Every big health reform plan has tradeoffs and winners and losers — no exceptions. It’s not really a huge contribution to voters for debate moderators to find elements of the candidate’s plans they can nail them on. Voters don’t focus on the details of plans; they use them as proxies or signals to figure out what candidates are really about and how they differ from other candidates. What voters really need to know is where candidates would take the health system, how they differ from other candidates on direction and basic choices and what that says about the kind of president they would be.
No plan proposed today will become law in any recognizable form. The details of any plan — the role of private insurance, new taxes, consumer cost sharing or how much providers are paid — will all be subject to heavy negotiation and compromise as they are written into legislation, get a score from the Congressional Budget Office and face scrutiny from the two parties and lobbyists.
Many candidates, if nominated, will also do the time honored pivot toward the center for the general election, modifying their approach to appeal to independents and swing voters in critical states.
We also know that issues — health care or any other — are only one factor voters care about. The fact that health care is the top issue in the election does not mean it will be the top factor in the vote. In the 2018 midterm elections, 73 percent of voters said a candidate’s character and experience was a top factor; 66 percent said the candidate’s support or opposition to President Trump was most important; and 66 percent voted based on their party affiliation.
We recently conducted focus groups with likely voters in swing districts across the country. Some conclusions:
- Voters are not tuned into the details — or even the broad outlines — of the health policy debates going on in Washington and on the campaign trail, even though they say health care will be at least somewhat important to their vote. Many had never heard the term “Medicare-for-all,” and very few had heard about Medicare or Medicaid buy-in proposals.
- When asked what they knew about Medicare-for-all, few offered any description beyond “everyone gets Medicare,” and almost no one associated the term with a single-payer system or national health plan.
- One focus group participant said: “You listen to it but it all sounds like the teacher on Snoopy – wah wah wah.”
- Overall voters were focused almost entirely on their out-of-pocket costs, not the merits of policy proposals, which they could not easily connect to their own difficulty paying medical bills.
Nothing will be more important than the details of plans when — and if — we get to legislation. For now, the most important thing voters need to know is whether a candidate is for a single national health plan such as Medicare-for-all or is instead for building on the Affordable Care Act and setting up a new public plan as an option. That tells voters where candidates stand on the role of government and on spending, as well as where they are on the ideological spectrum relative to other candidates. Both approaches signal that candidates want a greater role in expanding government involvement in our health-care system, but the former falls on the progressive side of the Democratic Party whereas the latter leans toward the more moderate wing. Drawing out these basic differences rather than focusing on details or gotcha questions could provide an enormous public service.
The voters, it seems, are smarter than the experts, the pundits and the media. They are looking for fundamental differences between the candidates. They don’t have Plan-itis.