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Contact Us Fall 2000; Volume 1, Number 1
Features: Election 2000

Health Care: Does It Matter in the Presidential Campaign?
David Blumenthal, MD, MPP
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Seen through the prism of health care issues, the 2000 Presidential campaign is shaping up to be a closely fought struggle that reflects both the economic contentment and the gnawing anxieties of the American people. The battle over health care will be waged, like the campaign generally, in the center of the political spectrum, with quick jabs and body clinches rather than decisive blows. The Democrats, as always, will win the fight to convince Americans that they are the party that will work hardest and smartest to protect their health care security. However, they will win on points, not by a knockout, and that likely outcome suggests a central dilemma for Democrats and for health care reformers generally in the early years of the third millenium.

To understand how health care will play out in the coming campaign, a few basic points are useful to keep in mind.

First, health care has historically been a Democratic issue. The American people assume, based on long experience, that Democrats will take the lead on health care problems, will propose more aggressive solutions, and will honor their campaign commitments. Virtually every major health care initiative in our nation's history, from Medicare and Medicaid in the 1960s to the Clinton plan of the 1990s and the recent efforts to extend coverage for children, has been conceived of and championed by Democrats. Recognizing their disadvantage on health care terrain, Republicans have often avoided health care altogether in presidential contests. Not infrequently, Republican candidates have gone into the first presidential debates without ever releasing a formal health care position paper. When I served as health policy adviser to Governor Michael Dukakis during his 1988 presidential campaign, I traveled the country responding to invitations from health care groups to debate representatives of Vice President George Bush on health care issues. As often as not, the Bush campaign did not even bother to send a spokesperson, and they rarely sent the same person twice. The message was clear: the less said about health care, the better.

Second, for most of the twentieth century, Presidential campaigns provided an opportunity for Democratic candidates to promote comprehensive solutions to national health problems, and especially to rally support for universal health care coverage. Starting with Harry Truman's proposal for comprehensive national health insurance in the 1948 campaign against Republican Thomas Dewey, virtually every Democratic party platform and every presidential contender has advocated one or another proposal for national health insurance.

Third, and this is often hardest for health care policy aficionados to hear, health care issues are rarely decisive in Presidential elections. The reason is that the voting groups for whom health care is most salient—the uninsured, the poor and minorities—are less likely to vote than better off Americans, and when they do vote, they are firmly in the Democratic camp. Thus, health care sensitive voting blocks are rarely in play during Presidential election campaigns. Democrats' emphasis on health issues is usually designed to motivate their traditional base rather than to attract independent and swing voters who provide the critical margins in so many Presidential elections. Of course, health care is vital to the elderly, who have the greatest burden of illness and the greatest need for service of any population group. And the elderly vote. However, since 1965, they have not been active in health care debates because most believe their health care security has been assured by the Medicare program.

These three general considerations provide essential background for understanding the role that health care seems to be playing in the 2000 Presidential campaign, and how that role differs from past precedents. First, health care will continue to work better for the Democrats than for the Republicans in this presidential election. Vice President Gore's positions are generally more detailed and far-reaching than Governor Bush's. Gore prominently mentioned health care in his acceptance speech for the Democratic nomination, unlike Bush (who covered few specific issues of any type). However, the health care debate will be less asymmetric this year and will provide less advantage for Democrats than it has in many preceding campaigns. The experience with Clinton's health care reform, rightly or wrongly, has left Americans extremely cautious about comprehensive federal solutions to health care problems. This has forced Gore to advocate a series of cautious, incremental steps toward eliminating the problem of uninsurance in the U.S. His principal proposal has been to assure that all children have access to health insurance by the year 2005. He has also advanced limited ideas to cover the parents of uninsured children, and working Americans between the ages of 55 and 64. Though laudable, these concepts are conservative by traditional democratic standards and place Gore firmly in the center of the American political spectrum. In 1972, when Richard M. Nixon advocated a plan called the Comprehensive Health Insurance Program that would have insured all Americans, the Gore proposal would have placed him at the conservative extreme of American health care politics, far to the right of mainstream Republicans of the time.

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