Economy is Top Presidential Issue

Every quarter the Kaiser Family Foundation publishes a survey on what issues matter to voters. The new poll is out and, for the first time, the economy is preceived as more important than Iraq or health care. Health care reform remains a critical issue, especially among Democrats, but the cumulative impact of the mortgage crisis, rising gas prices and the general feeling of financial unease has clearly shifted voter thinking.

If you’re interested in learning more, I’ve added a post to my health care reform blog discussing the poll.

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Getting Candidates to Focus on Health Care Cost Containment

All the candidates want to fix America’s health care system. Yet the debate has been mostly about increasing access to treatment. On the Democratic side, whose plan will provide coverage to more of the country’s uninsured has dominated. That’s an important issue, but it’s only half of the equation. What’s as important is how to control skyrocketing medical costs. And that’s been too often ignored by the candidates and the media.

I found it amusing to watch a discussion on CNN in which the pundits lamented the failure of the candidates to address health care cost containment. Did they miss the irony? They’re CNN. They’re a news organization — or at least they are between all the commercials. Like their 24 hour news competitors they’re desperate for something to talk about. They’ve spent hours rehashing the same discussion about super delegates and who is failing to congratulate whom. If CNN wants the candidates to discuss constraining medical costs they have the power to make that conversation happen.

CNN is even hosting the next Democratic debate on February 21st. Maybe one of their pundits could ask a question or– or three — on cost containment? It couldn’t hurt.

There’s more on the need for candidates to address medical cost containment over on my health care reform blog. I hope you’ll take a look.

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Clinton Needs to Change Attack on Obama’s Health Care Reform Plan

When it comes to health care reform, Senator Hillary Clinton is fixated on universal coverage. Her plan promises it; Senator Barack Obama’s health care reform package doesn’t. She considers it a moral responsibilty and a litmus test for her party. So she pounds her opponent on the issue in virtually every speech she gives. It doesn’t seem to have much impact as he continues to build momentum. The time has come, and passed, for her to change her message.

Senator Clinton has seized on the right flaw in her opponent’s reform proposal, but is using it to make the wrong point. Unlike her own plan, Senator Obama does not require everyone to buy coverage. This does mean, as Senator Clinton points out, it is unlikely to lead to universal coverage. But it’s worse than that. Because Senator Obama requires carriers to issue policies to all applicants, but fails to require consumers to buy coverage, it’s out of balance. As I point out on my Health Care Reform blog, this imbalance means that Senator Obama’s health reform package can’t lower health insurance premiums. And lowering costs is the central justification for his entire plan.

This isn’t a policy wonk argument. Her own state of New York is an example of what Senator Obama is proposing. And premiums there are twice what they are in California.

The imbaance is easy to explain, just compare it to allowing drivers to wait until after they have an accident to buy car insurance. Senator Clinton could, with just a slight shift in her attack on Senator Obama’s plan, emphasize how her experience on the issue helped her avoid such a “rookie error.” This, in turn, would bolster her “ready on day one” mantra. It’s a small, but easy pivot to make.

It does, however, require Senator Clinton to recognize that her current approach isn’t working any more. Whether she can do that remains to be seen.

Then There Were Two: Clinton versus Obama

It’s hard to believe that less than a month ago there were eight candidates for the Democratic presidential nomination.  But Senators Joseph Biden and Chris Dodd dropped out after Iowa. Governor Bill Richardson withdrew after New Hampshire and Representative Dennis Kucinich accepted reality shortly after the South Carolina primary. Today Senator John Edwards suspended his campaign. That leaves only Senators Hillary Clinton and Barack Obama. Oh, and former Senator Mike Gravel, too. However, he’s failed to raise either money or support, failing to get even one percent of the vote in any caucus or primary to date. So although he deserves better, he’s not really a factor.

So it’s now down to Senators Clinton and Obama. Democrats have a clear choice — not based on the issues, but on character, vision, experience and their approach to politics.

On most policy matters the Senators positions are very close. In tonight’s debate they’ll make the most of what little differences they have, but for the most part these nuances don’t mean a lot.

On the other hand, when it comes to how they approach politics and how they’re likely to govern there are real differences. Senator Clinton’s political career has been marked by constant attacks from her opponents. The right wing really were out to get her and her husband, President Bill Clinton, during their years in the White House. Listen to any conservative talk show and the vitriol leveled against her is harsh, cruel and vicious.

The result is a politician with an understandable bunker mentality. Listening to Senator Clinton one gets the feeling she sees the world as those who are with her and those who are against her. Us versus them. Within the Clinton camp the inevitability of her election was an article of faith and Senator Obama’s threat to reaching the promised land (apparently 1600 Pennsylvania Avenue is the promised land in the Clinton gospels) is nothing short of blasphemy.

In this regard, her political style is similar to that of President George Bush. In the current Administration, loyalty is highly prized, seemingly more than competence. Opponents are more than, well, opponents. They’re at best misguided and at worse unpatriotic enemies of all that’s right.

Senator Clinton’s bunker is, thankfully, more porous than President Bush’s. He’s the extreme case. She’s more open to working with opponents. She demonizes the enemy less, is capable of admitting mistakes and of evolving her position in a sincere effort to find the right solution. Yet, even though it’s a less virulent form, her world view is remarkably similar.  As is her husband’s, which could explain the anger he’s flashed on more than one occasion when reporters ask obvious, but to him, unfair, questions.

If she’s to wrap up the nomination quickly, Senator Clinton needs to vacate the bunker — or at least lower its walls a bit. She needs to emphasize the times in her career when she’s reached out to those who disagreed with her to accomplish a greater good. She needs to show the ability to break away from the harsh partisanship that pervades Washington. And she needs to do so soon.

Senator Obama’s political career has been different. He learned the art in the rough context of Chicago politics, but he quickly established himself as a bridge builder. He worked with Republicans in Illinois on tough issues like expanding health care and confronting the state’s approach to the death penalty. He seems to have lived out his constant phrase of “disagreeing without being disagreeable.”

This ability — and desire — to seek compromises that incorporates the views of his opponents stands in stark contrast to how Washington has operated for the past 15 years. Senator Obama seems more interested in co-opting the other side than demonizing them.

The other side of this coin, however, is that it makes understanding what he stands for difficult to define. Senator Clinton has more five-point plans on more issues than a herd of policy wonks. Senator Obama has … some. Senator Clinton plays on this dynamic by proclaiming herself ready to lead on Day One. Senator Obama’s response is that he’ll be right on day one, but that pithy rejoinder does little to bolster his credentials as being ready to lead the free world starting January 20, 2009.

Does this mean Senator Obama should whip together a few more five-point plans? Well, yes, it does. He can still emphasize his current theme, that this is an election between yesterday and tomorrow. But if he’s to deflect the attacks from the Clinton campaign, he needs to find his inner wonk. He needs to explain in more detail what tomorrow looks like. And he needs to do so soon.

Why the need for speed? First, because half the delegates to the Democratic Convention up for grabs this coming Tuesday. Second, because in a two person race (sorry Senator Gravel) the odds are one of the candidates will begin to be perceived as wrapping things up. The media, needs something to fill up time between commercials, A horse race makes for an easy story, but someone needs to pull away. That creates the tension — can anyone stop her?  will he stumble before the finish line? — that grabs viewers.

This tendency to simplify things also means, in a two person race, only one can be considered “winning.” And being labeled as the one who is “losing” is often a self-fulfilling prophecy. To avoid being on the wrong side of this equation, both candidates need to break out of their comfort zone. Whether either can, however, remains to be seen.

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Obama Needs to Reframe Health Care Reform Debate

In the Democratic presidential debate held in South Carolina on January 21st, Senator Barack Obama was put on the defensive over his health care reform package. Both Senator Hillary Clinton and former Senator John Edwards blasted Senator Obama for putting forward a proposal that fails to cover all Americans. Universal coverage, they claimed, is the Holy Grail of health care reform, at least in the Democratic Party.

And they’re right. Polls consistently show health care is one of the highest priority issues Democratic voters consider when selecting a candidate. Being perceived as the candidate who doesn’t care about universal coverage is not a recipe for success in Democratic primaries. By allowing Senators Clinton and Edwards to frame the debate as their universal coverage packages versus Senator Obama’s plan “that leaves 15 million Americans uninsured,” the Illinois Senator is at a severe disadvantage.

What’s surprising is that Senator Obama is on record as favoring universal coverage. Last year I wrote on my health care reform blog a post concerning a speech Senator Obama made to Families USA. In his talk, Senator Obama lamented the politics-as-usual approach to health care reform all too common in the nation’s capitol. “While plans are offered in every campaign season with ‘much fanfare and promise,’ they collapse under the weight of Washington politics, leaving citizens to struggle with the skyrocketing costs.”

Senator Obama told his audience that his goal would be to find a way to make universal coverage a reality, but warned it would probably take him four years to do it. As I wrote then, “By being agnostic about the means, a president could actually achieve the desired end. On the other hand, a president could take a ‘my way or the highway’ approach like the Clinton Administration did in the 1990s. The result from that effort: nothing much.”

Here it is, a full 12 months later. Senator Obama’s health care reform plan focuses on controlling costs. It does not require every American to purchase coverage, but instead tries to make the cost of coverage affordable for more Americans. There’s nothing wrong with that as a goal, especially if you’re plan is defined as part of a journey, not the ultimate destination.

There’s also nothing wrong with tying a mandate to buy coverage with a mandate for carriers to sell coverage to all applicants. Recent polls in California, where a health care reform package including these twin mandates is being considered by the State Senate, shows a majority of Democratic and Independent voters supporting this approach. Perhaps surprisingly, nearly four-in-ten Republicans back these requirements. This is also the road to universal coverage proposed by Senators Clinton and Edwards. 

The California reform debate suggests a way for Senator Obama to reframe the debate. Liberal and union opponents of the mandate to require individuals to buy insurance condemn the provision for forcing consumers to purchase something that may be beyond their means. Supporters argue there are safeguards and hardship exemptions that will prevent this.

Senator Obama needs to seize on the legitimate concern voters have that government safeguards don’t always work. He should say something along the lines of, “Senators Clinton and Edwards want to force you to buy health insurance and to trust them that it will be affordable. That’s putting the cart before the horse; trust before the proof. I’m saying ‘let’s prove we can make coverage affordable,’ then we’ll see if mandates are required. They’re forcing you to buy before you see the price tag. I’m going to show you the price tag first. Then we’ll continue to the march to universal coverage.”

This is consistent with his past statements. The key is to focus on his long term vision (which, I assume, includes universal coverage) while positioning his opponents as typical politicians who promise everything and ask voters to trust them to deliver. It’s a more complicated, nuanced message than the others have, but it’s better than simply accepting the charge that his health care reform plan is out of step with Democratic voters.

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Democrat’s Debate on Health Care Reform Echoes California’s

There were a lot of fireworks during the Monday night debate among the three major Democratic candidates. Some of the more interesting sparks involved health care reform. What struck me is how closely the debate echoed the health care reform wrangling taking place in California with Senator Hillary Clinton and former Senator John Edwards playing the role of Republican Governor Arnold Schwarzenegger and Senator Barack Obama filling in for the legislature’s Democratic leadership.

The differences among the Democratic candidate’s health care reform plans are inconsequential when compared to those put forward by the Republican candidates for president. (The New York Times offers a quick summary of the proposals). But that’s not going to stop campaigns embroiled in a close nomination fight from emphasizing what differences do exist.

On one side: accessibility. The health care reform plans of Senators Clinton and Edwards emphasize universal coverage. Every American must be insured either through government programs, their employers, or purchasing their own medical plan. Senator Clinton went so far to say advocating anything less than universal coverage was contrary to the principles of the Democratic party.

This accessibility argument mirrors that of Governor Schwarzenegger, who back in January of last year made universal coverage one of the core principles of his health care reform plan. He fought hard to keep it in the compromise plan he reached with Assembly Speaker Fabian Nunez, Assembly Bill ABX1-1. As it is, he was unsuccessful. Studies indicate ABX1-1 will help 70 percent of California’s uninsured obtain coverage, not 100 percent. Think of it as “mostly” universal coverage.

Then there’s the other side: affordability. Senator Obama’s health care plan doesn’t require people to purchase coverage. He believes most Americans want medical insurance and would buy it if it was affordable. His plan focuses to a greater degree than do his opponents’ on the need to corral the spiraling cost of health care and of health insurance premiums.  

In leaving out the mandate to buy, Senator Obama’s reform package is similar to that introduced by Speaker Nunez and Senate President Pro Temp Don Perata more than a year ago, Assembly Bill 8. The proposal expanded coverage, but without the mandate to buy. It was, as the sponsors admitted, not universal coverage. The Democratic leadership, and their allies among Labor and liberal groups, thought it unfair to force people to buy coverage that might be priced beyond their means.

In Senator Clinton’s mind, apparently defines Speaker Nunez and Senator Perata, both of whom endorse her, as bad Democrats. (Whether it makes Governor Schwarzenegger a Clinton Republican is unknown).

In tonight’s debate, Senator Obama tried to cast the debate as one between access and affordability. He failed and he remained on the defensive. Calling for universal coverage is simply good politics, even if affordability is potentially the most potent public policy.

What finally bridged the gap in California was the introduction of an “affordability standard” to the mix. As initially introduced, the idea was to exempt individuals from the obligation of obtaining coverage if the cost of premiums and out-of-pocket expenses exceeded a specified percentage of their family’s income. The specifics of the affordability standard evolved during the negotiations, and it is still a source of continued contention. The concept, however, remains the same.

Senator Obama would to introduce an affordability standard into the presidential debte — and to specifically mention how it became a part of the California health care reform compromise. Doing so allows him to remain consistent to his priorities, while showing how his approach can lead to (near) universal coverage. And, of course, aligning himself with Speaker Nunez and Senator Perata before the February 5th primaries couldn’t hurt. Besides, it would be fun to see how Senator Clinton would explain how her Democratic Party litmus test includes the Legislative Leadership, but not her rival for the nomination.