Onslaught of pro-, anti-Obamacare spots is waiting in the wings

Unlike the last few election cycles, paid political advertising that features healthcare issues hasn't played a starring role in the early primaries.

But once the Democratic and Republican nominees are selected, watch out.

The Affordable Care Act and other healthcare issues are going to get plenty of screen time, according to experts who track campaign advertising. Indeed, one analyst estimates healthcare messages, combining both pro- and anti-Obamacare ads, will account for nearly one-fifth of the more than $6 billion that will be spent in this year's massive onslaught of television and digital advertising to voters in the presidential, congressional and gubernatorial campaigns.

That's not surprising since healthcare remains one of the top five issues for voters of both political parties. It's particularly salient for rank-and-file Democrats, according to a Kaiser Health Tracking Poll in January.

“People are confused and uncomfortable with what they have and would like to have something better, but they aren't sure how that would work or what that would be,” said Kip Cassino, executive vice president at Borrell Associates, a media research and consulting firm. “They would love to have someone say in clear, definitive words what the answer is.”

Up to this point, the public isn't getting a clear, simple healthcare message with one exception: Democratic candidate Bernie Sanders is championing a government-run, single-payer financing system, the long-sought objective of the progressive wing of the Democratic Party.

Still, healthcare isn't entirely missing from the campaign. Candidates and the outside groups backing them have mentioned the Affordable Care Act, Medicaid expansion and drug costs in their ads, but it's mostly in passing.

Republican TV spots have stressed opposition to abortion and Planned Parenthood, with some ads attacking GOP candidate Donald Trump for his past support for abortion rights. Republican ads also have attacked GOP candidates, including Ohio Gov. John Kasich, for expanding Medicaid under the ACA. While all the candidates vow to repeal Obamacare, only Sens. Ted Cruz of Texas and Marco Rubio of Florida have made it a major talking point in their advertising.

It's not clear that any Republican advertising—whether on healthcare or any other issue—has been productive. The GOP candidates who have received the most advertising support from super PACs or their own ads—such as retired pediatric neurosurgeon Dr. Ben Carson and erstwhile candidates former Florida Gov. Jeb Bush and New Jersey Gov. Chris Christie—have not done well in the primaries or public opinion polls.

On the Democratic side, Vermont's Sen. Sanders uses the phrase “healthcare for all” in his ads. But he always includes it as just one part of his broader progressive agenda. And while Hillary Clinton has attacked Sanders' single-payer proposal on the campaign trail, she has so far failed to feature the issue in her campaign ads.

Rather, she is plugging her role in passing the State Children's Health Insurance Program in the 1990s and her promise to defend Medicare from GOP privatization efforts. Clinton also has called out high prescription drug prices in her ads, citing her plan to cap consumers' out-of-pocket costs.

Elizabeth Wilner, senior vice president for political advertising at Kantar Media, a market research firm, said that unlike the 2012 and 2014 elections in which Obamacare was a huge issue, the ACA “is taking a back seat so far to other issues,” such as immigration, terrorism and Wall Street reform. “But I'm sure there will be a fuller discussion of a wide range of healthcare issues in the general election,” she said.

Healthcare messaging will be part of the $4.4 billion in spending Kantar projects for TV ads by presidential and congressional candidates over the entire 2016 election cycle. Of that, only $200 million had been spent as of early February.

When the presidential, congressional and gubernatorial campaigns are all considered, Borrell Associates estimates that healthcare-related ad spending to promote candidates will total $1.1 billion for the 2016 election cycle. That's nearly 18% of the projected $6.2 billion total that will be spent by the candidates and outside groups for all advertising.

Borrell's Cassino cautioned that spending on healthcare-related ads could change significantly but certainly will remain large. It could go up if the nation experiences a major healthcare crisis, but it could drop significantly if some other issue, such as a terrorist attack or new economic recession, grabs the political spotlight.

The broad outlines of the ads people are likely to see during the general election campaign are already taking shape. Likely targets for political ads by the eventual Democratic nominee will be whatever healthcare reform alternative the Republicans cobble together, such as reducing health insurance premium subsidies or converting Medicare into a defined contribution, voucher-style program. Should Clinton win the nomination, the most likely scenario, she will also tout her support for improving and expanding the ACA and tackling high drug costs.

Republicans, on the other hand, will go after the ACA's individual mandate and insurance regulations and tout their free-market proposals to bring down healthcare costs. Should Sanders win the nomination, they will flood the airwaves with messages attacking his single-payer plan as unaffordable socialized medicine that would lead to rationing of care.

“There will be a Republican healthcare plan when there is a candidate, and I imagine the Democrats will go after that plan in debate and ads,” said Robert Blendon, a professor of health policy and political analysis at the Harvard School of Public Health. On the Republican side, “if Sanders is the candidate, the word socialized would appear everywhere, and that he wants to give away free things the country can't afford.”

Outside groups in the deregulated campaign financing world made possible by the U.S. Supreme Court's Citizens United ruling and other federal rules will play a big role in disseminating healthcare ads. One lavishly funded group, Americans for Prosperity, a conservative advocacy group backed by the billionaire Koch brothers, has held its advertising fire so far, but that probably won't last long.

It advertised heavily in the last several elections against the ACA. It's already running social media and direct mail advertising in Arkansas and half a dozen other states in an effort to roll back or block Medicaid expansion.

“It's certainly on the table to challenge Sanders' or Hillary's healthcare proposals because their stance is very different from what we see as the more successful free-market direction,” said Levi Russell, spokesman for Americans for Prosperity, who declined to disclose how much his group plans to spend on political ads this year. “We see our role as pointing out the failures of the ACA and showing a better way.”

Meanwhile, two healthcare industry groups have launched ad campaigns to influence the health policy agenda without taking sides in the presidential race. Pharmaceutical Research and Manufacturers of America said it plans to spend several million dollars this year on digital, radio and print ads to convince Washington policymakers that drugmakers are dedicated to helping patients, the Wall Street Journal recently reported. An obvious goal, though it's not mentioned in the ads, is to dissuade Congress or the White House from taking steps to curb high prescription drug prices.

On the flip side, the Campaign for Sustainable Rx Pricing, a not-for-profit coalition of healthcare provider, business, labor and consumer groups that has been a strong PhRMA critic, has run nonpartisan ads in early primary states to raise awareness with candidates and voters about drug costs, with titles such as “Stop exploding drug prices.”

It wouldn't be surprising if other healthcare industry and policy groups also roll out marketing campaigns to frame the health policy options for the next president and Congress. “The smart players realize this isn't a healthcare election,” said Lawrence Jacobs, a political science professor at the University of Minnesota who studies healthcare politics. “But that doesn't mean you're not actively preparing the ground for post-election discussions.”

Up to now, the GOP presidential candidates and the outside groups backing them have mostly focused on issues and attacks not having to do with healthcare or the ACA, according to an analysis by the Wesleyan Media Project at Wesleyan University. Only ads supporting Cruz and Rubio have included opposition to the ACA as one of the top three issues mentioned.

Still, the super PAC supporting Jeb Bush, who dropped out of the race in February after his poor showing in South Carolina, repeatedly blasted Kasich for expanding Medicaid in Ohio. The super PAC supporting Rubio attacked Christie, who ended his campaign in February, for New Jersey's Medicaid expansion. While polls consistently show that the public, including Republicans, strongly supports Medicaid expansion, these anti-expansion ads are aimed at very conservative voters who dominate GOP primary voting in many states and who are more inclined to oppose the coverage extension. “I would expect to see ads attacking Kasich's position on Medicaid if he continues to do well” following his second-place finish in the New Hampshire primary, said John Geer, a Vanderbilt University professor of public policy who co-directs the Vanderbilt Poll.

Geer noted the irony that in Tennessee, which held its primary March 1, Republican Gov. Bill Haslam's proposed Medicaid expansion is very popular in polling. “But if you invoke Obamacare, that changes the conversation,” he said. “The state dislikes it.”

Meanwhile, the pro-Rubio super PAC has touted the senator's role in blocking funding for the federal program compensating insurers that enrolled a disproportionate share of sicker enrollees. Insurers say that funding cutoff has badly hurt exchange plans. “On Obamacare, some Republicans gave up,” the ad said. “One Republican presidential hopeful has actually done something.”

Another piece of GOP healthcare messaging came from an outside group called Our Principles PAC, which has focused on attacking Trump without expressing support for any candidate. It targeted Trump's past statements in support of abortion rights and healthcare for all. One ad quoted Trump's comments during an interview on “60 Minutes” last year in which he said, “Everybody's going to be covered. I'm going to take care of everybody … the government's going to pay for it.” The spot ends with the voice-over question: “Can we trust Donald Trump?”

Among the Democrats, Sanders' ads have emphasized his support for a universal coverage plan funded by higher taxes on wealthy people and corporations. His ads receive praise from Mark Bryant, vice president of Ace Metrix Politics, which uses public opinion polls to measure the effectiveness of political ads.

“The consistent theme among Sanders' ads is accessible, affordable healthcare, and his ads have done exceptionally well, not just among Democrats, but particularly among Independents,” Bryant said. As of early February, Sanders' spots held eight of the top 10 Ace Metrix effectiveness scores among this year's presidential campaign ads.

Cassino agreed that the Sanders campaign has succeeded in crafting ads that clearly address people's desire to have better healthcare. “A lot of people are paying attention to what he's saying, and look at the popularity he's enjoyed from it,” he said.

Whether Clinton or Sanders wins the nomination, Cassino predicts the Democratic candidate will spend at least 10% more on healthcare messaging than the GOP nominee because healthcare, always a compelling issue for Democratic voters, is one issue where the party can show progress over the past eight years. “The Democrats feel healthcare is a strong issue for them,” he said. “It hasn't lost its power, because (otherwise) people don't think that they're better off.”

One wild card on advertising is whether the Republican presidential nominee will explicitly support the long-standing GOP proposal to shift Medicare to a so-called premium support model, which Democrats have described as “ending Medicare as we know it.” Cruz and Rubio have backed the premium support model in the recent past, while Trump has rejected big changes in Medicare.

If the GOP nominee explicitly supports Medicare restructuring, “Democrats will go after that like hawks,” Harvard's Blendon said. “That will open up a whole different healthcare debate.”