Bernie Sanders, Hillary Clinton, and Medicare for All

In this column for The Wall Street Journal’s Think Tank, Drew Altman explores the differing positions of presidential candidates Hillary Clinton and Bernie Sanders on a single payer or Medicare-for-all health care system and whether Democratic voters consider it an important factor in the 2016 primaries.

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Prescription Drugs’ Sizable Share of Health Spending

In this column for The Wall Street Journal’s Think Tank, Drew Altman explains why prescription drug spending may be a larger share of health spending than most people think, depending on how you look at it.

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What’s the Political Power of Those Newly Insured Under Obamacare?

In this column for The Wall Street Journal’s Think Tank, Drew Altman takes a look at whether the 17 million people newly-insured since 2014 will make an impact in the first presidential election since Affordable Care Act enrollment began.

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Why Painkiller Addiction and Abuse Are Rising Health-Care Priorities

In this column for The Wall Street Journal’s Think Tank, Drew Altman uses new polling to explore why painkiller abuse and addiction is rising as a health issue among state and federal policymakers.

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Health Care and the 2016 Debates

In this column for The Wall Street Journal’s Think Tank, Drew Altman discusses the lack of attention to health in the primary debates and last week’s Democratic forum in South Carolina.

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GOP Views of Medicaid Expansion Differ From Conventional Wisdom

In this column for The Wall Street Journal’s Think Tank, Drew Altman examines Republican attitudes on Medicaid expansion in light of the election of Republican Matt Bevin as Kentucky’s next governor.

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                    [post_content] => This was published as a Wall Street Journal Think Tank column on December 20, 2015.dawsj122015

Kaiser Family Foundation data from December polling on Democrats’ views of Medicare for all.

A skirmish broke out recently between Hillary Clinton and Bernie Sanders about the merits of single-payer health care, an idea that Mr. Sanders has long advocated. The candidates jousted about the financing of single-payer health care during the Democratic debate Saturday night. The differences between the two candidates on single-payer health care paint Mrs. Clinton as more moderate and Mr. Sanders as more liberal (no surprise there).

The question is: Do any Democratic primary votes turn on this issue? Single-payer health care and the Medicare-for-all variant of the idea has generally been popular among the left, but not many votes will be moved by this issue alone.

Most Democrats either strongly favor (52%) or somewhat favor (24%) the general idea of Medicare for all. Meanwhile, 62% of Republicans either strongly or somewhat oppose the idea. But, as the chart above shows, even though single payer has long been a cause celebre for many on the left, just 5% of Democrats are pure “single-payer voters” who favor Medicare for all and say that the candidate’s stand on the issue will be the single most important factor in their vote. Thirty-four percent say it would be an important factor but not the most important, and 36% say that it would be just one of many factors they would consider. The poll did not test how much support for Medicare for all might diminish among Democrats in the face of arguments for and against the idea.

There is a large body of literature about the role of issues and single-issue voting in U.S. elections. In 2012, Gallup found that 17% of registered voters made a candidate’s position on abortion a litmus-test issue. My sense is that voters perceive a presidential candidate’s positions on issues as signals of the candidate’s beliefs and of the direction he or she will attempt to take the nation if elected. Yet voters focus less on the details of candidate’s policy plans, however much candidates and their staffs may slave over those details or the media may scrutinize them.

In his advocacy of Medicare for all, a policy that he recognizes cannot be achieved any time soon, Mr. Sanders is signaling his outside-the-box approach to policy and politics, while in opposing the idea Mrs. Clinton may have been signaling her more practical and incremental approach to achieving policy change.
                    [post_title] => Bernie Sanders, Hillary Clinton, and Medicare for All
                    [post_excerpt] => In this column for The Wall Street Journal’s Think Tank, Drew Altman explores the differing positions of presidential candidates Hillary Clinton and Bernie Sanders on a single payer or Medicare-for-all health care system and whether Democratic voters consider it an important factor in the 2016 primaries.
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                    [post_content] => This was published as a Wall Street Journal Think Tank column on December 13, 2015.
dawsj121315Kaiser Family Foundation analysis of data from the Centers for Medicare and Medicaid Services and Truven Health Analytics showing that drugs account for 10% of U.S. health spending but 19% of employer insurance benefits.

The cost of prescription drugs is the hot health-care issue, but almost every discussion about it includes this caveat: As big a problem as rising drug prices have been for consumers and payers, drug spending represents only 10% of national spending on health. Yet, as the chart above shows, drug spending represents almost double that share of health spending (19%) in employer health insurance plans. That is not too much less than the 23% employers spend on inpatient hospital care.

Why the disparity? First, the $3 trillion in national health spending is a broad catchall that includes hospital care, physician services, drugs, research, administrative costs, public health activities, and long-term care. Second, some of the people served by Medicare and Medicaid, whose spending is counted in the national totals, require lots of services not typically used by those covered by employer health insurance plans.

Even that 19% figure is understated. It includes prescriptions that patients fill at pharmacies but not many of the expensive drugs administered in physicians’ offices or hospitals. In Medicare, for example, retail prescription drugs represent 13% of overall spending while drugs administered mainly by physicians add an additional 6%.

High drug prices have been in the news because of costly drugs to treat Hepatitis C, among other illnesses, and because elected officials and political candidates have been talking about drug costs. Rising drug prices, expanded coverage of the uninsured under the Affordable Care Act, and an improving economy have also contributed to an uptick in the rate of increase in health spending. But depending on what you count and how you count, drug spending may be an even larger problem than many thought. It clearly is for employers, who foot a large share of the nation’s health-care bills.
                    [post_title] => Prescription Drugs' Sizable Share of Health Spending
                    [post_excerpt] => In this column for The Wall Street Journal’s Think Tank, Drew Altman explains why prescription drug spending may be a larger share of health spending than most people think, depending on how you look at it.
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                    [post_content] => This was published as a Wall Street Journal Think Tank column on December 3, 2015.


dawsj120315

Kaiser Family Foundation data on voter registration and party identification among the uninsured and newly insured.

An estimated 17 million uninsured have been covered by the Affordable Care Act. As that number grows in the coming years, it could have political implications: How will the newly insured behave at the ballot box? Will they vote? Will they become a Democratic constituency? The ACA may be an issue in the 2016 elections, but the newly insured are unlikely to become an important electoral factor themselves.

One potential indicator of future behavior is how the newly insured behaved politically when they didn’t have health coverage. As the chart above shows, in 2015 slightly more than half of the uninsured (52%) reported that they were registered to vote; among those with insurance coverage, more than three-quarters, or 77%, were registered. We have known for a long time that the uninsured are among the least likely to vote. Perhaps more surprising, while the uninsured shade Democratic as a group, they are a reasonably heterogeneous. Twenty-seven percent of the uninsured report that they are Democrats, 13% Republicans, and 36% call themselves independents. The largest share of uninsured independents describe themselves as not leaning Republican or Democratic. These uninsured independents are the most likely to be disengaged from the political process.

We also know that the uninsured are slightly less favorable toward the ACA than is the public overall. This may seem counterintuitive, as the uninsured benefit most from the ACA. But there are several reasons: By definition the uninsured have not yet been helped; they generally believe that coverage will not be affordable because it never has been before; they may not know that they can get help paying for it under the ACA; and they face a penalty if they do not purchase coverage.

Surveys have found that most of the previously uninsured like their coverage–a Kaiser Family Foundation poll found that 76% do–but it’s not known whether appreciation for that coverage will be a factor when they vote or if they will vote in significant numbers. It is a fair bet that in the short term the newly insured will behave politically much like the uninsured have: Many will not vote, and they will continue to represent a very small slice of the electorate.

Since the days of Republican opposition to Lyndon Johnson‘s Great Society programs–and even before that–many in the GOP have opposed Democratic social programs on policy grounds and because they perceived them as mobilizing liberal advocacy efforts and potentially strengthening Democratic governors, mayors, and other elected officials who could use the support to build larger constituencies. ACA health coverage is different; it’s a direct entitlement to qualified individuals. Unlike those earlier programs, the ACA’s coverage expansion would not seem to present a similar political threat for Republicans or a political tool for Democrats. Over the longer term, however, people with ACA coverage may come to see Democrats as better protectors of their coverage than Republicans, much as seniors do of Medicare coverage, although that has not always translated into support for Democrats at the ballot box.

There is overwhelming evidence that coverage matters to health access and economic security for people who are newly insured. But neither the newly insured or the remaining uninsured are likely to play a significant role at the ballot box anytime soon.
                    [post_title] => What's the Political Power of Those Newly Insured Under Obamacare?
                    [post_excerpt] => In this column for The Wall Street Journal's Think Tank, Drew Altman takes a look at whether the 17 million people newly-insured since 2014 will make an impact in the first presidential election since Affordable Care Act enrollment began.
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                    [post_content] => This was published as a Wall Street Journal Think Tank column on November 24, 2105.



dawsj112415

Kaiser Family Foundation November 2015 tracking polling results of share of Americans who report a personal connection to painkiller abuse and addiction or know someone who has such an addiction.

Discussion of health care in this country has been dominated by Obamacare since debate about the law began in earnest before its passage in 2010. Now other issues such as rising drug prices and deductibles are edging onto the agenda. This was apparent last week when United Health Care said it would consider pulling out of the insurance marketplaces and a Department of Health and Human Services forum on drug prices also made headlines. A third issue may be joining the others as a top-tier health topic at the state and federal levels: the problem of painkiller and heroin abuse and addiction. Governors and candidates are paying more and more attention to this growing health problem.

The latest Kaiser Family Foundation tracking poll, published Tuesday, looked at this issue, which touches a remarkably broad share of the public. As the chart above shows, more than half of Americans know someone who has died from an overdose of painkillers, have been addicted themselves or know someone who has been addicted, or know someone who has taken painkillers that were not prescribed for them. More than a quarter of the public (27%) say that they or someone close to them has been addicted, and 9% have a family member or close friend who has died from an overdose of painkillers.

One reason this problem is gaining political traction is that it affects a broad cross-section of society. By a significant margin (63%), whites are more likely to report a personal connection to the problem than blacks (44%) or Hispanics (37%).

This is a very different kind of issue than the ACA or rising drug prices and deductibles. It is far less partisan and both more personal and relatable for the public than the intricacies of the Affordable Care Act. Painkiller abuse and other drug abuse and addiction are also problems that can be addressed at the state and local levels, unlike covering the uninsured or controlling rising drug prices.

Our poll found that, across all 50 states, reducing painkiller and heroin abuse ranked in the middle of the public’s priorities for their governors and legislatures. Several governors have declared painkiller and heroin abuse a crisis in their states, and a poll in New Hampshire published last month found it to be the Granite State’s top priority, even ahead of the economy and education.

Painkiller abuse and addiction are rising issues in a health agenda that is now somewhat less dominated by the Affordable Care Act. As the national discussion of health care becomes more multifaceted, will elected officials have the bandwidth to take on yet another big health problem? Many governors seem to feel that they have no choice.
                    [post_title] => Why Painkiller Addiction and Abuse Are Rising Health-Care Priorities
                    [post_excerpt] => In this column for The Wall Street Journal’s Think Tank, Drew Altman uses new polling to explore why painkiller abuse and addiction is rising as a health issue among state and federal policymakers.
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                    [post_content] => This was published as a Wall Street Journal Think Tank column on November 11, 2015.

Until Carly Fiorina criticized Obamacare during Tuesday’s prime-time Republican debate, there hadn’t been much attention to health care in the GOP debates. During last week’s Democratic candidate forum in South Carolina, I didn’t detect a single question about health care or the Affordable Care Act. This is not a knock on hosts and moderators; debates and forums such as the Democratic meeting last week are not the best vehicles for drawing out presidential candidates on the intricacies of health policy. The result, however, is that the public is not learning much from these widely viewed events about what candidates would do regarding one of the country’s most divisive issues should he or she be elected president.

And against that backdrop, some things are notable:

There are big differences between former Secretary of State Hillary Clinton and Sen. Bernie Sanders on health care. Mrs. Clinton favors building on the ACA and, actually, going further with a set of pro-consumer proposals that would take on rising out-of-pocket costs and drug expenses. She is aggressively taking on the drug and insurance industries. Mr. Sanders, by contrast, supports a Medicare-for-all single-payer health-care system, which would represent a far more sweeping change. He mentioned single-payer and Medicaid expansion in response to a question from Rachel Maddow at last week’s forum about how his agenda was relevant to African Americans. His Web site includes a petition that people can sign to support single-payer (and his candidacy), but the document does not lay out a single-payer plan. It describes two other health proposals: one to lower prescription drug costs and another to improve care for veterans. Former Maryland Gov. Martin O’Malley doesn’t feature a health plan on his Web site.

Among Republicans, Jeb Bush, Marco Rubio, and Bobby Jindal have plans for health-care reform, but it’s hard for moderators to single out their proposals for scrutiny amid so many candidates on stage, and with every one of them supporting repeal of the ACA.

Health care won’t disappear from the 2016 primaries altogether. All the Democratic candidates will discuss it on the campaign trail, regardless of whether it is a focus of nationally televised debates and forums. And speculation about whether the election of Republican Matt Bevin in Kentucky’s gubernatorial race last week constitutes a rejection of Obamacare in a state previously viewed as an ACA success story in the South may become a talking point in future Republican debates. It will be a while–probably not until the general election–before a clear and substantive contrast between the two sides on health re-emerges as a focus in campaign debates; when that happens, the contrast promises to be sharp. The eventual Democratic nominee may run against policy ideas expected from House Republicans such as Medicare premium support or Medicaid block grants. In the past, Democrats have had some success portraying these as threats to Medicare and Medicaid. Of course, Republicans in the House will reject those criticisms, and they may decide to wait until after next November to put forward specific plans in an effort to deny Democrats an election issue. [post_title] => Health Care and the 2016 Debates [post_excerpt] => In this column for The Wall Street Journal’s Think Tank, Drew Altman discusses the lack of attention to health in the primary debates and last week's Democratic forum in South Carolina. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => health-care-and-the-2016-debates [to_ping] => [pinged] => [post_modified] => 2017-02-06 16:42:46 [post_modified_gmt] => 2017-02-06 21:42:46 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.kff.org/?post_type=perspective&p=169347 [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) [5] => WP_Post Object ( [ID] => 168699 [post_author] => 36621681 [post_date] => 2015-11-04 11:38:06 [post_date_gmt] => 2015-11-04 16:38:06 [post_content] => This was published as a Wall Street Journal Think Tank column on November 4, 2015. dawsj110415 Kaiser Family Foundation polling in December 2014 found that many Republicans in states that have not expanded Medicaid have favorable views of expansion. We don’t know yet whether Republican Matt Bevin, who was elected governor of Kentucky on Tuesday, will try to abolish the Medicaid expansion put in place by outgoing Gov. Steve Beshear (D.), attempt to cap enrollment, or do nothing at all. But his election sets up new discussion of Republican attitudes toward Medicaid expansion. Thirty states have expanded Medicaid under the Affordable Care Act since the Supreme Court made it a state option in 2012. Ten of them have Republican governors, two of whom are presidential candidates, John Kasich and Chris Christie. If, however, you follow campaign commentary on cable TV you would think expanding Medicaid is a political black mark in the eyes of all Republicans. To be sure, the most activated elements of the GOP base–conservative campaign contributors, super PACs, and conservative legislators–oppose Medicaid expansion, primarily because they see it more as embracing Obamacare than providing federal funding to states to help them expand coverage for low-income residents. But the limited polling the Kaiser Family Foundation has done on the issue has found that most Republicans do not oppose Medicaid expansion. In fact, they favor it. In a December 2014 poll, 52% of Republicans said they had a favorable view of Medicaid expansion, 44% had an unfavorable view, and 3% did not voice an opinion. In the same poll, as the chart above shows, 56% of Republicans in states that had not expanded Medicaid had a very favorable (23%) or somewhat favorable (33%) view of expansion. This survey was conducted too far in advance of the 2016 primary elections to poll likely Republican voters. Views were also different in two strongly anti-expansion states in polling Kaiser did with the New York Times in 2014. A majority of Republicans in Louisiana (66%) and North Carolina (53%) preferred that their state keep Medicaid as is. We don’t know from the polling why most Republicans say they support expansion. Gov. Kasich has argued that expansion is a moral imperative and that he sees it as broadening Ohio’s Medicaid program rather than embracing Obamacare, which he opposes. We do know that 47% of Republicans in a May 2015 poll said Medicaid was a very important program; only 14% said it is not an important program. But that is far fewer than the 69% who said Medicare was a very important program. As might not be surprising, given their generally higher income levels, fewer Republicans (35%) than Democrats (61%) say Medicaid is important to them or their family. That even a slim majority of Republicans favor expansion is notable given the tone of debate on this issue on the campaign trail, where expansion has become like a third rail for GOP candidates. This is not to suggest that Republican candidates or governors who oppose Medicaid expansion in conservative states will be anxious to flip any time soon. But Medicaid may not be as unpopular with Republicans overall as the conventional wisdom suggests, and other issues may be more salient for Republican voters in primary and general elections across the country than opposition to Medicaid expansion. [post_title] => GOP Views of Medicaid Expansion Differ From Conventional Wisdom [post_excerpt] => In this column for The Wall Street Journal’s Think Tank, Drew Altman examines Republican attitudes on Medicaid expansion in light of the election of Republican Matt Bevin as Kentucky’s next governor. [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => gop-views-of-medicaid-expansion-differ-from-conventional-wisdom [to_ping] => [pinged] => [post_modified] => 2017-02-06 16:45:38 [post_modified_gmt] => 2017-02-06 21:45:38 [post_content_filtered] => [post_parent] => 0 [guid] => https://www.kff.org/?post_type=perspective&p=168699 [menu_order] => 0 [post_type] => perspective [post_mime_type] => [comment_count] => 0 [filter] => raw ) ) [post_count] => 6 [current_post] => -1 [in_the_loop] => [post] => WP_Post Object ( [ID] => 173050 [post_author] => 36621681 [post_date] => 2015-12-20 11:40:48 [post_date_gmt] => 2015-12-20 16:40:48 [post_content] => This was published as a Wall Street Journal Think Tank column on December 20, 2015.dawsj122015 Kaiser Family Foundation data from December polling on Democrats’ views of Medicare for all. A skirmish broke out recently between Hillary Clinton and Bernie Sanders about the merits of single-payer health care, an idea that Mr. Sanders has long advocated. The candidates jousted about the financing of single-payer health care during the Democratic debate Saturday night. The differences between the two candidates on single-payer health care paint Mrs. Clinton as more moderate and Mr. Sanders as more liberal (no surprise there). The question is: Do any Democratic primary votes turn on this issue? Single-payer health care and the Medicare-for-all variant of the idea has generally been popular among the left, but not many votes will be moved by this issue alone. Most Democrats either strongly favor (52%) or somewhat favor (24%) the general idea of Medicare for all. Meanwhile, 62% of Republicans either strongly or somewhat oppose the idea. But, as the chart above shows, even though single payer has long been a cause celebre for many on the left, just 5% of Democrats are pure “single-payer voters” who favor Medicare for all and say that the candidate’s stand on the issue will be the single most important factor in their vote. Thirty-four percent say it would be an important factor but not the most important, and 36% say that it would be just one of many factors they would consider. The poll did not test how much support for Medicare for all might diminish among Democrats in the face of arguments for and against the idea. There is a large body of literature about the role of issues and single-issue voting in U.S. elections. In 2012, Gallup found that 17% of registered voters made a candidate’s position on abortion a litmus-test issue. My sense is that voters perceive a presidential candidate’s positions on issues as signals of the candidate’s beliefs and of the direction he or she will attempt to take the nation if elected. Yet voters focus less on the details of candidate’s policy plans, however much candidates and their staffs may slave over those details or the media may scrutinize them. In his advocacy of Medicare for all, a policy that he recognizes cannot be achieved any time soon, Mr. Sanders is signaling his outside-the-box approach to policy and politics, while in opposing the idea Mrs. Clinton may have been signaling her more practical and incremental approach to achieving policy change. [post_title] => Bernie Sanders, Hillary Clinton, and Medicare for All [post_excerpt] => In this column for The Wall Street Journal’s Think Tank, Drew Altman explores the differing positions of presidential candidates Hillary Clinton and Bernie Sanders on a single payer or Medicare-for-all health care system and whether Democratic voters consider it an important factor in the 2016 primaries. 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