Editor’s Note: In connection with the publication of its May/June issue, a thematic issue on health reform, Health Affairs organized a May 5 conference call on the role of health reform in the presidential election. The call was moderated by Health Affairs editor-in-chief Susan Dentzer. Participants included Robert Blendon, a professor of health policy and political analysis at Harvard University and director of the Harvard Program on Public Opinion and Health and Social Policy; Robert Laszewski, the president of Health Policy and Strategy Associates Inc. and the author of the widely respected blog Health Care Policy and Marketplace Review; and Julie Rovner, a health policy correspondent for National Public Radio and a contributing editor for National Journal’s CongressDaily.

The transcript of the call appears below, and a shorter post featuring highlights from the call is also available. Check the Health Affairs Blog in the coming days for more blogging based on the new Health Affairs issue and on the May 13 event on health reform sponsored by the journal.

SUSAN DENTZER: How is the debate over health care reform playing in the current election campaign? Bob Blendon, since you have your finger on the pulse of the American public, let’s start with you.

ROBERT BLENDON: I think health care reform is part of the split that we see in who’s voting for Senator Obama and who’s voting for Senator Clinton, but it’s not the way we normally describe it. The differentiation is not around the policy debate about who has a particular mandate or not in his or her plan. It’s around who’s likely to carry the battle through.

The voters who haven’t finished college are increasingly seeing Senator Clinton as the scrapper, the fighter who will get things done. And better educated people see Senator Obama transforming the way politics and policy will be made, and he will have a way of reaching across the aisle. So the issue is important in the way that people perceive the leadership skills of the candidate, but not on the substance of the proposals.

SUSAN DENTZER: Bob Laszewski, how do you see it? And let’s not just talk about the Democrats, since on the Republican side, Senator John McCain has been talking a great deal recently about health care as well.

ROBERT LASZEWSKI: Interestingly, McCain really got into the details for the first time and said some things about how he would make his health care system work better. But it’s way too soon to know what kind of reaction we’re going to have there.

Looking at the Kaiser Family Foundation’s tracking poll data, the country continues to be split right down the middle between the Democratic approach to health care reform — building on existing systems and dealing with the insured -– and the Republican approach of using the individual health insurance markets as the basis of a new system, and focusing on health costs.

McCain clearly tried to respond to the half who believe that cost and moving toward individual-controlled health insurance is important. I was surprised, and I’m going to be very interested to see what the reaction is going to be as we get into the heart of this campaign, in that McCain did very, very little on the issue of what do you do with people with pre-existing conditions. You know, everyone either has a pre-existing condition or thinks they’re going to have one in the next six months, and I’m not sure from a policy perspective he did a very good job there. But he clearly responded to the 50 percent of the people who think cost and moving toward an individual-based system are the things to do.

SUSAN DENTZER: Julie Rovner, what’s your perspective?

Will Health Care Be Overtaken By Other Issues In Voters’ Minds?

JULIE ROVNER: The conventional wisdom among political reporters is that health care is being subsumed by bigger economic issues, particularly gas prices, and that’s certainly what we’re seeing play out right now. But I think if you look at the Kaiser polling, health care costs are a rather large subset of economic concerns. Certainly as gas prices go up, people get more and more worried about being able to pay other bills, particularly health care bills.

I’ve been out in the middle of the country the last couple of weeks, and I don’t see any waning in people’s concerns about health care costs. I think the fact that McCain is emphasizing health care suggests that there’s something that his pollsters are saying that people are still awfully concerned about health care. So I think to write health care off at this point as a major issue for the general election campaign is probably a mistake.

On the other hand, I think the one thing we’ve seen so far with this campaign is that, boy, you can’t predict anything. So I’m not ready to predict a whole lot about what we’re going to see going forward.

ROBERT BLENDON: I think the health care issue is actually going to be bigger than people think, and there are two reasons. One is that people are getting extremely frustrated by what has happened in the Democratic primary contests. The issues just aren’t being addressed, and yet there’s a hungering to have a great debate over issues.

Senator McCain came out with a health care plan and framed it in a very philosophical way. The majority of voters in 2008 will not have graduated from college. They will have not a taken a graduate course in economics. And so what they’re looking for are very big differences in values and beliefs.

So what’s going to happen is a small number of issues, on which the candidates’ positions can be easily understood as fundamentally different, are really going to be debated, and health care is going to be one of them. And Senator McCain has framed this in a way that people can make a real choice. Do you want basically individuals in the marketplace, or do you want government fixing the employer system? Do you want something big done about the uninsured or not? And he put it in a way that someone didn’t have to have gone to college to understand what that debate is about.

How Will The Philosophical Debate Over Health Care Be Resolved?

ROBERT LASZEWSKI: Bob, is there any preliminary data to tell us which side will win when the choice is framed that broadly?

ROBERT BLENDON: Generally, we know from almost all the earlier polling that middle-income people who have insurance, who make up the bulk of independents, are risk-averse for big changes. So we’re going to be in an odd situation in that the conservative candidate, McCain, could sound like he proposes the biggest change — pushing away from employer-based insurance and actually putting people in a market where they’re more at risk. For people who now have protection against cancer, or Alzheimer’s, that is going to be tough for them, and they will get worried.

But otherwise I think there is going to be a fair debate about this, and people are really going to think about it. The differences are so wide that it’s going to be easier for audiences to be interested in the debate. It’s not just a whole series of little policy differences; it’s about philosophy. My gut feeling is that people will lean more towards the security of the Democratic side.

SUSAN DENTZER: Julie, when you’ve been out in the heartland, as you said, are people picking up on this philosophical distinction that Bob Blendon just talked about?

JULIE ROVNER: Oh, I think absolutely. In fact, I continue to be surprised by the support I see for a single-payer approach to paying for health care. I was in Kansas a couple of weeks ago at a church, and I finally asked the audience of about 300 how many people would like to see a single-payer plan like they have in Canada, where the government provides the financing for the system. About 80 percent of the people raised their hands. I was stunned by this. It’s not just a matter of people wanting the security of what they have now. People, if anything, want to go more towards the government and less towards the market.

Now, clearly, that was not a representative of the population as a whole. I’m not suggesting that there is a groundswell of a majority for a single-payer system, but I am suggesting that as people see costs go up, I think they are looking more towards the government and less towards the private market as a way to protect themselves. Every week you see Exxon’s profits go up. It’s not the market that seems to be doing good things for them right now. I’m not sure this is the year to be advertising market forces and health care.

SUSAN DENTZER: We’ve just said that voters will not be paying attention to the details of health reform plans, but our May/June 2008 Health Affairs issue devotes much of its coverage to the details. It deals with tax options that might be available to finance health care reform, as well as the good old question of estimating the costs of reform proposals. And as we know from previous health reform debates, when the Congressional Budget Office and others have gotten into the game of estimating what health reform plans have cost, that has had a definite impact on the debate.

Bob Blendon, are people continuing to think about efforts to expand coverage and tying it to the notion that this could potentially mean higher taxes for all of us, or certainly a change in the tax regime? Are they leery about a major health reform push because of that issue?

ROBERT BLENDON: Leaving aside the philosophical debate, there are three issues that will get a lot of visibility. One is the one you just mentioned. The opponents of the Democratic plans –because those plans are larger — will add up everything the Democrats propose and come up with a huge number, and what it will imply to a lot of people is they could be hit by a tax increase. So that will be one of the issues, and people will struggle to figure out what it will cost them.

The second issue that people will focus on, because Senator McCain has just paid so much attention to this, is that if I have insurance in the workplace, what’s this $5,000 tax credit he proposes going to do for me, or not? So for most voters, it’s not going to be a question of whether or not this helps the uninsured; it’s going to be whether or not I’m going to be better off or worse off if this change occurs.

And the third issue Bob Lazewski hit, as did Elizabeth Edwards, which is something that is not a large part of the actual health care problem now because most people aren’t buying insurance on the individual market. It’s this issue of whether or not you allow policies to be sold that don’t cover pre-existing conditions; is it possible that more and more people with cancer and AIDS and Alzheimer’s are not going to be able to get decent insurance?

That’s three things I believe you do not need a college degree to understand the gist of, and can vote on. These will really be very important to average voters, and I think the expert community has a lot to say here.

ROBERT LASZEWSKI: I would add one other bullet point to that, which I think reinforces what you’ve just been saying, Bob, and that is that there’s going to be a debate over whether we abandon the employer-based system of health coverage. The employer-based system is something everyone understands, and people who vote are largely covered in the employer-based system.

And give McCain the credit, he does have the most radical, if you will, health care reform plan here, and I don’t say that in a critical way. The Democrats have really an incremental system. It may be a $100 billion dollar incremental system, but it’s an extension of where we all sit right now, employer-based coverage and so forth. He’s talking about moving from a defined-benefit system to a defined-contribution system, doing with health care what we did the pension system over the last twenty years, as we moved from defined-benefit, fixed-benefit, pension plans, to 401(k) kinds of plans. The problem is this is a much bigger leap. When you look at who’s satisfied with the health care system in the United States, it’s people who are in a good employer-based plan. Walking away from that is a huge thing to ask them to do.

So I think this is going to be a combination of the Democrats saying McCain wants to ditch the employer-based system and throw you into the individual market where, if you have a pre-existing condition, he’s going to chat with the governors about what he’s going to do with you after he is elected. I mean, there is a lot of opportunity to throw fear into the system, fear that everyone can understand.

SUSAN DENTZER: Bob Laszewski, staying on that point, McCain is not only talking about an individual market that works — as distinct from the one we have now, that doesn’t — but also a series of high-risk pools around the country that states would run, that the feds would contribute to as a way of providing this GAP [guaranteed access plan] coverage for people who would otherwise be uninsurable. In effect, he proposes taking models already in use, like these high-risk pools, and actually making them work, in a way that we haven’t been able to see them work before. Do voters really understand what the issues are behind these proposals, and do they really see these mechanisms coming into being and working?

Will McCain’s Plan Protect Those With Pre-Existing Conditions?

ROBERT LASZEWSKI: At a policy level, we really haven’t had any of these state pools work well. I have a great deal of respect for McCain’s proposal and for the fact that he wants to transform the system. So I want to put this in the right context, that I’m not necessarily critical of the direction he’s going. But I can’t believe his GAP proposal.

I spent 35 years in the insurance industry. He could have stood up there and looked everyone in the eye and said, “I want to go in the individual direction, and I will offer health insurance proposals that will cover everyone.” And he could have done that without extraordinary mandates and so forth. We just did it with the Medicare Part D drug benefit. We just offered an individual policy, voluntary to the marketplace, and covering people’s pre-existing conditions — and people over sixty-five have a lot of pre-existing conditions. McCain could have guaranteed access to everyone, and instead what he said was, We’re going to use these high-risk pools, and we’re going to figure it out. “I’m going to go talk to the governors after I’m elected.” That’s what he said. And I think that it’s so easy for the Democrats to scare the hell out of voters just on those issues.

It gets back to what Bob Blendon says: what are the things that people can easily understand? They can easily understand that high-risk pools have never really worked well before. The Democrats can show any number of train wrecks in that regard. And I’ll figure it out after the election, trust me. You know, if you’re asking people to make this leap away from the employer-based system that everyone loves, get to the voters’ level. They aren’t going to get into the details of what’s good and bad about the employer-based system, whether a third-party payment system is right or not. What these people know is, when I’ve got employer-based health insurance, I’m set, I’m taken care of. Now he’s asking us to take this jump off the end of the pier with him, into something that it’s going to be very easy for the Democrats to point out doesn’t work very well: the individual insurance market, the high-risk pools. He needed to describe an individual insurance system that people felt like they could jump into and not crash.

Have The Democrats Been Realistic About Financing Their Plans?

JULIE ROVNER: On the other hand, the one thing that McCain is going to be able to do is pin the old tax-and-spend label on the Democratic candidate. The idea that you can pay for these plans by simply letting the Bush tax cuts expire does not hold up, and the Democrats know it and McCain knows it. If you want to do the Democrats’ plan, you’re going to have to raise taxes.

SUSAN DENTZER: And the Democrats, I think it’s fair to say, have been completely unrealistic about the financing that will be required by their plans. Julie, is that picked up on by voters?

JULIE ROVNER: Absolutely, I think the voters know this. To do either of the Democrats’ plans, which fundamentally are the same other than the mandate issue, would be quite expensive, and they have absolutely ducked on the cost issue.

Scoring By The Congressional Budget Office:
Will It Play A Crucial Role Again?

SUSAN DENTZER: Let’s move to another area that our Health Affairs issue deals with, which is the question of how to score, in a budgetary sense, these various plans. Again, it’s hard to believe that voters have this on their minds, but we know from the last debate that scoring can play a very critical role in determining whether any policy proposal that any president makes has any legs to it or not.

Let’s say it’s a year from now. We have a new president. We have a plan proposed to Congress and perhaps marked up as legislation. The Congressional Budget Office goes to work scoring it. We know from the last debate that the way CBO scored the Clinton plan did have a role in defeating it. Bob Blendon, how do you think that things could potentially play out next year in this regard, assuming there are major reform proposals put forward by the president and Congress? Is scoring likely to be determinative, or is the will on the part of the public to get something done going to transcend that?

ROBERT BLENDON: From the public perspective, scoring has a few issues, but the most important point is that whoever is president will want to do their plan, arguing it’s almost budget neutral. And CBO may or may not allow them to do that. If not, backers of particular reform proposals have to come up with additional financing in the form of taxes. In California’s recent efforts to enact health reform, the need for additional taxes emerged. And if scoring of national proposals for reform indicate that new taxes will be needed, it’s going to be a different debate.

The two other issues that are going to show up are whether or not middle-income people are going to be better or worse off, and, if there are employer mandates, whether or not there would be estimates of how many jobs would be lost.

SUSAN DENTZER: Just last week the CBO took the bill proposed by Senator Ron Wyden from Oregon and Senator Robert Bennett from Utah, which has picked up a lot of bipartisan support, and scored that as budget-neutral. Bob Laszewski, does that give an edge to that particular plan?

ROBERT LASZEWSKI: Absolutely. While Bob was talking, I pulled out from my stack last week the Wyden-Bennett revenue-neutral report. The Congressional Budget Office and Joint Committee on Taxation said that the health care plan would be fully operational by 2012, and become budget-neutral by 2014. Watch Wyden-Bennett.

Talking about what happens before the election, I think the good news here is we finally have a health care debate that is not going to be buried in the minutiae. As Bob Blendon pointed out early in this conversation, there are easy philosophical choices for regular people to make, and they will make those choices.

What remains to be seen is when the election is decided, will we have 50 percent of the people having made once choice and 50 percent of the people having made another choice. Today’s polling seems to indicate that’s where we’re going to come out, and if we have a Democratic president and a Democratic Congress, it still isn’t going to be easy. If we have a President McCain and a Democratic Congress, where are you going to compromise if, in fact, you’re able to compromise? So watch Wyden-Bennett, because Wyden-Bennett gives everybody something. It moves the system from the employer-based system, the third-party payment system that Conservatives are very worried about, to an individual system, but an individual system with a pretty good safety net, and a financing mechanism.

JULIE ROVNER: And a way to cover people with pre-existing conditions.

SUSAN DENTZER: And Julie, last word to you. Did you hear any comment on the Wyden-Bennett bill when you were out consulting with voters in the heartland?

JULIE ROVNER: I didn’t. I think it’s still kind of a stealth bill, but I’ve also been watching it with a lot of interest, and I think it was very significant last week when CBO and Joint Tax came out and said that it would be revenue-neutral.

SUSAN DENTZER: All right, we will wrap it up there. Thank you all for your very astute comments.