Posted by: Jeff | January 27, 2010

Did Massachusetts Voters Reject Health Care Reform?

On the surface, the answer is “yes.”

A poll run by The Washington Post, The Henry J. Kaiser Family Foundation and the Harvard School of Public Health found that 48 percent of voters in Massachusetts are opposed to the health care reform bills in Congress, while only 43 percent support them. Furthermore, 56 percent of the voters listed health care reform as “extremely important” in deciding how they voted – 62 percent amongst Brown voters and 50 percent amongst Coakley voters – a higher score than was given to any other issue. When asked what single issue was most important in determining their vote, voters again named health care almost twice as often as any other issue. So it appears that health care reform, while certainly not the only factor driving the outcome in Massachusetts’ special election, was at the top of the list. And voters there did not like what they were seeing.

But like I said, that’s what’s on the surface. Beneath the surface, things are far more complicated. And complicated in ways of significant consequence to the question of where Democrats and Obama should go from here. So let’s break down the numbers.

The first wrinkle arrives with this question: “Thinking specifically about the changes to the country’s health care system proposed by Obama and the Democrats, would you prefer that Brown work with the Democrats on these changes or try to stop these changes from happening?” Not surprisingly, Coakley voters overwhelmingly said Brown should work with the Democrats. Additionally, 69 percent of voters who sat the election out said the same. But what’s really interesting is that Brown voters, rather than being the mirror opposite of the Coakley voters, were split on the issue. 48 percent said Brown should work with the Democrats and 50 percent said he should try to stop them on health care. (All told, 70 percent of the voters said Brown should work with the Democrats.)

Now, one could quarrel with how much this finding actually means. Americans are generally smitten with the idea of bipartisanship and the general notion that politicians should be able to “come together” to solve the country’s problems. So it’s hard to imagine a majority of voters explicitly endorsing oppositional politics even when they’re genuinely freaked out by a particular legislative agenda. Still, when voters say they want the candidate they elected to work with the opposition party on a piece of legislation, even when that candidate expressly presented himself as the vote to kill said legislation, the idea that the voters have rejected the legislation wholesale becomes rather muddled.

Furthermore, of the voters who listed health care reform as “extremely” or “very” important to their vote, 19 percent said the political process was what they specifically meant. This was higher than general support for the bill, at 18 percent, or general opposition to the bill, at 15 percent. Amongst Brown voters, concern with the political process rose to 30%, again significantly higher than general opposition to the bill. (At 22 percent.) This reinforces the contention that what has poisoned health care reform for Americans is not so much the content of the bill but rather the process that has accompanied the bill. As Megan McArdle has repeatedly observed, the bill gets less popular every time it’s debated. The debate itself is to a large degree the problem.

This is significant because dissatisfaction with the political process behind a particular bill is inherently ephemeral. Eventually, the process ends and the bill is either passed or allowed to die. And the voters, having famously short memories, move on to other issues.

The mid-term elections remain ten months away. Democrats don’t necessarily need to drop health care reform, they just need to quickly bring the process to a conclusion one way or another. At the risk of sounding cynical, that way voters have plenty of time to forget how much they hated the process before November rolls around. What really should concern Democrats is whether or not voters will like health insurance reform once it has passed, because the bill itself will stick around long after the sausage-making has faded from memory. And in sticking around, it will constantly remind voters of whether they like or dislike it.

Obviously, if voters wind up disliking reform when they actually live under it, that would be a political disaster for the Democrats and a good reason, from the standpoint of self-interest, to let the bill die. But if voters wind up liking the bill, it will be a trump card Democrats can deploy in their favor for decades to come.

To follow up on what I said above, we should remember to distinguish between whether voters don’t like a bill when they contemplate it as an abstract possibility, and how they react to the bill when they actually experience it in concrete terms. American voters are not terribly coherent or self-aware about their policy preferences, meaning there’s no reason to assume a negative reaction in the first circumstance heralds a negative reaction in the second. And if there’s evidence that Americans don’t really understand the substance of the health care bills (and there is) then that’s even more reason to think a positive reaction to the actual bill is possible, even when there’s a negative reaction to the idea of the bill.

So, all we have to do now is answer this question: Do voters actually like living under the kind of system health care reform would bring? And happily, we can do that. Or at least lay out some evidence that points in a pretty clear direction.

This is where the occurrence of this special election in Massachusetts becomes kind of fortuitous, because Massachusetts is the only state in the country to already have a universal health care system. And the structure of this system is very similar to the bills passed by the House and Senate. One, regulate the insurers to see that everyone gets good coverage and that no one gets denied based on technicalities or pre-existing conditions. Two, mandate that everyone purchase insurance and thus contribute to the risk pool, which will prevent the regulations from driving insurers out of business. Three, provide subsidies so that everyone can afford the mandate. And four, set up taxes to fund the subsidies.

This has inspired a good number of pundits to posit a narrative in which Massachusetts voters chose Brown because he vowed to kill national health care reform, and voters want that reform dead precisely because they have direct experience living under such a system on the state level. In other words, the Massachusetts’ voters rejected the national system because they rejected their own state system.

There’s just one problem with this narrative: Massachusetts voters don’t reject their state’s system. Out of all voters in the WaPo-Kaiser-Harvard survey, 68 percent supported the Massachusetts system, and over half described themselves as “strongly” supporting it. Only 27 percent opposed the system, again just over half strongly. Both Coakley voters and voters who didn’t participate in the election supported the system, by 87 percent and 64 percent respectively, and again over half supported it strongly in both instances. And the voters who cast their ballots for Brown? They supported the system by 51 percent, a bit more than a third strongly, while 44 percent opposed it, a bit over half strongly.

So half of the Massachusetts voters who cast their ballot for the candidate explicitly opposed to the Democrats’ health insurance reform effort, nonetheless support the same structure of reform when they actually live under it. Everybody got that?

Brown’s campaign itself actually embodied this paradox, as the candidate went out of his way to praise the Massachusetts system while condemning the Democrats’ reform bill. How exactly a health insurance structure which is just fine at the state level becomes a jobs-killing, tax-hiking socialist monstrosity at the national level was never explained, needless to say. And as Daniel Larison,* among others, has noted, Brown’s argument against the bill often boiled down to an “I’ve got mine, now you can’t have yours” mentality. Since the people of Massachusetts already have universal coverage, why should they burden themselves with the additional changes and taxes necessary to extend that system to the entire country? This is a perfectly rational argument (if also a morally repugnant one) for why Massachusetts voters should reject national health care reform. But it’s a terrible argument for why the rest of the country should reject it. Indeed, if anything, it militates in favor of the rest of the country passing the Democrats’ reform. That way they’ll finally get it as good as Massachusetts does.

Now, the Massachusetts system does have problems. It has proven to be more expensive than anticipated and has done nothing to control the ongoing rise of health care costs, as conservative pundits have again repeatedly noted. And this has hurt the system’s standing amongst Massachusetts residents since support, while still strong, has been falling in recent years. The thing is that the Massachusetts system was never intended to control costs. It was intended to expand coverage, and at that goal it has been a success. Even the supporters of the reform acknowledge that it was the first part of a two-step process: first universalize coverage, then institute the reforms necessary to bring rising costs under control.

This matters, first of all, because as of 2008, support for Massachusetts’ system rose from around 60 percent to 70 percent when voters were asked if they supported continuing the program on the condition that further changes and reforms would be instituted. But what matters even more is that the national health care bill in the Senate does not engage in this two-step process. It expands coverage through the same structure Massachusetts used, but then it also controls costs at the same time. The Senate bill has the excise tax, the Medicare Commission and a massive grab-bag of delivery system reforms, all of which will help mitigate the structural forces driving the nation’s health care costs upwards. It creates health insurance exchanges which will increase competition amongst providers, again driving down costs. In other words, all the worries voters have with the Massachusetts system (Which they still support regardless!) are addressed in the Senate’s bill. Yet more reason to think American voters will like living under the Senate’s bill just as Massachusetts voters currently like living under their state’s system.

The final thing to mention is that much of the Senate’s health care bill is not scheduled to kick in until well after the 2010 mid-terms. This could be a problem, since even if the bill is something voters would like, they won’t know they like it in time to help the Democratic politicians who are worried about their jobs now. But Jonathan Cohn dealt with this question in his open “letter” to House Democrats, pointing out that the Senate bill includes a whole slew of “deliverables” – benefits for seniors, families and individuals which will kick in within months of the bill’s passage, and give beleaguered Democrats something to run on in November.

Of course, what I’m discussing here is politics and polls, which have nothing to do with whether the bill is good on the merits. I mentioned Daniel Larison, who while presenting basically the same analysis of the polls that I have, nonetheless opposes the bill because he thinks it will be bad for the country’s fiscal health. Needless to say, I disagree. But the difference between polls and policy merit cuts both ways – if the drop in approval for the bill doesn’t invalidate support for the bill on the merits, it doesn’t validate opposition to the bill on the merits either. Larison knows that, but a lot of conservatives and Republicans crowing about Brown’s victory in Massachusetts – and declaring it a referendum on health care reform – seem to have forgotten this simple fact.

And frankly, the debate on the merits of the bill is over. Congress has already passed their versions of the bill. The only step left was for the House and Senate to haggle out the details between the two bills and reach a final compromise, which is when Brown’s win threw a wrench into the works. Presumably, whatever merits the bills had when majorities passed them the first time still remain, regardless of whatever political dust-ups occurred in the interim.

And if Democrats let the bill die, Republicans will remember that Democrats still voted for it the first time around, and they will make sure the voters remember as well. They’ll tar the Democrats as spineless flip-floppers (they were for the bill before they were against it) and for supporting a bad bill which only Republicans had the will to stop. And since there won’t be any actual bill to assess, the voters will have no reason to contradict the Republicans on this score. Let the bill die, and the Republicans will get to write the narrative of why it died.

And this gets to the concluding point. If the Democrats decide to cut their losses and scuttle the bill, I can see no positive political results that would have for them come this November. On the other hand, if the Democrats square their shoulders, lower their heads, and drive health insurance reform the few remaining yards to the end zone, that won’t guarantee them positive results in November either. But it should significantly increase their chances.

And hey, regardless of the political outcomes, they’ll have actually done something, you know, good for the country. That’s worth remembering too.

*For some reason, Larison’s blog is down as of this posting, so I can’t link to it. I’ll fix this as soon as I’m able.

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