Health-Care Issues and Voter Apathy
Fourth Quarter 2006
Senator Joseph Lieberman did not lose the Connecticut Democratic primary because of his stance on embryonic stem cell research, Medicare Part D, or the spiraling cost of health insurance. The Iraq War was the defining issue. In Georgia, Ralph Reed's bid for the Republican nomination for Lieutenant Governor fell short because of his entanglement with disgraced lobbyist Jack Abramoff, not because of his stance on Medicaid funding or expansion of health care for children. Michael Shiavo's campaign (including a Political Action Committee) against incumbents who voted for a federal law to keep his wife, Terri, connected to nutrition and hydration is highly unlikely to affect substantially those candidates' chances of reelection.
In short, health-care issues will not have much effect on the coming mid-term elections. It is instructive to reflect on why this might be so, despite the overwhelming dissatisfaction of Americans with their health-care system, a dissatisfaction expressed repeatedly over the last decade in public opinion polls. More significantly for readers of the Public Justice Report, what does this lack of impact say about citizenship and public justice?
Think first about the largest questions facing medical care in the United States.
1. Access to care and insurance expansion. The number and percentage of persons without health insurance grows over a million persons each year, with no end in sight. About 47 million persons (16 percent of the population) are uninsured. The evidence is clear that persons without insurance have worse health and health-care outcomes than insured persons, and they suffer major financial setbacks if they need medical care.
For Christians the injustice of this unequal access is a moral affront. It is a personal affront as well, since it is the rare parishioner who does not know someone in the congregation, in his or her family, or in the workplace, who lacks insurance and has put off needed medical care.
Some state governments, notably Massachusetts, have begun to develop plans to cover more of the uninsured within their borders. These plans face an uncertain future and, even if successful, only address the problem piecemeal. Yet Christians are no different from the rest of the American public. They do not rank health-care access high on their list of significant issues in the 2006 elections.
2. Medicare's long-term future. The federal Medicare program for persons 65 and older (and for some disabled persons) faces more dire financial difficulties than the Social Security program that drew so much attention in 2004 and 2005. Can Christians be insensitive to the fate of a program that provides access to health care for so many family members and fellow citizens? Yet neither candidates nor the general public seem inclined to offer plans for reform or to make Medicare an issue in the campaign. Medicare indeed will matter (see below), but only in the form of reactions to the new Part D (drug benefit) implemented earlier this year.
3. Cost-control and the movement to "consumer-driven health care." One reason for the high number of uninsured is the rapidly increasing cost of health care. Insurance to pay for medical expenses begins to exceed the lower middle-class's ability to pay. It is already impossible for the working poor to afford insurance without significant employer subsidies. Yet employers are increasingly reluctant to pay these subsidies. They and Republicans in government (under a provision of the Medicare Modernization Act) have begun to encourage consumer-driven health care as a method to hold down costs.
Neither the general public nor Christian citizens have given much thought to the moral legitimacy of placing greater responsibility on individuals to pay for their own care and to "shop" intelligently for insurance products and for hospitals, physicians, and other providers of medical care. All of this is too complex to summarize briefly, but one would think that such a movement away from traditional health insurance arrangements might concern voters. There is no evidence that it creates a blip on the electoral radar.
Why are the most important health-care issues not likely to have any direct effect on voters or campaigns this election season? The first and most important explanation is that voters typically have mental room only for two or three large issues in any campaign season. Citizens lead other lives than as voters! Family, personal health, church ministry, employment, and recreation properly occupy a large space in anyone's field of concerns. There is just not much room for political issues, especially complex and difficult issues. At the same time, other less legitimate interests crowd our psyches—internet porn searches, television's pervasive stare, the latest spectacular crime, and the lives of entertainment personalities. Christian citizens, unfortunately, are seldom different from other citizens, devoting inordinate mental space to accumulated junk.
In addition, there is already a daunting list of big, hairy, complex issues this election cycle: the Iraq War quagmire, jobs and the economy, and immigration. Citizens have these packed into that limited political attention space. For Christian citizens, other issues have remained prominent over the years: abortion, euthanasia, racial justice, schooling, and the plight of the poor. Of course, the War and the popularity of President Bush dominate headlines as well, as sometimes do political corruption investigations and whether they have snared one's own Member of Congress!
In the face of all this, it is very difficult to place access to health care, the financial fate of Medicare, or the rising cost of health care high on the list of issues that will determine one's vote. It is not that citizens are ignorant of these problems. It is rather that it is very difficult to place them in a political and electoral framework, unless candidates choose to make them issues and to frame them in such a way as to suggest simple remedies. Yet, most of us intuitively understand that there are no simple remedies for these major health-care problems. And very few candidates place these issues high on their campaign agendas.
Issues with Potential Impact
All this having been said (lamentably), a few policy issues could impact some House and Senate races: Medicare Part D, Human Embryonic stem cell research, and Medicaid and the State Children's Health Insurance Program (SCHIP). The diversity of these issues, however, testifies to a fragmented health policy agenda and decreases the likelihood of health-care issues having much general effect on the campaign.
1. Medicare Part D. Seniors turn out to vote. Seniors take a great interest in issues that affect their lives, particularly Medicare and Social Security. (Of course, seniors are also interested in Iraq, the economy, and other big issues.) Therefore, the new Medicare prescription drug benefit could affect the re-election prospects of incumbents who voted for (or against) the new benefit in 2003. Part D had a limited impact on the 2004 campaign, because it was implemented only on a limited basis before 2006. Therefore, this election represents the first test of the prescription drug benefit's electoral force.
Recent Medicare changes, of which Part D is the most prominent, were primarily a Republican invention. However, some conservative Republicans voted against a new public entitlement, and some Democrats voted in favor in order to create a platform upon which to build more extensive Medicare reform. The initial rollout of Part D, with sign-ups beginning in late 2005 and completed by Spring 2006, was accompanied by massive confusion and difficult choices among a large number of prescription drug plans with widely different effects on Medicare enrollees. After that period of initial confusion, a large proportion of Medicare enrollees did sign up, and most were satisfied with the plan's savings compared with their former, private drug coverage. This satisfaction, which lasted through the summer, bodes well for incumbents, especially Republicans. Seniors who like the new benefits will be inclined (all else being equal, as it seldom is) to vote for the Senator or Representative who made the program possible and against those who did not support it.
However, Medicare Part D has a so-called "doughnut hole," where all coverage ceases once a recipient reaches total prescription spending of $2250 ($750 by the enrollee and $1500 by Part D), and coverage does not kick back in until a recipient has spent $2850 additional dollars out of her own pocket! This provision has just begun (as of this writing in late summer) to affect beneficiaries with these high prescription expenditures (a sizable percentage, though not nearly a majority). They soon will go to their pharmacists expecting a $15-20 co-pay for their refill and discovering that the bill is $100 or more. Many will be angry to discover this feature of Part D, and the anger could be taken out on incumbents (again, mainly Republican). Family members of such recipients will also hear of the problems, and their vote also could be affected.
At this point, it is very difficult to tell how all of this will play out, but it is notable that by Election Day in November, the full effect of the "doughnut hole" will have become manifest to voters in a way not yet apparent. I suspect that the positive and negative perceptions of Part D will cancel each other, but in certain districts for certain incumbents who have difficulties over other issues, it could make enough difference to swing the election results. (I should add that there is another group of seniors, low-income enrollees in both Medicaid and Medicare, for whom Part D should be a great benefit. However, most have been slow to enroll, and some are starting to lose former Medicaid drug benefits. Yet such beneficiaries are the least likely seniors to vote. Their plight will have little effect on the election outcome.)
2. Human Embryonic Stem Cell Research. For many Christians (I include myself), government support of human embryonic stem cell research (HESCR) is morally anathema. Public opinion polls, however, show strong majority support among the citizenry (and among most Christians). Some candidates, especially Democrats, have tried to capitalize on this popularity of stem cell research by making it a campaign issue, especially since the most famous and influential opponent of public funding has been the incumbent Republican President. The most notable example was Senator John Kerry in the 2004 presidential campaign. Yet the issue did not seem to help him. Other issues weighed more heavily in voters' minds. For most, the issue has low salience.
The most prominent supporters of HESCR have been groups and individuals concerned about particular diseases for which HESCR has been touted as the path toward a cure: diabetes, Parkinson's, and Alzheimer's, for example. This promise of miracle cures has given public funding of the research its greatest potency, leading some states to pass laws funding the research, given the federal ban on funding. Prominent Republicans such as Senate Majority Leader Bill Frist (R-TN) have also come out in support, reducing the partisan salience of the issue.
Disease support groups, however, do not generally endorse candidates. Few ordinary voters, unless personally touched by these diseases, have HESCR high on their list of concerns. Therefore, like Medicare Part D, it is an issue that could make a difference in a very close House or Senate race in which the candidates have clearly distinguishable HESCR issue positions. For example, there is a ballot measure in Missouri to finance HESCR, and Democrats hope its popularity will work against incumbent Republican Senator Jim Talent. Such races will be rare.
3. Medicaid and SCHIP. Providing health care access for children traditionally is politically popular. Therefore, Medicaid and SCHIP funding can be an issue on which candidates, especially Democrats, might campaign. There is even a non-partisan effort to encourage political support for this goal, The Campaign for Children's Health Care, supported by a wide variety of groups such as the Catholic Health Association.
Two factors, however, will keep this issue from having much impact on election results, again except in a few districts with unique electoral circumstances. First, Medicaid is a relatively unpopular welfare program in the eyes of many voters. SCHIP does not have this stigma, but it is a new program relatively unknown to most voters. Medicaid and SCHIP's natural constituents—low-income persons—are precisely those least likely to vote in off-year elections. Second, government programs for the poor, especially Medicaid have become tangled in the politics of immigration. Despite the fact that undocumented immigrants are not eligible for Medicaid, lurid stories and rumors of illegal persons receiving benefits stoke anti-immigrant fires and reduce support for the programs and for candidates who support them.
So the politics of health care for low-income persons tug both ways. The popularity of children's health care produces support for Democrats. The unpopularity of welfare plus pockets of anti-immigrant sentiment favor Republicans. In sum, not much of an electoral impact.
Minimal electoral impact, however, does not necessarily produce a negative governing result. Despite not campaigning on these issues, most candidates and their political parties have health-care issue priorities. The outcome of the voting will mean either (1) the Republicans hold their own with no change in the partisan make-up of Congress (unlikely), (2) slight gains for Republicans (more unlikely), or (3) slight to significant gains for Democrats (most likely given the early September projections). Results (1) and (2) will produce very little health-policy change beyond modest tinkering with Medicare D, continued minor reductions in Medicaid eligibility, and modest expansion of consumer-driven health care. Health-insurance coverage will continue to shrink, the number of persons without insurance will continue to rise, and the cost of health care will continue to escalate.
If the Democrats take control of the House and/or the Senate, health insurance coverage will continue to shrink, the number of persons without insurance will continue to rise, and the cost of health care will continue to escalate. That is, even in victory the Democrats will not have sufficient power to alter the larger picture of American health care. There is one other (unlikely, but possible) scenario: an even congressional balance between the parties could produce a compromise health-care access expansion plan combining some Republican features (tax credits for purchasing individual policies) with some Democratic features (Medicaid and SCHIP expansion). Other minimal policy changes are more likely: minor changes in Medicare Part D, perhaps to shrink the "doughnut hole," and modest expansion (or at least no reduction) in Medicaid eligibility.
Finally, it is probable that Democratic control of House and Senate will produce legislation authorizing federal funding for human embryonic stem cell research with enough support to override a presidential veto. Indeed, widespread (but, I believe, mistaken) public HESCR approval has already increased Republican support for this research and could produce veto-proof funding legislation even if Republicans retain control of Congress.
A final concern about health-care issues in the 2006 election is whether the relative lack of impact with respect to governing or electoral terms says anything to Christian citizens about citizenship and public justice. Of course, Christian citizens should reflect on and pray seriously about the major and lesser health-care issues and integrate them into their voting decision. These are issues that touch the heart of Christian faith—healing, suffering, death, human dignity and well-being. These are issues where deep injustices exist in the distribution of medical care. How can they not be part of one's concern as one looks at the candidates?
The evidence, however, shows that for most Christians these are not major issues, that they do not closely evaluate candidate stances on these issues. Moreover, like other voters, Christians too often make up their minds on issues according to simplified alternatives offered by media and candidates, not according to profound reflection on core commitments. This should be a matter of deep concern for readers of the Public Justice Report.
And yet, Iraq, the economy, immigration, and the other issues that loom larger in public consciousness are also profoundly moral issues with deep connections to public justice, human dignity, and the well-being of fellow citizens (and, indeed, the citizens of other nations who are loved by God as much as we). If citizens make their voting choices on these issues for principled reasons, we cannot complain too much about their neglect of health care issues. There is, after all, only so much issue attention available to most of us.
And yet . . . . This paucity of issue attention points to the structural problems in the American polity. Why do the political system and the media conspire to oversimplify issues and to fill our minds with intellectual and spiritual junk? Why are we so ready to consume the junk, rather than the abundant information available (with some effort) on significant policy issues facing the nation? Why do the two-party system and a flawed electoral system present voters with only two candidates, each with a vested interest in reducing issues to slogans and making their justice dimensions obscure?
If readers of the Public Justice Report wish to understand why health-care issues are so electorally lame, the reasons lie as much in our political culture as in the issues themselves.
Clarke Cochran is Professor of Political Science and Adjunct Professor of Health Organization Management at Texas Tech University. His latest book, with David Carroll Cochran, is Catholics, Politics, and Public Policy: Beyond Left and Right.
