Panel 1: A Second Look: Voter Priorities in Health Care

Claire:
So, Rachel Rachel Cohrs Zhang is the Chief Washington Correspondent for STAT, reporting on the intersection of politics, business, and health policy. She’s also the author of the twice-weekly DC Diagnosis Newsletter and leads STAT’s DC Bureau. She previously covered healthcare policy for modern healthcare and prescription drug pricing for inside health policy. She earned a degree in journalism from the University of Southern California.
Liz Hamel is Vice President and Director of Public Opinion Survey Research for KFF. So she knows where all the locations are in this building, which is helpful. She oversees KFF’s polling work, including ongoing surveys aimed at understanding the role of healthcare issues in elections and survey participants with national news organizations. Her research focuses on public attitudes, awareness and experiences on a range of topics, including healthcare affordability, views on the ACA, Medicare, Medicaid, and private health insurance, reproductive healthcare, racial and ethnic disparities and discrimination, and health misinformation. Hamel serves on the board of directors for the Roper Center for Public Opinion Research and has previously served on the executive council of AAPOR, the American Association for Public Opinion Research. She holds a bachelor’s from Harvard. And we always love when Liz joins us because she brings data.
So with that, we’re going to have Liz share some updated findings. Liz and Rachel and I had a conversation in May, you can go see the webinar. I think of it as the prequel to this panel, where we thought what might happen in the election, given the polling that Liz was seeing at the time on voter opinions on things related to healthcare policy. So, we’re going to look at some fresh data and see what we can learn from that. Liz?
Liz Hamel:
Great, thank you, Claire. I actually work out of KFF’s San Francisco office, but I’m very excited to be here and to see so many people at the Barbara Jordan Conference Center. So, welcome to KFF.
So, I’m going to just share some data and then hope that that will spur some thoughts for the conversation that we’re going to have. So, some of you may have tuned into that pre-election discussion that Claire mentioned that we had in May, but for those who didn’t and just to refresh everyone’s memories, here’s what I said in that presentation about the role of healthcare in this election. The gist here is that voters were more focused on issues like the economy and immigration than on healthcare, but that discussions of key issues like healthcare costs, protecting popular health programs and reproductive rights would play a role in the campaign and could motivate key groups of voters to turn out. A lot has changed since May, including a change in the candidate at the top of the Democratic ticket, a couple of assassination attempts, lots of other events happened in the campaign, but really when it came to the role of healthcare, these same themes pretty much held up. Although, as we’ll see, the issue of reproductive rights didn’t turn out to be as decisive as Democrats hoped that it would in the presidential race.
So, most of the data that I’m going to share come from the AP VoteCast, which is a survey of more than 115,000 voters. It was conducted nationally and in 48 states between October 28th, and then it concluded as the polls closed on November 5th. And KFF was one of several partners with the AP on this survey. So this question that I’m showing here, ask voters to pick the most important issue facing the country, and you can see that healthcare did play a role with about one in 10 voters each picking abortion and healthcare as their top issue. But as was true back in May, by far the dominant issue on people’s minds as they filled out their ballots was the economy and jobs, and that was followed by immigration.
So this is from a separate question on that survey, and this one looked more directly at the important factors in people’s vote, somewhat different than the list of issues that was asked about and here you can really see the big partisan split. So among Democratic voters, we saw that the future of democracy was a top concern. 63% of Democratic voters said that was the single most important factor in their vote, and that was followed by abortion policy at 37%. So this was pretty consistent with what we saw in the pre-election polling, abortion was showing up as a motivating factor mainly for Democratic voters. For Republicans, you can see the top issues were high prices and the situation at the US-Mexico border, and again, that was consistent with what we were seeing pre-election.
So with the economy a top issue, one thing that we saw once again was that the cost of healthcare was an important component of people’s economic concerns. So you can see here when we ask people when it comes to how the economy affects you, how concerned are you about each of the following? About two-thirds said they’re very concerned about the cost of food and groceries, right? This makes sense, this is a cost that people are encountering on a weekly or even a daily basis. But right behind that, we saw over half of voters saying they were very concerned about their healthcare costs and that was slightly ahead of the shares who said the same about the cost of housing and gas. So we continue to see that the cost of healthcare is a big component of what people mean when they name the economy as their top issue.
So, how did the issue of healthcare play when it came to people’s vote for president? So here you can see which candidate voters trusted more to handle various issues, and these are ranked on this chart by the share who named each as the most important problem facing the country. And you can see that Kamala Harris had the advantage on both abortion policy and healthcare, that’s consistent with the pre-election polling and it’s consistent with historical Democratic advantages on these issues. However, you can see that President Trump was seen as better able to handle the top two issues, the economy and immigration.
And another piece of data that I think is important to point out is that despite the fact that Kamala Harris had the edge on which candidate voters perceived as better able to handle healthcare, we found in the survey that Trump won a majority of votes among people who expressed the highest level of concerns about their own costs, and that’s even true when it comes to healthcare costs. So, this chart here is showing you the vote choice just among those voters who said that they were very concerned about the cost of food, about the cost of healthcare, about the cost of housing and gas. And for each of these groups we saw that a majority voted for Donald Trump and smaller shares voted for Kamala Harris. So that kind of tells us a little bit about what happened in the election, but I think we can also look a little bit about what the polling data tells us about how the public may react to a Republican agenda on healthcare going forward.
We know that President-elect Trump was pretty vague on his healthcare policies during the campaign, but we do have some clues about the types of policies that he might pursue based on his first term in office and some of the proposals that have been put forward by conservative groups. And one general theme we would expect from Republican proposals on health would be decreases in the level of government involvement in various areas, but you can see here that this is also from the AP VoteCast survey. When voters were asked whether they would like to see more or less government involvement in each of these areas, we see that majorities of voters actually say they would prefer to see the government more involved in lowering the cost of prescription drugs, in forgiving medical debt, and in ensuring that Americans have healthcare coverage. Support was a little lower, but still at 50% for increasing government involvement in ensuring that children are vaccinated.
Now, not surprisingly, partisan voters differ in how much government involvement they want in each of these areas, but you’ll notice here that when it comes to lowering drug prices, we found that majorities of Democratic, Independent and Republican voters said they would like to see the government more involved. So as most of you know, the Biden Administration took a step in this direction with the drug pricing provisions of the Inflation Reduction Act. And one of the open questions going forward is what President Trump and a Republican Congress will do with these. What we’ve seen in our polling is that large majorities of the public across partisanship say that they favor drug price negotiation, but we’ve also found that public awareness is pretty low. So most voters don’t actually recognize that the IRA has already started to make progress in that direction.
So with public knowledge about the IRA’s drug pricing provisions fairly low, I think it’s also worth pointing out that this is from some of our polling prior to the election. We found that many Republican voters were already crediting President Trump more than President Biden for passing laws aimed at lowering drug prices for people on Medicare. So, while most voters have not yet begun to feel any direct benefits of those drug price negotiations, this is an area where Trump could embrace a law that’s already on the books and claim credit for making progress on affordability of prescriptions, which is as we know, a top concern for voters.
So, another thing we heard on the campaign trail is that President Trump has promised tax cuts and that will necessitate cuts in government spending. He has also promised not to make cuts to Medicare and Social Security, and so that really leaves the ACA and Medicaid as two costly programs that are potentially vulnerable to cuts.
So just a quick review here of what we know about public opinion on these programs. We’ve been tracking public opinion on the Affordable Care Act for a long time, and our polling shows that it’s as popular as it’s ever been. We have almost two-thirds of the public now viewing the law favorably. Of course, those views continue to be divided along partisan lines, but we find in our polling that even Republicans say that they would prefer to see the law either changed but not fully repealed. And we also know that in 2017, the latest repeal attempt failed, at least partly because of backlash over protections for people with pre-existing conditions.
The enhanced premium subsidies under the ACA that are set to expire next year are popular with the public as well, and they do affect a lot of people in red states that haven’t expanded Medicaid. They are also expensive, and so allowing them to expire could be a big budget saver for Trump’s tax cuts.
On Medicaid, this is also a popular program. Our polling finds that about two-thirds of Americans have some level of connection to Medicaid, either saying that they’ve relied on the program at some point or a close friend or family member has. We also find that Medicaid expansion under the ACA continues to be popular. In fact, in that VoteCast survey, even as Republicans won big in the election, we saw that seven in 10 voters in Alabama, Kansas, and Mississippi said that they would want their state to expand Medicaid under the ACA.
One Republican proposal that we may see come up again is converting the Medicaid program from a guaranteed benefit to a block grant to states. We polled on this earlier this year and found that seven in 10 adults, including about half of Republicans, would prefer to keep Medicaid as is, rather than converting it to a block grant system. But I will be the first to say that this is a very complicated topic that’s hard to ask the public about in polls and so I think it really remains to be seen how public opinion would take shape if we actually had a national debate on that issue.
So finally, I just want to wrap up on what the election told us about the future of reproductive health and abortion access. Here’s a trend from a couple of our pre-election polls, and we did see over the course of the campaign that after Biden dropped out of the race and Harris became the Democratic nominee, the share of voters who believed the presidential election would have a major impact on abortion increased, particularly among Democrats and Independents. So in March, about half a voters saw this election as having high stakes for abortion access, and that increased to 61% in September. Among Democrats, the share went from 71% to 84%, and among Independents, they went from 44% to 58%. So we did see some momentum towards the energizing of Democratic voters around the issue of abortion throughout the campaign.
As most of you probably also know, 10 states voted directly on the question of abortion access through measures placed on their ballots. Here in this map, you see the outcome of those ballot measures. So the dark green is the states where measures to protect abortion access passed, and the beige is where they failed. I overlaid this, I did this myself, sorry for the somewhat clumsy graphic, but the red dots are the states that Trump won, and the blue dots are the states that Harris won. And really, what you can see is that there were four states where an abortion ballot measure passed, but Trump also won a majority of votes for president. Really, we could also consider Florida in that list because 57% of voters in Florida supported the ballot measure but it didn’t meet the threshold of 60% support required for passage in the state.
And so in one sense, you can think that voters are sending a conflicting message about what they want going forward on abortion policy by voting for these ballot measures at the same time as voting for the president who took credit for the overturning of Roe. There’s been a lot of hot takes about this in the last few days, so I’m not going to review all the theories there, but I do think this one piece of data kind of helps explain something here. So this chart shows the presidential vote choice among those who voted in favor of abortion protections in their state. And you can see most of these voters supported Kamala Harris, but between one in five and a third of voters who chose to protect abortion access also voted for Donald Trump. These positions may seem counterintuitive, but I think it once again suggests that the economy and immigration or a dislike for Kamala Harris as the democratic nominee were more important to those voters than Trump’s record on abortion, as they decided how to vote for president.
So one question as we move forward is whether Republicans will put forward a national abortion ban. Our with VoteCast found that most voters do not support a national abortion ban, and two-thirds say that they want abortion to be legal in all or most cases, but even in the absence of a national ban, it’s worth reviewing the current status of abortion laws across the country. So the red on this map is states where abortion is banned completely, and the dark orange are states with strict gestational limits between six and 15 weeks. And so with Florida’s ballot initiative failing to meet the 60% requirement for passage, you really see here that the south is an entire region with very limited or no abortion access. And only two of these states, Oklahoma and Arkansas, actually allow citizen initiative ballot measures. So the pathway that’s been used by abortion rights advocates in many states is unlikely to change this landscape anytime soon. So, that is my summary of the data, I look forward to the discussion.
Claire:
[inaudible 00:15:51], thank you, Liz.
So there’s so much to talk about there. Liz. One thing I do, I was just listening, I mentioned to our conversation in May, and one thing I didn’t write down on my questions, a little bit of a surprise, but is this point you made about the message about the IRA and the drug pricing negotiation not breaking through. We spent a good five minutes talking about that in May. And I wonder, and it seems like in addition to not breaking through that it was a Biden priority, it actually with some voters has shifted to being something they’re giving President Trump credit for. So I’m just wondering if, since we talked in May, have you done further polling on that and did it change over time? Was there any more breakthrough? I think you were seeing initial breakthrough with the older population, was what we talked about in May.
Liz Hamel:
Yeah, it was interesting. We did repeat that question that I think I had shown in May, and we repeated it later, a few months later, and we actually didn’t see an increase. We saw that it was pretty flat. We continued to see that people over 65 are more likely to know, and they’re more likely also to know about the cap on insulin prices. So we do see slightly greater awareness among the older population, but we didn’t see throughout the campaign an increase in awareness of what the IRA did, in terms of drug price negotiation.
I will just say that this is, as somebody who’s been polling on health policy for a long time, a lot of the things that we want voters to understand, we know that they are focused on other things, right?
Claire:
Right.
Liz Hamel:
And so they are really… This is why I think we continue to see the focus on healthcare costs. It’s not on, how do you get there, but this is something every time I go to the pharmacy, every time I go to the doctor, every time… I even have health insurance but my deductible is so high. I think voters are often more focused on the problems that are immediately in front of them than the policies that politicians are putting forward.
Claire:
Right, so it’s the experience that people have. You talked about it being a pocketbook issue, right?
Liz Hamel:
Yeah.
Claire:
I think Rachel, you actually in our May conversation, talked a little bit about that there was some momentum behind conversations not just about drug pricing, but about some of the broader conversations on affordability of healthcare, particularly around hospitals or other sites of care. I just re-listened to our webinar, highly recommend. But yeah, so I think that definition is more about the experience than it is about a specific, necessarily a solution. So thinking about the key health policy issues that voters prioritize leading up to the 2024 election, are there changes since we talked in May? Did they shift, did they remain steady? We had all these changes in the environment, right? Big changes, changes that should break through or make a difference, but did you see big shifts anywhere?
Liz Hamel:
I think the biggest shift we saw in the polling was that shift, and it really happened after Biden dropped out of the race. I think it did energize Democratic voters who cared about abortion rights, the fact that Harris was out there speaking in a way that I think voters found more authentic on reproductive rights. And I do think that moved some energy in the direction of for Democrats who cared about abortion rights, but in the end, it didn’t become an overwhelming issue in the campaign.
Claire:
Got it. And then when we looked at the issues back in May, we didn’t know which was going to be one, two, three, four, right? And it seems like some of these issues on healthcare costs and they were then an even more now, kind of like were riding in the passenger side to this conversation about overall costs and inflation. Rachel, do you think we’ll see any policy vehicles that sort of start from solves around inflation or costs that might include healthcare considerations? Might those two go together in the policy conversation as well?
Rachel Cohrs Zhang:
Yeah, I certainly don’t see any immediate action on healthcare costs coming from Capitol Hill. I think we could see some traditional Republican ideas around price transparency, I think that’s been something they talked about a long time. But I think the initial battle that they’re going to be having is whether to extend these Affordable Care Act subsidies and if they choose not to extend them, healthcare is going to get a lot more expensive for a lot of people. And the people who’ve benefited the most from these enhanced subsidies are Republican states, where they haven’t expanded Medicaid. So if you’re looking at Florida, if you’re looking at Texas, those are the states that benefit the most.
And so I think they’re going to have a choice to make about the ideological opposition to government subsidies for the Affordable Care Act, and the choice to have voters potentially blame them for raising their healthcare premiums. And I think there’s a potential that there’s some sort of middle ground here, where the subsidies aren’t extended in their current form. There are maybe some more limits on them, some more guardrails. There are a lot of concerns about fraud that I think are breaking through in Republicans policy circles, but I think that’s going to be their first question. And I think as Liz mentioned, we can move forward to issues around Medicaid, and that’s maybe not going to necessarily lower people’s costs, lower states’ costs.
So I think we’ve seen a lot more energy around kind of addressing the distrust in public health institutions following the pandemic and policies against mandates, asking questions about reform of public health agencies. I think we’re going to see a lot of energy around these more ideological issues and less focus on cost because that wasn’t really what Republicans ran on in the first place.
Claire:
Yeah, one thing that also came up in our May conversation was fraud, waste, and abuse. And having looked at my share polling over the last 20 plus years of working in healthcare policy, no one’s for fraud, waste, and abuse. But I agree, I think we’re starting to see some momentum in the policy conversation around fraud, waste, and abuse. Did you see that come through in any of the Republican responses? Was there any difference from the Democrats and Republican responses on fraud, waste, and abuse?
Liz Hamel:
I mean, we haven’t pulled on that specifically in this election cycle. I will say that sure, especially when you frame it as fraud, waste, and abuse, people will be happy to say yes, that’s a big reason the costs are so high. But they also, the public willing is always happy to find a villain, blame the insurance companies, blame the pharmaceutical companies. And so I don’t think there’s a sign that the public is keyed into a nuanced discussion about how to tackle something like fraud and abuse in health programs.
Claire:
Makes sense, they don’t have the full policy solution. But I think the point that… we made the point on the conversation, nobody’s for fraud, waste, and abuse. There’s no coalition for fraud, waste, and abuse, right? It’s a pretty good talking point, and so it’s the policy conversation. You can look at a number of different policy vehicles potentially, that people might actually put forward under that umbrella. So, I guess watch that space.
Liz, we talked about these dramatic events, right? And you talked about this in your presentation. I wonder, again, we talked about whether things changed or stayed the same. Were there any October surprises that impacted healthcare? Was there anything relevant there?
Liz Hamel:
Yeah, I mean, I think we usually think of an October surprise as something that’s going to fundamentally move the direction of an election. We certainly didn’t see that, but I will say in the last few weeks before the election, I think that President-elect Trump’s embrace of RFK Jr. and some of the discussion around what that influence might do to particularly public health programs, vaccine confidence, I think that was something that at least for those of us who are paying attention to those things was a new entry into the discussion.
Rachel mentioned the declining trust in public health agencies, it’s one thing we tracked very closely during the pandemic. Particularly CDC and even FDA, we saw that those were agencies that started out at the beginning of the pandemic with high levels of public trust, and we saw an erosion of that trust over the course of the pandemic that was largely driven by a decline in trust among Republicans. I think one thing I’ll be watching for depending on the direction that things go, is if we have RFK, a vaccine skeptic, having more influence over some of these agencies, are we going to see a shift in who trusts them? Are we entering an age where trust in the CDC and the FDA is going to flip-flop depending on who is in the White House? And so I think that that obviously has big implications for… I mean, It has implications for the decisions that people make to protect themselves and others when we’re dealing with public health threats like COVID. And so I think it’s definitely something worth watching.
Claire:
Great. So I want to pull in the thread of trust because you just talked about institutional trust and I wonder, during the campaign, were there any key moments or things that brought to mind the institutional trust? Obviously, the RFK piece for sure, but just wondering if there’s any other ideas or elements of the conversation that brought on this. I mean, we talked about it in the last session as well, in terms of where people go to for information and how that is impacting how they think about healthcare. But just wondering if there was anything, and were you tracking anything on that, on disinformation or anything like that?
Liz Hamel:
I mean, we have been, we have a new program sort of tracking health misinformation. I think one of the things that came up in the campaign, there was already a trend in this direction, but I think, and I’m sure Rachel will have thoughts on this as a journalist, sort of the, again, decline in trust of the traditional media and the use of a lot more non-traditional news sources, podcasts. We saw Joe Rogan being called out in Trump’s victory speech. And so I think that the sort of dispersion of the information environment makes it a lot more difficult, particularly when you’re dealing with a public health crisis like COVID to communicate to people and to have a single trusted source of information, so.
Claire:
Do you have any thoughts there, Rachel?
Rachel Cohrs Zhang:
I mean, I think, yeah, I think we’ve covered it mostly. I mean, RFK and just I think my thought on his rise was that I think we saw the roots of this polarization with Operation Warp Speed. I think that was a great kind of case study on where when President Trump was in power, you had Democrats saying, “Well, he’s going to rush the vaccine to try to get votes,” and then when it flips, then they’re the ones trying to convince people to take up the vaccines when there had already been these seeds of doubt. And I think that we’ve seen President Trump realize that he wasn’t really getting a lot of credit with his base for developing COVID-19 vaccines and that Operation Warp Speed was something that when he brought it up, he would get booed at rallies. And I think he figured out that there’s a different message that resonates more with his base and I think he’s made a pivot that makes sense to his voters. And I think at least for now, he is definitely humoring that and has kind of made that adjustment with the times.
Claire:
Yeah.
Liz Hamel:
Yeah, I think one of the other trends that we’ve seen, because there was this sort of partisan difference in interest in the COVID vaccines and there’s been a lot of concern about whether that spills over into other vaccines. What we’ve seen in the polling is that at this point, most people across partisanship still are confident in the safety and effectiveness of vaccines, but we’ve seen a much bigger split on, for example, whether vaccines should be required for children to attend schools. And so I think that that may be a sign of things to come.
Claire:
Makes sense, and I think I just saw a graph that showed Joe Rogan’s podcast reach next to Fox News, CNN, and NBC, and it’s like five x, combined. So the media world has definitely shifted and changed.
So Rachel, we know that Liz’s research showed that voters value the preservation of some of these popular government programs. You talked a little bit about the ACA. Are there other ways that this might show up in our policy conversations? For example, Liz talked about how Medicaid, many people know someone who’s in Medicaid or touched by the program. How that was very interesting, particularly with the rising numbers of people with disability in the country, that there’s more people in families or communities that people would know and would be using the program. Do you have any other thoughts on that?
Rachel Cohrs Zhang:
Yeah, I think we did see this, the other kind of October conversation that was happening was whether Mike Johnson really promised to repeal the Affordable Care Act. And you listen to the tape over and over and over again and I think his office says that he didn’t promise that, that’s kind of been the line he’s maintained since then. And so I think you have really seen a lack of an appetite for another repeal and replace conversation that’s been something consistent that we’ve heard. So things can change, but I think that’s not going to be something that’s top of mind for them. And so I think they would much rather focus on taxes and all these other things. And I don’t necessarily think that popular support for Medicaid would preclude budget cuts. There’s a time, especially early in a cycle where there’s a remove, where lawmakers can pass reconciliation bills with control of the White House and the House and the Senate, where they don’t need any democratic support. And there is a moment where we see Congress kind of operating outside of public opinion.
And I think we’re kind of in that phase now where a lot of popular policies, you look at something like Medicare negotiation had 90% support when you would pull on it, but there were other forces at play here. And I think it depends what they want to pay for and what else they want to really do and how big they want to go on smaller government and really getting into the weeds of cost-cutting measures that could hurt their own constituents. I’m unclear as to how that plays out, but I don’t necessarily think that a 70% popularity is going to move the needle on the conversation. I almost think there’s more of a mindset of like, I’ve been empowered, the voters picked me, not my ideas, it’s time to shine. And so I don’t think they’re checking necessarily every decision against that metric.
Liz Hamel:
Yeah, and one of the things we always say, public opinion data doesn’t tell you what the right answer is. It also doesn’t tell you necessarily where lawmakers going to go, but it can give you a sense of, what are some of the constraints that voters might put around lawmakers? Where might they sort of fear a backlash and not take certain in actions?
Rachel Cohrs Zhang:
And one thing I also wanted to bring up is that a lot of lawmaking gets done in packages now, like big packages where a bunch of stuff is crammed together. I think that’s again, what you saw with the Inflation Reduction Act, where popular policies were crammed together and were difficult for the public to kind of digest each individual portion. So you could also see that happen with unpopular or cost-cutting policies, where these big packages where they’re kind of balancing out these different policies happen and there’s kind of less accountability for any one portion. It is just hard to tell ahead of time what would get the most attention.
Claire:
Yeah, and this is an echo of before, because we talked about this in our webinar about. Liz was careful to give us all the cautions and she didn’t give us her methodology talk today, but I’m sure if you get her afterwards at the reception, she will give you the methodology talk. But I think we talk about, does this attitude or this affinity, does that actually translate into how people vote? That’s one question, right? And then when you look from how people vote, then does that actually translate into whether anyone’s going to do policymaking on it? So this relationship between public opinion and public policy is a very complex one with lots of pieces going in and out. So they’re not a foregone conclusion, and it’s not a one-to-one kind of relationship. But I think that parameters is, it is almost like a warning sign or something for people to be aware of.
So in our discussion in the spring, we had the concerns about healthcare costs, we talked about this being a little broader and that the focus on drug pricing seemed to be lower than concerns about the overall cost of care. And then your data though also shows that it’s a rare area of bipartisan agreement among voters who are amenable to more government intervention in this space. So if I did my math right, 80% of voters on a nonpartisan basis wanted to see a focus from candidates on the affordability of care more broadly. So I have one question for Liz and one question for Rachel on this. Liz, do we think that this is a function of change in opinion over time? Is it a matter of how the question is asked? These two things kind of don’t necessarily add up.
Liz Hamel:
Yeah, I mean, I don’t think that voters have changed how they prioritize lower prices. I think we did have a question that was focused on prescription drug prices and that we did see bipartisan support. I think if we had asked that question about lowering hospital prices or lowering deductibles or creating out of pocket limits in health insurance, that we would’ve seen bipartisan support for all of those. So I think that was more of a function of the questions that we had. The other questions on that list were a little bit more about providing access to health insurance. And so I don’t think it reflects a big change in priorities.
And I don’t think prescription drugs are the top thing that people worry about. We know when we… Or the top thing that they’re having problems affording. It is, there are some people who are having extreme problems affording their prescription drugs, but we do find when we ask people the types of things that are leading to medical debt or that they’re having problems affording, it’s doctor’s visits, it’s lab fees, it’s hospital charges, it’s emergency care. And so I think it is one area where we’ve seen some action and maybe the public is sort of hungry for more because they haven’t felt it in their pocketbooks yet, so.
Claire:
Got it. And then Rachel, we talked about, will this won’t make policy change more likely? These attitudes on pricing or on affordability, do you think there’s any sort of pressure that would come out of-
Rachel Cohrs Zhang:
No, not really. I just haven’t felt much of an appetite toward that. And I think if you look at what Democrats did over the past two years, they kind of addressed as far as Republicans would be willing to go in the Medicare program and Republicans as we see, and ideologically oppose a lot of the next steps that at least Democrats had framed as the next steps on drug pricing. Expanding some of these copay caps to private plans, Republicans see it as an interfering in the private insurance market. I think you see a lot more conversation among Republicans about deregulation, like kind of cracking down on prior authorization practices. You see a lot more just kind of around the idea of HSAs and consumer choice and I think we could see some of those options return where’s they’re advocating for different options that may be cheaper, but also may be lower quality as well. So I think we’re not going to see the same conversations happening about price regulation from a government standpoint that we’ve seen. It’s just going to look very different.
And I think, yeah, there’s some things that can happen. I know you were mentioning site of service, payment reforms, and that’s something that we’ve seen at least leaders in the Senate very engaged on, some leaders in the House. There’s been agreement, that I think in Congress there’s an attitude of like, we kind of did pharma already. We’re going to address PBNs at some point soon and then I think the next kind of logical step is looking at some bipartisan reforms for hospital and physician payment. But that’s again, not something that they’re going to be taking home to their constituents. It’s very wonky, they weren’t talking about it on the campaign trail. It’s something that fiscally, I think makes sense to a lot of people kind of on the think tank policy side, but it is a little bit harder to explain to the general public. So I think that’s kind of where we’re going to see the conversation go on cost containment.
Claire:
Makes sense. So I wanted to ask Rachel, we focus a little bit on the story in our earlier conversation, and I’m wondering as we look at Liz’s data, what is the story line for people who care about healthcare policy? When we look at where the attitudes were, the election is a time where people outside of this town engage in conversations that are tangentially at least related to healthcare policy, and try to align it with what their values are. And I’m wondering, compared to what we’ve seen before or what we have seen in previous different iterations, what is the storyline here, in terms of what we learned in this election?
Rachel Cohrs Zhang:
I think one thing that I learned in this election was I think this election challenged a lot of the orthodoxy and the Democratic Party about their advantages on healthcare policy. I think first, I think Liz Liz’s data presented this issue really well on abortion, where we did see split ballot voting for president, for Senate, and for these abortion initiatives. And I think the Republican Party positioned them, so President Trump specifically positioned himself where he was advocating for state’s choice, that’s been his talking point the whole election cycle. And I think that resonated, where people were like, well, I can decide on that separately and that doesn’t necessarily affect the rest of my vote. And they were able to successfully get split ticket voting on some of these voters. I think those numbers were shocking for anyone who in prior cycles had seen over and over and over again voter support for these ballot initiatives to protect abortion rights. And so I think it really broke that orthodoxy that that would necessarily translate to support for specific candidates after the fall of Roe.
And I think we also saw that kind of some of these tired talking points about accusing Republicans of wanting to wholesale repeal the Affordable Care Act were tired, and that they didn’t have the same resonance as they had in prior cycles like we saw in 2018, as we saw in 2020, kind of after that repeal and replace fight and that failure. So, I think there’s a lot of soul-searching for Democrats as to what their next message is and I think just kind of finding the next step that maybe maintaining what we have might not be capturing voters’ imagination enough to turn them out on that issue specifically. There are other things that are higher or more important in their minds.
Claire:
Got it, thank you. So this is a follow-up question to that, which is, how do we think that these election findings or the voter sentiment might be relevant in the first 90 days or the first year? I mean, you mentioned it’s a little bit of an enclave, right? That the first 90 days, you’re a little bit protected in some ways from that outside public opinion. Do you see any ways, maybe the time horizon’s a little longer, maybe it’s a year and a half, two years, where these kinds of sentiments or these kinds of attitudes that came out of the election may be relevant in our policymaking?
Rachel Cohrs Zhang:
I mean, I think we’re going to see the reconciliation process play out again, which is, it was ugly last time and I think it’ll probably be ugly again with the narrow majority in the house. And I am a little bit less, I believe less that Republicans will have a full reconciliation package ready to go in the first 90 days, especially with as they’re trying to replace some of these members who are getting picked for cabinet positions-
Claire:
[inaudible 00:42:44].
Rachel Cohrs Zhang:
… they’re going to have. They’re going to be down in numbers, and I think they’re going to need every vote they can get. So I think certainly this campaign, this transition has been much more disciplined than we’ve seen in the past, in terms of their readiness to roll out nominations and some of the background work that’s been done to lay out an agenda. We have some statutory deadlines, so it’s not like they’re just picking out of a hat like, what do we want to focus on today? They have this vehicle that’s perfectly suited for this process that they want to use for renewing the Trump tax cuts. And then the ACA subsidies also will fit into, I think that bucket. And I think after they clear that, can take credit for that, it’s an area of wide agreement among their caucus, then I think we’ll move to see, are we going to do some of the harder things? And you saw it with Democrats that took significantly longer.
We had the American Rescue plan in the spring, it was like March, after kind of everything that turned for Democrats. But then you saw more than a year and a half later that the next reconciliation bill followed, where they really hashed through, what is the Democratic agenda? Some of those really hard issues and coalition billing that had to happen.
So I think certainly we could see something relatively fast, but I don’t don’t know that it’ll come in 90 days. And I think when they do turn beyond these statutory deadlines that are forcing their hand, I think we’ll see just more jogging for position, more hearings. They’re all about regular order, things are much more democratic and on the hill, there’s less top-down decision-making like we saw during the days of the pandemic where a lot of the hill was still remote back in 2021. So I think it’ll be different, but I think they have issues that are forcing their hand at the beginning, and then it’ll give them some time to figure out where they want to focus their efforts next.
Claire:
Got it, that’s super helpful in timing. So I wanted to give each of you a moment. I know you’ve both done a lot of work since the election, and I wanted to ask each of you, is there something really relevant for this audience that you wanted to call out or mention that we didn’t talk about today?
Liz Hamel:
Yeah, I mean, one of the things we haven’t really touched on because I was focused on the voters, but we’ve also done a lot of polling of some of the people who are most vulnerable in our healthcare system. We did a big poll of immigrants last year, and that is an area where we expect to see action early in Trump’s term. And we found that even before the talk of immigration in the campaign, a lot of fear and misinformation among immigrants was leading people not to take advantage of programs they were eligible for. Even people who are citizens or are in the country legally. And so that is, in terms of the effects of the election outcome on people’s ability to access care, that is one population that we’ll be very concerned about and we’ll be watching, so.
Claire:
Are you going to continue that work, or?
Liz Hamel:
Yeah, we’re trying to figure out how to continue it. We sort of waited on planning the next round of it to see how the election played out. So yes, we will be continuing it.
Claire:
Got it. We’ll keep an eye out for that. And Rachel, any thoughts? I know your team has filed 14 stories. [inaudible 00:46:06].
Rachel Cohrs Zhang:
Yeah, it’s been a sprint. Yeah, I’ll say. I think we’re thematically most focused now and kind of the divide that we’ve seen in the Republican policymaking world between your more traditional bureaucrats, lowercase C conservatives who we saw kind of the first time around in top personnel positions in the Trump Administration. You saw Alex Azar, who came from the pharmaceutical industry, you Seema Verma, who came from a state government, like some of these more traditional pools and some of these more kind of make America healthy again, orbit people. And I think there is absolutely this tension and I don’t know that we’re going to have a full resolution on what exactly those administration positions are going to look like tomorrow, but I think we’ll see it play out in the coming weeks.
And I think some of the questions that we’ve been focused on are, how much change could some of those make America healthy again, people who really want to disrupt the way bureaucracies are working, how much could they really do? And I think without congressional checks on their power. And I think in some cases they could do quite a bit really, with depending on what those appointments look like. In some cases they could do less. I know they’ve kind of talked about banning pharmaceutical advertising, which I think would trigger lawsuits and be kind of a long road for them, but so I think we’re just trying to sift out, what can they do?
And then just obviously learning what we can about personnel, because I think that’s just such a big… it’s less of a top priority for the President himself most of the time. There are certain concepts that he has latched onto in the past, like making sure Americans get a good deal, that sort of rhetoric. But it’s not, healthcare isn’t something that’s at the top of its priority list. So a lot of these priorities will be driven by the people who he appoints. And honestly, you all may know more than me at this point if you’re checking your notifications on your phone. It’s all coming very fast, so.
Claire:
There’s a ticker [inaudible 00:48:10], I caught a few updates when that came in.
Rachel Cohrs Zhang:
Yeah, so [inaudible 00:48:14].
Claire:
Absolutely. Well, news keeps filing, and thank you both so much for sharing today, both Rachel, all your perspective with all the news that’s been swirling and landing and sort of not quite landing yet. Thank you for sharing your perspective. Liz, thank you so much for sharing all your background and all this data. I’m really grateful that you both came to join us today and give them a round of applause. Thank you so much.