Voters, candidates at odds on healthcare

Wisconsin Gov. Scott Walker made a play to seize healthcare as an issue central to his campaign in the fiercely (and densely) competitive race for the Republican presidential nomination. In a nationally covered campaign event last week, Scott introduced his Day One Patient Freedom Plan to replace the Affordable Care Act.

The plan includes age-based tax credits for health insurance, allows health plans to be sold across state lines and offers some protection for Americans with pre-existing conditions. Other GOP candidates have signaled they'll campaign on variations of these conservative approaches to healthcare reform.

But it's not at all clear that they will have much resonance with voters, who have indicated that the healthcare issues they care most about now are the ones that affect their pocketbooks.

Americans are most concerned about being able to afford drugs for chronic conditions and want the president and Congress to bring down drug prices, according to recent polls conducted by the Kaiser Family Foundation.

Still, 51% of respondents favored marketplace competition over government regulation for keeping drug prices low. Three-quarters of those surveyed said drug companies make too much profit and fewer than half had a favorable opinion of drug companies in general.

Most respondents reported little difficulty affording prescription drugs, but those in poor health and those taking four or more prescription drugs had more trouble. But Bianca DiJulio, associate director of public opinion and survey research for the Kaiser Family Foundation, said most people become aware of prescription drug costs at some point in their lives or know someone who relies on medication.

Katherine Hempstead, who directs the Robert Wood Johnson Foundation's work on insurance coverage, said candidates stumble to address drug costs because there are no easy solutions at hand.

More than 75% of Americans favor price caps on certain high-cost drugs, and about the same percentage would like to be able to buy prescription medications imported from Canada, according to the Kaiser survey.

John Graham, senior fellow at the conservative National Center for Policy Analysis, said the bipartisan 21st Century Cures Act, which is intended to encourage medical innovation and research, as well as speed up the review process for certain drugs and medical devices, could provide a platform for candidates to discuss concrete proposals on how to give Americans relief from high drug costs. The House passed the bill in July and the Senate is said to be working on similar legislation.

Another pocketbook issue that could get traction in the campaign is the so-called Cadillac tax that the ACA will levy on high-end health plans beginning in 2018. Employers are expected to scale back benefits to avoid it. But it could be too obscure to resonate with the average voter, and candidates generally agree about it.

Legislation introduced to remove the tax has received bipartisan support and Democratic candidates Hillary Clinton, Sen. Bernie Sanders and former Maryland Gov. Martin O'Malley have all criticized the tax. “Everyone seems willing to at least 'revisit' the issue,” Hempstead said.

The Republican candidates who made decisions on Medicaid expansion as governors will be called on to explain their determinations. Govs. John Kasich of Ohio and Chris Christie of New Jersey will have to defend to Republican voters why they raised eligibility under the ACA, while Walker, Louisiana Gov. Bobby Jindal and former Texas Gov. Rick Perry will be able to tout—during the primary, at least—that they did not.

For the general election, the political calculus around Medicaid may become more complicated. About 4 million Americans are in the so-called “coverage gap”—meaning they don't qualify for Medicaid or insurance subsidies—in states that declined to expand coverage, and healthcare providers and business groups have lobbied aggressively for expansion.

The Republican candidates have all said they want to repeal the ACA, although Walker and Jindal are the only ones so far to provide an outline.

Graham said the nuances in the GOP plans could create a good debate for the party. He also believes that will resonate with voters because about 10 million people now have a health plan through an exchange and will want to know how replacing the ACA would affect their coverage. “Those people are not going to tolerate (no plan),” he said.