The Politics of Health

In almost all recent polling, voters say health care is their number one concern. They also trust Democrats more than Republicans on the issue.

But why?

Obamacare is the most flawed health system Americans ever created. If you combine the average premium and the average deductible people faced last year, a family of four with Obamacare insurance had to spend $25,000 before getting any benefits from their Obamacare plan. And in most places, the best doctors and the best hospitals are not included in Obamacare plan’s narrow networks.

By contrast, Trump era reforms were a godsend when Covid struck . Because of a Trump executive order, seniors on Medicare have been able to talk to their doctors by phone and email and receive virtual consultations in the comfort of their own homes. Another Trump executive order lets employers give their employees individually owned insurance they can take with them—from job to job and in and out of the labor market.

Covid vaccines became available at least six months earlier than anyone thought possible because of Trump’s deregulation of vaccine production—before Covid hit. University of Chicago economists estimate this regulatory change saved an estimated 182,000 lives.

So why do Democrats do so much better than their Republican rivals when voters think about health care? Because Democrats are much better at following five rules for how successful candidates should talk about the subject.

Rule 1: Talk about benefits, not about how benefits are created. Bernie Sanders is a master at this. Everyone who hears “Medicare for All” immediately thinks they will get first rate care, mainly paid for by someone else. Sanders rarely makes the mistake of talking about how we would get 156 million people from an employer plan to a Medicare-for-all plan or who would pay the taxes to fund all of that.

Republicans, by contrast, almost always talk about how they want to reform things, never about how anyone would benefit. For example, the Republican alternative to Obamacare (which almost passed Congress) would have sent all the Obamacare money to the states in the form of a block grant .

How would a block grant lower anyone’s deductible or give them access to better care? Since that was never explained, it was anyone’s guess.

Rule 2: Talk about people, not about complicated rules. Democratic talking points almost always focus on pre-existing conditions or the high cost of drugs or other real problems faced by real people. Republicans, by contrast, want to allow association health plans, allow insurance to sell across state lines, abolish certificate-of-need laws, and use antitrust laws to go after hospital conglomerates.

The Republican ideas may be commendable, but how do they help you? You can be forgiven if the answer isn’t obvious.

Rule 3: Focus on people who vote. Obamacare was originally designed to insure the uninsured, and that’s how the Democrats initially tried to sell it. But then Chuck Schumer discovered a very important fact: almost everyone who votes already has insurance. That meant Obamacare would spend billions of dollars on people who don’t vote.

So, on the eve of passage, Democrats made a mid-course messaging correction. From that point on, their every speech about Obamacare focused on working families. These were voters who might worry about being denied coverage because of a preexisting condition if they retired or became too sick to work and had to turn to the individual insurance market.

Never mind that preexisting condition denials rarely ever happened. Democrats quickly learned how to talk to people whose votes they needed.

Republicans, by contrast, miss just about every opportunity that comes their way. While the Obamacare exchanges have faced one embarrassing problem after another, there is a Republican-created exchange that works really well. It’s called Medicare Advantage. Democrats used to attack this program, but since it now serves about 40 percent of all seniors and is really popular, they don’t talk about it at all.

Seniors vote in higher percentages than any other age group and Republicans could be bragging about the program they created and how much better it works than Obamacare.

Have you ever heard them do that? I haven’t.

Rule 4: Advocate changes that are easy to understand and obviously different from an opponent’s position. Sometimes Republican candidates say they advocate high-quality, low-cost health care. The problem? Democrats advocate the same things. Sometimes Republicans say the two parties agree on goals but disagree on how to get there. The problem? If the Democrat solution is simple and the Republican solution is complicated, Democrats win.

Suppose a Republican runs against government policies that create outrageously high out-of-pocket exposure and close off access to the best doctors. Most voters will know exactly what problems are being addressed and which party created them.

Rule 5: Don’t bow to special interest pressures. As Steven Brill has documented, Obamacare was created by special interests. Big Insurance, big Pharma, big hospitals and big business—they all sat around a table and designed the whole program. Without their participation, Obamacare would not have passed.

Yet, Democrats rarely hesitate to bite the hand that feeds them if there is political advantage in doing so. In no time at all, such terms as “greedy drug companies” and “greedy insurers” cropped up in their speeches.

Republicans, by contrast, are hampered by misplaced loyalties. They never held a single hearing on Obamacare’s victims. Apparently, this was at the request of insurance companies who feared Democrats would blame them for Obamacare failures if the hearings took place.

Republicans would be wise to learn what Democrats seem to know instinctively. The special interests have no lasting loyalties to either party.

Putting the rules to work. All too often politicians who follow our rules advocate bad policies, while the rules are ignored by politicians with better ideas. How can we fix that?

For the past two years, more than 70 think tanks and advocacy organizations have been working on what health reforms are most needed . Marie Fishpaw (Heritage Foundation) and I are now developing ways to communicate those reforms so that they appeal to voters.

For starters, families need to be able to buy health insurance that meets their medical and financial needs, instead of insurance with sky high deductibles and unaffordable premiums. They also need to be able to buy insurance that gives them access to the doctors and hospitals they need.

Many of the Trump Administration’s good reforms were accomplished by executive order. They can be undone by a Biden administration executive order or even by an act of Congress. One reason these reforms are so vulnerable is that Trump himself did a poor job of communicating his own health care accomplishments.

In the coming weeks, we will have more to say on how health reform can be both responsible and have vote appeal.