202.776.9066 | www.lakeresearch.com | November 6, 2008

Health Care in 2009Health Care in 2009

Celinda Lake

Lake Research Partners

2

Key PointsKey Points• The 2008 election delivered a substantial mandate for real change. Barack

Obama’s central argument in the closing days of the campaign was that it was time to turn the page on the last 8 years and try something new. The margin of victory underscores that the voters are ready for change.

• The results of the presidential and congressional elections complete the wave that started in 2006. Four years ago, voters wanted change, but felt cross-pressured by the 9/11 dynamic. In 2006, terrorism was not enough to offset weak job approval ratings for President Bush and the Congress. And in 2008 voters completed their repudiation of conservative Republican ideas.

• Health care reform is a key element of the change that voters demand. Consistently over the past year and a half, voters have expressed concern over rising costs and limited access and expressed an appetite for a larger government role.

• The economy dominated this election as a voting issue. All other issues took a back seat to the economic crisis. The health care issue was the top personal economic issue.

• The weak state of the economy presents a challenge to health care reform, but also an opportunity. While many politicians will instinctively seek to pull back on spending, health care is one of the key components of voters’ economic anxiety. Advocates need to drive this point home to policy makers.

3

The economy dominated this election. Obama won The economy dominated this election. Obama won by being the most trusted voice on the economy. He by being the most trusted voice on the economy. He also appealed to voters specifically concerned about also appealed to voters specifically concerned about health care. health care.

7%

9%

9%

10%

63%

0% 10% 20% 30% 40% 50% 60% 70%

Energy Policy

Terrorism

Health Care

Iraq

Economy

Issue (%) Obama McCain

Economy (63%) 53% 44%

Iraq (10%) 59% 39%

Health Care (9%) 73% 26%

Terrorism (9%) 13% 86%

Energy Policy (7%) 50% 46%

Source: CNN 2008 Exit Polls. 17,836 Interviews

4

Key PointsKey Points

• Even after the financial collapse on Wall Street, health care remains one of the top economic concerns. In other words, even though the economy dominates health care and other issues, when voters say ‘the economy” there is strong overlap with healthcare.

• Despite the economic sensitivity that makes voters apprehensive about taxes and a strong anti-Washington sentiment—voters want healthcare reform even when they are told it will raise taxes or bring in more government.

• Affordable quality health care and keeping their coverage are the two main priorities for voters on this issue.

• These concerns made health care an important factor in their vote for president.

5

Even after the collapse of Bear Stearns, Lehman Brothers Even after the collapse of Bear Stearns, Lehman Brothers and AIG, health care was the top personal economic and AIG, health care was the top personal economic concern in voters’ everyday lives for both men and concern in voters’ everyday lives for both men and women.women.

LRP Poll for The Partnership to Fight Chronic Disease. October 4-9, 2008. 1500 Likely Voters (795 Women).

33%

24%

17%

17%

13%

11%

10%

9%

7%

3%

3%

1%

1%

35%

22%

17%

17%

12%

8%

12%

11%

6%

6%

3%

3%

2%

1%

38%

8%

39%Health care

Rising costs of gas and food

Jobs

Schools and education

Retirement savings

Affordable housing

The stock market

Being able to live on a fixed income

Medicare

Fear of another terrorist attack

Crime, drugs, and gangs

Getting government assistance like food stamps or Medicaid

Credit card debt

Nursing home care

(don't know)

Total

Women

Now I’m going to read you some problems you and your family may face. Please listen carefully, then tell me which ONE of these you personally worry the most about? … Now from the same list, please tell me which ONE of these you personally worry about second most?

6

Both men and women cite rising costs as the most Both men and women cite rising costs as the most worrying thing about health care today. Women cite worrying thing about health care today. Women cite losing coverage next, while men tend to cite quality.losing coverage next, while men tend to cite quality.

29%

27%

19%

19%

14%

12%

10%

6%

3%

45%

32%

23%

21%

19%

11%

12%

11%

6%

5%

3%

27%

30%

17%

19%

16%

13%

9%

6%

4%

2%

47%

4%

50%Your premiums and co-pays going up

The quality of health care

Losing your health insurance

Not having insurance

The cost of long term care

Having insurance fully cover care prescribed by your doctor

Having care that meets your family’s needs

Choice of doctors

Ability to find a doctor

(Other)

(Don’t know)

Total

Men

Women

LRP Poll for The Partnership to Fight Chronic Disease. October 4-9, 2008. 1500 Likely Voters (795 Women).

And thinking specifically about health care, what are you personally worried about the MOST? … And what are you personally worried about the SECOND most?

7

Leading up to the election, eighty-two percent of Leading up to the election, eighty-two percent of voters viewed health care as extremely or very voters viewed health care as extremely or very important to their vote for president.important to their vote for president.

49%

33%

15%

3%

0%

20%

40%

60%

ExtremelyImportant

Very Important SomewhatImportant

Not at allimportant

Source: Fox News Poll. 10/20-21/2008. 1,100 Registered Voters.

(How important will each of the following issues be to your vote for president (in 2008)?...Extremely important, very important, somewhat important, not at all important)...Health care

8

44%

50%

49%

23%

18%

17%

-40% -20% 0% 20% 40% 60%

Strongly Favor Not strongly favor Strongly oppose Not strongly oppose

For the past year leading up to the election, the For the past year leading up to the election, the public appetite for progressive reform remained public appetite for progressive reform remained strong—even if it meant raising taxes.strong—even if it meant raising taxes.

 

FavorOppose

September 2007

February 2008 64%27%

69%28%

Do you favor or oppose providing access to affordable, quality health care for all Americans even if it means raising your taxes? Do you feel strongly or not strongly about that choice?*

October 2008 31% 64%

* Asked of half of sample.

9

Similarly, voters have consistently been more than Similarly, voters have consistently been more than willing to accept a strong federal government role in willing to accept a strong federal government role in making sure all Americans have access to making sure all Americans have access to affordable, quality health care.affordable, quality health care.

September 2007

February 2008

October 2008 51%

57%

46%17%

18%

22%

-30% -10% 10% 30% 50% 70%

Strongly Favor Not strongly favor Strongly oppose Not strongly oppose

28%

23%

28%

66%

69%

64%

Do you favor or oppose providing access to affordable, quality health care for all Americans even if it means a major role for the federal government? Do you feel strongly or not strongly about that choice?*

10

Both Obama and McCain voters believe that reducing Both Obama and McCain voters believe that reducing the cost of health care is the top priority for reform. the cost of health care is the top priority for reform. However, Obama voters are much more likely to be However, Obama voters are much more likely to be concerned about access as well.concerned about access as well.

Health Care Priorities

13%

15%

14%

10%

44%

2%

8%

9%

33%

46%

7%

11%

11%

22%

45%

0% 10% 20% 30% 40% 50%

Reduce spending on gov't healthprograms like Medicare and Medicaid

Improve quality of care and reducemedical errors

Improve Medicare and Rx drugprogram

Expand health insurance coverage forthe uninsured

Make health insurance more affordable

Total

Obamasupporters

McCainsupporters

Source: Kaiser Family Foundation Poll. N=1622 Registered Voters. 9/2008.

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The Strategic Situation: The Context and The Strategic Situation: The Context and TargetsTargets

• Based on focus groups and survey findings, advocates of health care for all Americans are in a position for a successful push for health care reform in 2009.

• Voters are feeling more urgency about national health care reform and the need to fix the system but are also sensitive to the urgency of dealing with the economic crisis.

• Women continue to be a key constituency -- women bring up health care as a top concern unprompted in focus group discussions, while men mention the economy or the war in Iraq before mentioning health care.

• Core health care voters are African Americans and Democratic women. Attentive swing voters are older non-college women and seniors. They need to be reassured that reforms will not adversely affect the quality of their health care.

• The gender gap in intensity presents a challenge in launching and sustaining a campaign.

• Women see health care as being part of fixing the economy, rather than as being two mutually exclusive issues. Men want to fix healthcare, but are concerned that doing so will hurt the economy or that we may have to fix the economy first.

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The Strategic Situation: The Message The Strategic Situation: The Message DynamicDynamic

• Voters have negative feelings about the health insurance industry, and a narrative that ties the industry’s huge profits to increased costs and denying people coverage elicits anger that can be channeled into support for reform.

• Motivate anger, not fear. This anger can also be used to discredit the health insurance industry as the source of attacks on reform.

• Both men and women want the government to regulate and “police” the health insurance and drug industries, and do not view regulatory reforms as competing with fixing the economy.

13

Voters strongly identify the health insurance industry with Voters strongly identify the health insurance industry with negative traits of putting profits ahead of people and negative traits of putting profits ahead of people and being greedy, uncaring, and bureaucratic.being greedy, uncaring, and bureaucratic.

50%

46%

44%

34%

28%

26%

16%

9%

28%

23%

24%

27%

25%

32%

34%

30%

67%

78%

69%

61%

53%

58%

50%

39%

Puts profits ahead of people*

Greedy

Bureaucratic

Rips people off*

Unreliable

Treats people unfairly

Reliable

Caring

Very Well Pretty Well Total Well

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Among all voters, banning the practice of denying Among all voters, banning the practice of denying coverage due to “pre-existing conditions” is the highest coverage due to “pre-existing conditions” is the highest scoring feature of progressive reform, especially among scoring feature of progressive reform, especially among women.women.

41%

51%

53%

53%

58%

62% 78%

76%

74%

73%

69%

60%

0% 20% 40% 60% 80% 100%

Costs controlled by competition and negotiation

Employers required to offer all employees public and private plan

Guaranteed affordable private plan or public plan on sliding scale

All plans required to provide standard package w/preventive care

Employers and individuals could keep current plan

No one could deny people w/ pre-existing conditions

Very Convincing (5) Somewhat Convincing (4)

Among Women

o Very Convincing65%

o Total Convincing80%

o Mean Score4.2

Now, I'm going to read you the individual components that are in the health care proposal I just read you. For each one, please rate how favorable you are toward that item on a scale of 0 to 5, where 5 means it is a very convincing reason to support the initiative, and 0 means it is a not at all convincing reason to support the initiative. If you are not sure, please say so.

15

While voters feel healthcare reform is urgent, they While voters feel healthcare reform is urgent, they continue to have doubts about the specifics.continue to have doubts about the specifics.

• Voters often support reform proposals in principle — but pull away from policy specifics fearing higher costs or lower quality for them personally. They don’t want to lose what they have. Women and seniors are particularly sensitive to the details.

• The prospect of bringing 47 million uninsured people into the system elicits feelings of scarcity, especially because the slowing economy may increase that number significantly.

• Men are more sensitive than women to attacks claiming that overly ambitious healthcare reform will hurt the economy.

• Participants still want policy specifics, including how reforms will affect their specific plan.

• Voters still want reassurance that they can keep their current coverage and doctor if they want.

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• Insurance CEO Salaries generate anger and a desire to rein in their excesses.

• Focus group participants were also angered about health insurance companies denying coverage.

• Adding the rising profits of insurance companies and insurance company CEOs makes people really angry.

• Statistics about the rising cost of health care in relation to wages are good points for engaging voters. Vivid facts compare increases in costs with stagnant wages and CEO salaries. Though less powerful statistics about medical debt and dying because of lack of access also carry weight.

• Facts about wages, costs, and profits motivate voters, particularly women, in favor of taking on health care reform now rather than waiting to fix the economy first.

Key to avoiding Harry and Louise is to frame the Key to avoiding Harry and Louise is to frame the voice of the opposition.voice of the opposition.

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• A powerful formula for voters in favor of urgent reform centers on the fact that wages are stagnant, health care costs are increasing faster than wages, and yet insurance company profits are high.

Populist w/Regs: With an economic slowdown, stagnant wages, and rising prices for food, gas, and everything else, we can’t afford to pay more for health care with higher premiums and deductibles while insurance companies cut our benefits, double their profits, and give their CEOs salaries in the tens of millions. We need a solution to the rising cost of health care that regulates what insurance companies charge and the profits they make, and that prevents them from excluding people based on pre-existing conditions.

Message TextMessage Text

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In polling for Health Care for America NOW! In polling for Health Care for America NOW! we tested a Guaranteed Affordable Choice we tested a Guaranteed Affordable Choice framework for reform.framework for reform.

• Americans would be guaranteed to have a choice of health plans they can afford, either from a private insurer, or from a public plan. Everyone would pay on a sliding scale based on income.

• To maintain quality and allow fair cost comparisons, health insurance companies and the public plan would be required to provide at least a standard, comprehensive package of benefits including preventive care and all needed medical care. Employers and individuals could choose to keep their current health plans.

• The public plan would be paid for through a modest payroll tax on employees and employers and by rolling back tax breaks for those who make over $200,000 a year. Small businesses would pay a lower rate.

• No insurer could deny coverage or charge higher premiums to people with pre-existing conditions.  

19

Nearly two-thirds of voters rate the Nearly two-thirds of voters rate the progressive plan a six or higher on a scale progressive plan a six or higher on a scale from zero to ten.from zero to ten.

19%

15%18%

30%

17%

0-4 5 6-7 8-9 10

34% 65%

LRP Poll for Health Care for America NOW!. February 16-21, 2008. 800 Likely Voters.

20

When asked head-to-head, voters prefer When asked head-to-head, voters prefer Guaranteed Affordable Choice over health savings Guaranteed Affordable Choice over health savings accounts, tax credits, or a single payer plan by about accounts, tax credits, or a single payer plan by about three-to-one.three-to-one.

14%

43%

12%

43%

10%

48%

Single Payer

GAC

Tax Credits

GAC

HSA

GAC 67%

64%

65%

20%

20%

22%

Even among the health care base, Even among the health care base, intense support for single-payer is intense support for single-payer is far lower than for GAC.far lower than for GAC.LRP Poll for the Herndon Alliance, September 15-27, 2007. 1000 Likely Voters.

21

Text of GAC, HSA, Tax Credits, and Single Text of GAC, HSA, Tax Credits, and Single Payer plan.Payer plan.

Guaranteed Affordable Choice language:Guaranteed Affordable Choice language:An approach that would guarantee affordable health insurance coverage for every An approach that would guarantee affordable health insurance coverage for every

American with a choice of private or public plans that cover all necessary American with a choice of private or public plans that cover all necessary medical services, paid for by employers and individuals on a sliding scale.medical services, paid for by employers and individuals on a sliding scale.

Health Savings Account languageHealth Savings Account language: : A Health Savings Account program that would provide tax-deductible savings A Health Savings Account program that would provide tax-deductible savings

accounts to all Americans if they purchase a private insurance plan with at least accounts to all Americans if they purchase a private insurance plan with at least a thousand dollar deductiblea thousand dollar deductible..

Tax Credits languageTax Credits language: : An approach that would provide tax credits that will reimburse individuals and An approach that would provide tax credits that will reimburse individuals and

families for 25 to 50 percent of the cost of their private health insurance families for 25 to 50 percent of the cost of their private health insurance policies.policies.

Single Payer languageSingle Payer language: : A single government-financed health insurance plan for all Americans financed by A single government-financed health insurance plan for all Americans financed by

tax dollars that would pay private health care providers for a comprehensive tax dollars that would pay private health care providers for a comprehensive set of medical services.set of medical services.

22

41%

51%

53%

53%

58%

62% 78%

76%

74%

73%

69%

60%

0% 20% 40% 60% 80% 100%

Costs controlled by competition andnegotiation

Employers required to offer all employeespublic and private plan

Guaranteed affordable private plan orpublic plan on sliding scale

All plans required to provide standardpackage w/preventive care

Employers and individuals could keepcurrent plan

No one could deny people w/ pre-existingconditions

Very Convincing (5) Somewhat Convincing (4)

Mean

4.1

4.1

4.1

4.0

3.6

3.9

The most compelling aspect of GAC is that The most compelling aspect of GAC is that insurers would not be able to deny coverage to insurers would not be able to deny coverage to people with pre-existing conditions. It is also very people with pre-existing conditions. It is also very important for voters to hear that they could keep important for voters to hear that they could keep their current plan.their current plan.

23

Middle Class attack

36%

22%

46%

42%

0% 10% 20% 30% 40% 50% 60%

Responsible/morallyright for

hardworking people

Middle class pay forothers

Defending GAC from the charge that the middle class Defending GAC from the charge that the middle class will have to pay for the health care of the uninsured by will have to pay for the health care of the uninsured by appealing to the morality of providing affordable health appealing to the morality of providing affordable health care to those who work hard and play by the rules care to those who work hard and play by the rules works best.works best.

[Poor have no incentive] They call this a sliding scale, but immigrants and people on welfare will pay almost nothing and will have no incentive to take care of their health. This program will force middle class families who are already struggling with their health care costs to pay for health care for the uninsured. We can’t afford a big tax increase, and that’s what this big government health care program really is. When government gets involved, everything just costs more, and taxpayers are left to foot the bill.[Responsible/morally right] It’s just wrong for people who work hard and pay taxes to go without affordable, quality health care. Under the current system, many hard-working middle class people are finding it increasingly difficult to afford health care they can count on for themselves and their families. This program is about doing what is morally right by making quality health care coverage affordable for hard-working people who want to be responsible but can’t afford it today. It would give millions of hardworking families peace of mind.

24

Support for GAC remains close to initial levels Support for GAC remains close to initial levels even after hearing opponents’ attacks.even after hearing opponents’ attacks.

44%

50%

0% 10% 20% 30% 40% 50% 60% 70% 80%

Final GAC ballot

Initial GAC

8-10 6-7

Mean

6.9

6.5

67%

62%

-5

Rate how much you favor or oppose it on a scale of zero to ten, with ten meaning you very strongly favor the proposal, zero meaning you very strongly oppose it, and 5 meaning you are neutral.

25

Strategic Recommendations: The Message Strategic Recommendations: The Message DynamicsDynamics

• Populist language about reining in insurance and drug companies resonates with voters.

• While the concept of big, inefficient government remains a vulnerability for reform advocates, the Wall Street bailout presents an opportunity to rebrand “free market” principles and to galvanize support for regulatory reforms.

• The conservative position is vulnerable to the argument that we have already seen what the “free market” can do, and it has failed, leaving tens of millions without care and an equal number with insurance that works fine until they need to use it.

• Cynicism about government can be overcome in this context.

26

Strategic Recommendations: The Message Strategic Recommendations: The Message DynamicsDynamics

• The strongest messages continue to center around the experience of middle class voters and their increasing concerns about being able to get quality, affordable care for themselves and their families.

• Since the vast majority of voters are insured, it is better to start with arguments about cost and then move to access rather than the other way around. For example: “Today it is getting harder and harder for Americans who work hard and play by the rules to afford health insurance, and over 47 million can’t afford insurance at all.”

202.776.9066 | www.lakeresearch.com | November 6, 2008

Health Care in 2009Health Care in 2009

Celinda Lake