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The Keckley Report

Healthcare in the Mid-Term Debates: Heavy on Posturing, Lite on Substance

By October 22, 2018March 1st, 2023No Comments

In 15 days, we’ll elect 435 members of the U.S.Congress, 35 U.S. senators, 36 Governors, and legislators for 87 of our 99 state legislative bodies. For many, it will mark a welcome reprieve from non-stop political advertising and, in many races, uncivil discourse. For politicos and partisans, attention will quickly turn to Campaign 2020 and likely regulatory changes resulting from Campaign 2018 results.

Polls by Kaiser Family Foundation and others show healthcare has emerged as the most important issue to likely voters (30%) ahead of the economy and immigration. Pundits attribute its prominence to the confluence of a period of relative peace and prosperity and ample media coverage on healthcare issues like pre-existing conditions and Medicare-for-all.

Healthcare is fertile turf for campaign strategists: voters willingly share their views on healthcare issues with pollsters. Their opinions are based on their personal experiences and often change as their personal circumstances alter their views.

Donald Kinder and Kenneth KamIoe (Neither Liberal nor Conservative: Ideological Innocence in the American Public) studied the relationship between voting patterns and the underlying beliefs on which voters based their opinions. They reviewed voting patterns and opinion surveys across a wide range of issues from 1972-2009 to measure what if any correlation and causality exists between a voter’s ideology and how they vote. On healthcare votes, they found little.

They wrote “ideological differences have little influence over opinion on immigration, affirmative action, capital punishment, gun control, Social Security, health insurance, the deficit, foreign aid, tax reform, and the war on terrorism.” The only exception they found was abortion: every other healthcare issue that surfaced in those years—which included the HMO Act in 1972, the Medicare Modernization Act in 2003 and others—prompted votes not tethered to a particular political party or philosophy. They found voters change their minds on healthcare issues as they interact in their business or social circles or experience the health system firsthand.

In the current election cycle, polls show healthcare is more important to Democratic voters than Republicans. I watched 12 televised debates—7 for contested Senate seats and 5 for Governor’s races—to gauge how the campaigns and parties position themselves on healthcare issues. I examined the questions asked by moderators, the timing of healthcare in the debate agenda, follow-up queries posed in response to candidate responses and the intensity of the differences between candidate views. Though qualitative by design, the findings are no less insightful.

Four Healthcare Issues Have Figured Prominently in the 2018 Mid-Term Elections

Medicare-for-all, pre-existing conditions, opioid addiction and Medicaid expansion are the healthcare issues that have figured prominently in the debates. Senate debates devoted less attention to healthcare than gubernatorial contests: the Supreme Court confirmation of Brett Kavanaugh, gun control, tariffs, federal debt and foreign policy items were addressed in the Senate clashes, contrasted to Governors’ debates in which Medicaid expansion and opioid addiction got more attention.

Three of the four issues lent themselves to sharply contrasting views between candidates and their parties: opioid addiction and drug abuse less so. So, debaters used their 60-second time allocations to drive home one key difference between their view and their opponents:

The Four Healthcare Issues in Campaign 2018 Republican View Democratic View
Pre-Existing Conditions We will protect citizens against insurer denial of coverage due to pre-existing conditions by passing new laws that require coverage but allow insurers to charge what they must to address their added risk.
Bottom Line: The ACA is still bad policy: we will repeal it. What’s needed is health insurance reform.
Protections against the denial of coverage for a pre-existing condition by an insurer is in the Affordable Care Act, which Republicans have pledged to repeal (again).
Bottom Line: It’s the right thing to do.
Medicaid Expansion It’s dependent on a state to decide as 33 already have. For those considering expansion, newly insured eligible enrollees should be required to work and maintain eligibility for the cost of the entitlement to be contained.
Bottom Line: There should be no free rides. Medicaid waste and fraud should be addressed to protect taxpayers.
Low income families and kids need access to healthcare. They do not abuse the system, they depend on it. And the costs for Medicaid services which are coordinated by states and private managed care organizations, are substantially less than what’s spent in costlier settings like emergency rooms and hospitals.
Bottom Line: It makes fiscal sense to expand Medicaid to reduce overall health costs. The public believes access to health insurance is a fundamental right.
Opioid Addiction Drug addiction including opioids is a societal issue requiring a comprehensive approach including tighter controls on prescribing and access coupled with increased funding for mental health and counseling.
Bottom Line: It’s a problem that needs urgent bipartisan attention.
It’s a major problem requiring urgent attention. The solution should include penalties for manufacturers and prescribers who have abused the system for their financial gain. And funding for mental health, which has been cut, should be restored.
Bottom Line: It’s not enough to say there’s a problem. Action must be taken.
Prescription Drug Prices Drug prices are too high. Policies that promote price transparency, increase generic competition, remove gag clauses on pharmacists and “naming and shaming” companies guilty of price gauging are working.
Bottom Line: There no excuse for drug price gauging: current efforts are working.
Drug prices are inexcusably high because drug manufacturers put profits before patients. Lawmakers must hold them accountable. Importation of drugs, direct purchasing by Medicare, and more drastic measures should be taken.
Bottom Line: Access to drugs should not be limited by a person’s income.

Debaters were Long on Soundbites and Short on Specifics 

On healthcare issues, candidates lean heavily on focus-group tested “gotcha” responses and avoid specifics. Their answers tend to follow a formula: reinforce the underlying issue as a “real” problem by using a key statistic to demonstrate knowledgeability, convey sincere sensitivity about the problem by referencing a personal experience, assert a solution without offering specifics about how it might work or what it might cost, and attack the opponent’s solution as unworkable, expensive, untested or immoral. It’s a formula that works, especially in a debate format, and especially when terms and phrases are used to stimulate an emotive reaction from viewers: “government-run healthcare” and “liberal” were used frequently by the GOP Senate candidates to label opposing ideas and “drug company profits” and “far right” were popular as Dems characterized the ideas of their opponents.

Despite the Importance of Healthcare, It Got Inadequate Attention in the Debates 

In every debate, candidates alluded to the critical and unique roles played by healthcare and education in advancing and protecting our society. It’s political malpractice not to mention both. At 29% of federal spending, 34% of state spending and 14% of household spending, healthcare deserved more attention in the mid-terms.

In these debates, not a word about Veteran’s Health impacting 21 million, alternative payment models, the roles of mid-level clinicians or physician burnout, mental health parity, drug prices, physician shortages, total costs of care, workforce shortages or price transparency. No reference to industry consolidation, the Amazon effect, the future of medical education or precision medicine. Nothing about retail clinics, telemedicine, social determinants or reimbursement shortfalls. Just the four issues. Regrettable!

When the dust settles after November 6, a bigger issue will linger: how to engage voters so solutions to complex problems can be developed in a non-partisan constructive way based on facts. The American electorate is vastly uninformed and ill-equipped to address the pressing issues in healthcare.

In these debates, healthcare did not get adequate attention. It is up to the industry to fill the knowledge gap so voters in 2018, 2020, and beyond understand the facts, trends and implications of their actions.



Senate Debates Analyzed: Massachusetts (10/21), Tennessee (10/10), Indiana (10/8), Texas (9/21, 10/16), Ohio (10/20), California (10/17) Washington (10/20)

Gubernatorial Debates Analyzed: Michigan (10/12), Tennessee (10/12), Florida (10/21), Massachusetts (10/17), Arkansas (10/12)