The real question on voters’ minds on Wednesday, November 9th was not just who won which race, but what the election results meant for each one of us and the issues we care about. For professional psychologists, of course, one of our greatest concerns is the national health care system.
Most analysts agree and every poll published after the election clearly indicates that the war in Iraq was the driving force of the vast majority of voters. If you voted in the hope of getting some quick solutions to the domestic problems we face here at home, like the lack of health insurance for more than 40 million U.S. residents and the ever escalating costs of health care in general, don’t hold your breath. I say this for two simple reasons: first, the staggering cost of supporting the war in Iraq all but rules out any expensive new domestic programs, whether in health care or elsewhere until the 2008 general election (gearing up for the 2008 election is the theme of this column); and second, most congressional candidates haven’t the foggiest idea of how to fix the health care system given its inherent complexity and the vast number of stakeholders in it.
In the context of the issue of cost, serious movement toward real health care reform (not just incremental tinkering as has been the case for the past 13 years) is, in part, dependent upon a robust economy. While it may be true that the U.S. economy is stronger than it has been since President Bush took office, the huge war costs obliterate the potential for any additional federal spending in this area no matter what the merit of a proposed program may be.
Could, however, the change in control of Congress have sufficient positive impact on the economy to the extent that surplus dollars that might be spent on fixing the health care system become available? The good news is that historically the economy has benefited when different parties control the White House and Congress. During the 1990s when President Clinton was in office and the Republicans controlled Congress, we saw the largest expansion of the economy in U.S. history. The bad news is that this split in the branches of government often results in gridlock, which means not as much money gets spent, which helps to shrink the deficit (the cost of prosecuting the war has expanded the federal deficit to monumental proportions), which helps the economy. In addition, Wall Street sees this split as a good thing because there tends to be less regulatory change due to the fact that the parties can’t agree on what to do. Ergo, it is a good bet that the prospects for major changes in the health care system, to the extent that they hinge on a robust economic picture, are doubtful during the next two years.
So, what WILL it take for a system, deteriorating at a rapid clip, to alter its course? For change to occur, without a budget surplus in the federal coffers, requires reliance on: 1) The court of public opinion, and 2) A very healthy injection of good old-fashioned political leadership, with a capital L. While health care was on the radar screen in some congressional races in 2006, many polls made it very clear that, except in a few selected races, health care played a relatively minor role in determining the outcome of the midterm election. As a result, it is highly probable that elected officials will arrive back in Washington in January with little pressure from voters to change the current direction of the country’s health care system.
Why is this so? Data from surveys done by the Kaiser Foundation consistently have shown that health care is a top personal and family economic worry. People worry more about the costs of their health insurance going up than paying the rent or mortgage or being the victim of a terrorist attack. Further, the Pew Research Center found that twothirds of Americans were willing to pay higher taxes to insure health care for everyone. Similarly, other polls report high levels of dissatisfaction with the current health system and show support for fundamental changes. But in the 2006 election cycle, other issues, spelled I-R-A-Q, were paramount, and voters really didn’t take their worries about health to the voting booth.
This is one of the biggest differences between the current era and the early nineties, when health reform last had salience as a national issue. In the early nineties there was no war in Iraq, no 9/11, and no lingering memory of Hurricane Katrina to capture voters’ attention. But something else also happened in the early nineties, some of you may remember, which transformed the political landscape for health that is missing today. In his senate race in Pennsylvania, Harris Wofford demonstrated for the first time that a candidate for national office could tap into the public’s underlying concern about health insurance and health care costs to help win an election (Advance featured a cover story about AAP’s support of Wofford’s candidacy in the Winter 1992 edition). President Clinton picked up on that, made health care a top priority, and with the First Lady put forward his ill-fated Health Security Act. Media attention and a heated national debate followed, and health reform captured center stage, demonstrating that the national agenda is not just a bottom-up process, but is driven by political leaders and media coverage from the top-down, as well.
Today none of the politicians most often mentioned as candidates for the presidency in 2008 are talking much, if at all, about health reform, and there is no real national debate. Hillary Clinton, widely touted as the Democratic presidential frontrunner for 2008 and the chief architect of her husband’s Health Security Act in 1993, barely utters a word about health care reform today. This is likely the result of how the then First Lady Clinton was eviscerated by opponents of reform for her stewardship of her husband’s plan almost 15 years ago. After that debacle, major health care reform has become the virtual “third rail” for politicians.
One poll trend demonstrates the differences between the two eras vividly. In October 1993, 55 percent of the American people named health care as one of the two most important issues for government to address; that number fell to less than 10 percent in 2002, was 11 percent in November 2005, and is now consistently below 15 percent.
Surveys show that the underlying level of public concern about health care issues today and in the early nineties is about the same. It is the presence of other issues winning voters’ attention and, what I believe to be, the absence of leadership by political figures on the health issue that explains why health care reform has little real political appeal today. Imagine the debate on health care today, or where it would stand in the polls without 9/11 and Iraq, or if the candidates for Congress and the presidency had been on TV debating changing our current system.
For health reform to again gain a foothold at the top of the national political and policy agenda, it is critical for it to become a central issue in the 2008 election campaign, so that candidates who are elected to office and the new president feel that they were elected, at least in part, to address the nation’s big health care problems when they start work in 2009. This is by no means guaranteed, but there is a scenario under which it could happen. First, if we are fortunate enough to see external problems like Iraq stabilize or subside and no new big ones arise, health would have the opening it needs to compete for center stage as an election issue. Second, as Americans pay more and more each year out of their own pockets for health care, they will become increasingly concerned about health as a voting issue and policy priority. And third, as patients continue to face an increasing struggle to access quality health care, including mental health care, they are likely to be far more motivated to put reform on the front burner. Public concern about the state of health care, though, is not enough to move this issue forward by itself. It is unrealistic to expect public opinion, on its own, to reach some new tipping point that will create a tidal wave for health reform.
The bottom line is that unless politicians believe that they were elected to solve this problem, they are not likely to want to do the heavy lifting necessary to take on the tough issues that have been avoided for decades because of the deep partisan ideological divide which exists. What health needs most to rise up in American politics is for national political candidates, whether from the political left, right, or center, to begin talking about the issue again as they did in the early nineties.
Most important of all are the presidential candidates, who receive so much national media attention. If even one major candidate begins to seriously address health reform, the others will be forced to follow suit. The presidential candidates’ level of attention to health will be decisive as to where health ranks on the national agenda going into the 2008 election and 2009 Congress. If they do play a leadership role on health, the media will follow, and the agenda-setting power of a debate driven from the top will meet the public’s concerns rising up from the bottom creating real synergy.
Psychology and mental health are in a far better position in 2006 than we were in the early 1990s with regard to our standing in the health care universe. We have made substantial progress with how the public perceives psychology on a whole range of issues: From recognizing the high incidence of mental disorders, to placing greater value on mental health treatments, to decreasing the stigma of mental disorders, to better integrating psychological services into the general health care delivery system. We have also moved light years ahead in developing relationships with key members of Congress who support psychology’s agenda. One just has to look at AAP’s Leadership Circle Dinner honorees to see a “Who’s Who” of bipartisan political clout. Add to that the fact that two members of the 110th Congress are former professional psychologists (Brian Baird and Tim Murphy). And in January, Ted Strickland will become the first psychologist in history to serve as a Governor (OH) where he will be enormously influential as one of fifty members of the National Governors Association. We are positioned well to make psychology’s voice heard now and also when major health reform again reaches a level of prominence at the national level.
Be assured that we are not sitting around waiting idly for 2008 to roll around. We have plenty of work to do in the present. The new Congress is sure to inject new life into the Mental Health Parity bill, and the proposed Medicare reimbursement cuts require our immediate attention, just to name some hot button projects. Of course, we will continue to work hard to position ourselves for when all the “planets” are appropriately aligned and the national health care reform debates begin. I wish you all a very healthy and happy 2007 and am thankful for the support you provide for making psychology’s voice heard in Washington, D.C.