Health Care’s Cold Truth: An Iowa Perspective – Michael Millenson

Obama_webI am writing this blog from Cedar Rapids, Iowa, grateful that the
temperature has warmed from brutally
cold to pleasantly sub-freezing.
Fortunately, the warm feelings left by the extraordinary victory of
Sen. Barack Obama, the candidate for whom I was knocking on doors and
making phone calls these last few days, has trumped the temperatures.

Talking to real voters in the suburbs and rural areas surrounding this
small city provides a nice change from  the insular health care policy
world. For one thing, it reminds you that most people don’t care about
“policy,” per se, of any kind. Successful candidates connect first with
the heart and then the head. We instinctively believe that if we trust
a candidate’s values and broad beliefs, we will trust that candidate’s
detailed policy decisions.

Yet the sad reality is that a vast number of citizens won’t even make
that small emotional investment, and they don’t hesitate to proclaim
their apathy when you knock on the door or call. As much as you may
have heard about voters disenfranchised from the Iowa caucuses,
many more simply didn’t care enough to participate. That, alas, makes
Iowa quite representative of the nation as a whole. While Democratic
turnout at this year’s caucuses was double that of four years ago, that
merely turned a “tiny” slice of registered voters into a “small” one.

More broadly, the primaries should remind us how disconnected the details of policy are from the politics that put into place the leaders who will make the final policy decisions. While we may wade through bullet-pointed detail of health care platforms, few real voters share our interest at this time. Polls and interviews clearly indicate that Republican primary voters did not care much in Iowa, and show no inclination of caring elsewhere, about universal coverage or any other sort of health care “reform.” Their main issues are the economy and immigration. If any health-related issue is at all salient, it is abortion, part of a larger social agenda. The Republican candidates have responded by promising that tax-credit tinkering, and a little bit of faith, will bring good health and good health care to all.

The Democratic electorate, meanwhile, wants “affordable” health care for all, and wonks would do well to pay attention to that first word. A nurse in Marion, Iowa, told me she liked Obama, but worried that his health care plan would raise her taxes. I assured her Obama’s plan was less expensive than that of his Democratic rivals and that phasing out the Bush tax cuts for the rich would pay for it. Those assertions are true, but, of course, not quite the whole truth I would tell if sitting at my computer rather than shivering at a stranger’s doorstep. Yet in those simplified truths there is shortcut wisdom, for they are a way of saying that this candidate connects with your concerns. And your concerns about health care have nothing to do with health IT, evidence-based medicine or a score of other technical issues.

On the phone, a woman in a working-class rural area told me of medication for her five-year old hemophiliac son that runs a stunning $80,0000 a month – “more than the cost of my home.” Fortunately, she has a job where the insurance covers the cost and doesn’t count it against her family’s lifetime maximum of $2 million. “I’m glad I like my job,” she said, and I figured it wasn’t the time to discuss the fine points of pharmaceutical pricing on innovative biological products.

President Bill Clinton got the sound bite version of health care reform precisely right in 1993 when his “Health Security Act” referred to “health care that’s always there.” That’s the essence of what Americans want; the rest is commentary.