Health care, politics, and COVID-19

Long before the coronavirus paralyzed the country, healthcare was a top concern among most Pennsylvanians. And healthcare will remain a top issue through the crisis and well after the November national elections, according to experts who have been monitoring long-term trends.

Exactly how public opinions might shift will depend on the ways the state, national and local governments handle the current crisis.

“Healthcare traditionally has been reported as the most important issue for Americans,” said G. Terry Madonna, director of the Center for Politics and Public Affairs, professor of public affairs, and director of the Franklin and Marshall College Poll. “What we don’t know is, if at the end of the day, do the values shift, do the opinions shift toward more government control? We have to see how it plays out,” he said.

Going into April, Bernie Sanders remained in the race, running on a platform of “Medicare for all,” a stance that was consistently attacked by more moderate candidates, such as South Bend, Indiana Mayor Pete Buttigieg and Sen. Amy Klobuchar of Minnesota before they dropped out of the Democratic primaries. They argued that national health care would be too expensive, especially considering that most Americans want to keep their private insurance. Joe Biden continued his support of the Affordable Care Act, which was the signature legislation of President Barack Obama. Biden, who strongly lobbied for the ACA as Obama’s vice president, has argued for improvements to the system, while encouraging an expansion of Medicare and improvements for private insurance.

As for Trump, he succeeded in getting rid of the ACA’s individual mandate, which required people to get insurance or pay a penalty. Until it was shed, the mandate led many people to pay the penalty because it was less expensive than insurance, which continued to go up under the ACA. Trump also has been fighting the ACA in federal courts, while maintaining that any replacement plan must include covering pre-existing conditions.

Madonna and others said the stances of Sanders, Biden and Trump might hold through the election but the coronavirus has been such a disruption that public opinion could shift, forcing all elected officials to re-think their positions. For example, if the federal government handles the crisis expertly, more citizens might gain confidence that it could handle a national health plan. However, the opposite could happen just as easily, Madonna said.

Gene Barr, president and CEO of the PA Chamber of Business and Industry, noted that Trump often has made public comments that support traditionally Democratic positions, such as controlling the prices of prescription drugs. However, if the pharmaceutical companies step up during the crisis and find a cure for the virus quickly, that could back the argument of why the drug companies need their profits to test new drugs and bring them to market, Barr said.

“It is far too early to know how Covid-19 will change people’s perspectives,” Barr said in late March.

In addition to limited constraints on drug companies, the state chamber has supported healthcare plans that would expand Association Health Plans, which give businesses opportunities to pool resources to barter for better prices from health insurance companies. It also backs stronger liability protections for healthcare providers.

“We think the private sector works well, and we need to keep it,” Barr said.

He agrees with Trump and the Democrats that any path forward must include protections for pre-existing conditions. However, assurances must be put in place so that people don’t drop insurance only to add it when they get sick, then drop it again when they get better. An assumption behind the ACA was that it would lower insurance costs because it would increase the pool of healthy young adults who would buy insurance, he and others pointed out. 

“We need to find a system that works but that calls for individual responsibility,” Barr said.

Christopher P. Borick, professor of political science and director of the Muhlenberg College Institute of Public Opinion, noted that Pennsylvania residents increasingly support more government involvement in healthcare. The college conducted its annual healthcare poll in early March. That timing was coincidental to the coronavirus crisis but before widespread social distancing.

The survey showed that Pennsylvanians increasingly think the federal government is responsible for ensuring Americans have healthcare coverage — nearly 6 in 10 Pennsylvanians or 59 percent of those polled.

 “This is an increase of 5% since 2019, when 54% of Pennsylvanians maintained this view,” the report said.

Studying trends

Borick agreed that the virus will have long-lasting societal and political ramifications but that more people have been leaning toward increased government involvement for years. 

“We already had been seeing movement in terms of government involvement,” he said in late March, as the results of the poll were being prepared for public release. For example, plans that would allow people to buy into Medicare would be popular.

The details of such Medicare buy-in plans will make the difference as to whether they gain traction, said Robert Glus, a partner and consulting actuary for Conrad Siegel, a benefits management company based in Harrisburg. Glus gave a presentation early in the year to the Central Penn Business Group on Health, a Lancaster-based group that helps businesses wade through healthcare issues to improve quality and costs. The presentation included overviews of how the national candidates’ platforms compare. While the idea of expanding Medicare is popular, people often become concerned when they see the potential costs.

Ideas require careful analysis because, if proposals don’t offer a level playing field with private insurance, such plans might be just a way to eventually steer care into a nationalized system years later. However, if plans offer fair competition and allow more people to become insured by buying into the Medicare system, that might be something that could gain wider support.

“How you would implement it is going to be important,” Glus said.

He pointed out that he didn’t provide the group with an overview of Republican proposals because detailed plans don’t exist. Trump has talked about controlling drug costs and ensuring pre-existing conditions are covered, but the Republicans don’t have any “overarching plans,” Glus said.

“I call it nibbling around the edges,” he added.

Borick said Trump can act like a populist — as seen by his statements about controlling the costs of prescription drugs — which could make him amenable to plans that expand government involvement. That especially could be true if the federal government handles the crisis well and if the states demonstrate that they stepped up. Trump also hasn’t shied away from spending big when he wants to, Borick said.

“If re-elected, would he go for some sort of big-ticket expansion of government investment?” Borick asked rhetorically. “If they handle it well, and it is seen as a success, it might give everyone some confidence that government could expand its role.”

But Borick and others cautioned that a lot of “ifs” remained as the reaction to the virus plays out.

Politicians, journalists and policy experts react to a crisis differently than most average citizens, said Daniel J. Hopkins, a professor in the department of political science at the University of Pennsylvania. In the height of a crisis, many people seek solutions and ideas that might be a shift from traditional ways of thinking. However, Hopkins said, studies suggest that severe shifts among average people are not long-lasting. He cautioned that, depending on when the virus crisis ends, a lot of people likely will revert to their previous corners of the debate, which would include a reluctance to give up their private insurance for a national plan.

After a crisis, “the public is less likely to draw broader ideological conclusions,” he said. “When faced with some new event, oftentimes the public goes to its greatest hits album.”

Diane Hess, executive director of the Central Penn Business Group on Health, said her group is teaming up with other agencies to track how the virus is handled. Hess, who attended the presentation given by Glus, agreed that the Republicans and Trump don’t provide detailed alternatives to the ACA. They need to come up with a plan that can be compared to it.

“And then we can decide what we like and don’t like,” Hess added. 

Until then, Democrats will continue to push to improve the ACA. However, many citizens are skeptical about expanding it or Medicare because early promises — such as lower costs or that patients would be able to keep their doctors — were not kept, she said.

“I think there is some distrust in the eyes of the people,” Hess said, adding that the government response to coronavirus might help steer future conversations about healthcare improvements. “We are just too early in the process to know exactly what is going on.”

The overall issue isn’t going away, Hess pointed out.

“Healthcare will continue to be the No. 1 issue,” she said. “… We really need to go back to our roots. How can we improve access and cost?”