As numerous pre-election polls have made very clear, except in a few selected races, health care is playing a relatively minor role in determining the outcome of the 2006 midterm election. As a result, elected officials will arrive back in Washington with little pressure from voters to change the current direction of the country’s health care system.

Why is this so? Surveys conducted every two months at the Kaiser Foundation consistently show that health care is a top personal and family economic worry. People worry more about the costs of their health insurance going up than paying the rent or mortgage or being the victim of a terrorist attack. Similarly, other polls [2-week free access] report high levels of dissatisfaction with the current health system and support for fundamental changes. But in this election cycle, other issues -– most notably Iraq -– are paramount, and voters are not taking their worries about health to the voting booth.

Difference Between Today And 1990s

This is one of the biggest differences between the current era and the early nineties, when health reform last had salience as a national issue. In the early nineties there was no war in Iraq, no 9/11, and no lingering memory of Hurricane Katrina to capture voters’ attention. But something else also happened in the early nineties that transformed the political landscape for health that is missing today: In his senate race in Pennsylvania, Harris Wofford demonstrated for the first time that a candidate for national office could tap into the public’s underlying concern about health insurance and health care costs to help win an election. President Clinton picked up on that, made health care a top priority, and with the First Lady put forward his ill-fated reform proposal. Media attention and a superheated national debate followed, and health reform captured center stage, demonstrating that the national agenda does not just bubble up from the bottom but is driven by political leaders and media coverage from the top.

In sharp contrast, today none of the politicians most often mentioned as candidates for the presidency in 2008 are talking much, if at all, about health reform, and there is no real national debate. One poll trend demonstrates the differences between the two eras vividly: In October 1993, 55 percent of the American people named health care as one of the two most important issues for government to address; that number fell to less than 10 percent in 2002, was 11 percent in November 2005, and is now consistently below 15 percent.

Surveys show that the underlying level of public concern about health care issues today and in the early nineties is about the same. It is the presence of other issues winning voters’ attention and the absence of leadership by political figures on the health issue that explain why health care reform has little real political appeal today. Imagine the debate on health care today, or where it would stand in the polls without 9/11 and Iraq, or if the would-be candidates for Congress and the presidency had been on TV debating changing our current system.

Health Reform Needs To Be A Central Issue In 2008

For health reform to again gain a foothold at the top of the national political and policy agenda, it needs to become a central issue in the 2008 election campaign, so that candidates who are elected to office and the new president feel that they were elected, at least in part, to address the nation’s big health care problems when they start work in 2009. This is by no means guaranteed, but there is a scenario under which it could happen. First, if we are fortunate enough to see external problems like Iraq stabilize or subside and no new big ones arise, health would have the opening it needs to compete for center stage as an election issue. Second, as Americans pay more and more each year out of their own pockets for health care, they will become increasingly concerned about health as a voting issue and policy priority.

But what health needs most to rise up in American politics is for national political candidates, whether from the political left, right, or center, to begin talking about the issue again as they did in the early nineties. Most important of all are the presidential candidates, who receive so much national media attention. If even one major candidate begins to seriously address health reform, the others will be forced to follow suit. The presidential candidates’ level of attention to health will be decisive to where health ranks on the national agenda going into the 2008 election and 2009 Congress. If they do play a leadership role on health, the media will follow, and the agenda-setting power of a debate driven from the top will meet the public’s concerns rising up from the bottom like two weather fronts colliding.

The candidates need not have a detailed plan for their opponents to pick apart. The details can come later when they seek agreement with Congress if they are elected. History will recall that Senator Wofford had no plan.

The Next Opportunity For Action

The next significant moment of opportunity for national legislative action on health reform will not come until 2009, but it will not come at all unless the issue rises between now and then. If it does, formidable obstacles will still remain, such as reaching agreement on a plan of action and on a way to pay for it. But unless politicians believe that they were elected to solve this problem, they are not likely to want to do the heavy lifting necessary to take on these tough issues.

Public concern about the state of health care today is not enough to move this issue forward by itself. We poll the public all the time, and we believe that it is unrealistic to expect public opinion, on its own, to reach some new tipping point that will create a tidal wave for health reform. For health to compete more effectively with other issues on the national agenda, it will take leadership in the form of visible political candidates willing to champion the issue, and the media attention that follows. Greater attention on the part of all interested in achieving change in American health care should be directed towards that goal, and towards developing policy proposals that can bridge the ideological divide and provide a basis for legislative action when health reform makes it back to the national agenda. Unless these things happen, we are unlikely to see major change in health care in the foreseeable future.