
The question wording was the following: ‘Ifyou had to choose
between a federal law which would provide medical
care
for the aged by a
special
tax,
like Social Security,
or
a plan of extended private health insur-
ance, which would you choose?”
11.
The
wording ofthe question
is
the following: “(Regardless ofwhich
(2004)
presidential candidate you support, please tell me if you trust
...
George
W.
Bush
or
John
Kerry
to
do
abetter
job handling each of the following
issues.)
What about
...
health
care,
including Medicare? Which do you trust
to
do a
betterjob handling this issue
...
Bush or
Kerry?”
12.
Jacobs, Shapiro, and Schulman, supra note 3.
13.
Jacobs, Shapiro, and Schulman, supra note
3;
L.R
Jacobs and
R
Shapiro,
Politicians Don’t Pander: Po1itim.l Manipulation and the
Loss
ofDemocratic
Responsiveness
(Chicago: University of Chicago Press,
2000): 98-100.
Also,
see
Jacobs supra note
10.
14.
Jacobs
and
Shapiro, id. American Political Science Task Force on Inequal-
ity and American Democracy (Chaired by
L.R
Jacobs), “Inequality and
American Governance.” Available at
<http://www.apsanet.org/Inequal-
ity/govemancememo.pdf> (last visited July
26,2004).
15.
L.
Bartels, Economic Inequality and Political Representation, paper pre-
sented at
The
2002
Annual Meeting of the American Political Science
As-
sociation, Boston, August 29-September
1.
Available at <http://www.
princeton.edu/-barteIs/papers>
(last
visited July
27,2004).
16.
A
10
percentage point increase in support for policy
change
among the
wealthiest (i.e. those in the 90th percentile ofthe income distribution) was
associated with a
4.8
percentage point increase in
the
likelihood of a cor-
responding policy change; the preferences of the poorest (it. individuals in
the loth percentile of the income distribution) produced only a
2
percent-
age
point increase in the likelihood of
a
corresponding policy shift. M.
Gilens, Unequal Responsiveness, paper presented at the Inequality and
American Democracy Conference, Princeton, New Jersey, November
7-8,
2003.
17.
L.
Jacobs and B. Page, Who Influences US. Foreign Policy
Over
Time?
Amen’cnn
Political
Science
Review
(November
2004;
forthcoming).
18.
D.M. West and
B.
Loomis,
~eSoundofMooney:ff~Poli~caEInte7estsget
What
They
Want
(New York: W.W. Norton,
1999).
19.
R
Hall and F. Wayman, “Buying Time: Moneyed Interests and the Mobi-
lization of Bias in Congressional Committees,”
American Political
Science
Review
84,
no.
3 (1990): 797-820.
460
THE
JOURNAL
OF
LAW,
MEDICINE
a
ETHICS