Skip to main content

From Preexisting Conditions to Drug Prices, Midterms Show More Posturing Than Substance

Analysis  |  By Paul Keckley  
   October 24, 2018

The real healthcare issues burdening the industry are being tucked aside in posturing as Democrats and Republicans alike hide behind sound bites and scare tactics.

In 15 days, we'll elect 435 members of the U.S. Congress, 35 U.S. senators, 36 governors, and legislators for 87 of our 99 state legislative bodies. Polls by Kaiser Family Foundation and others show healthcare has emerged as the most important issue to likely voters (30%) ahead of the economy and immigration.

Pundits attribute its prominence to the confluence of a period of relative peace and prosperity and ample media coverage on healthcare issues like preexisting conditions and Medicare-for-all. Healthcare is fertile turf for campaign strategists: voters willingly share their views on healthcare issues with pollsters.

Based on recent debates, however, the real healthcare issues burdening the industry are being tucked aside in posturing as Democrats and Republicans alike hide behind sound bites and scare tactics designed to appeal to their lowest common denominators. The net effect may be that voters aren't being given electable distinctions in many critical healthcare issues in this election cycle.

In the current election cycle, polls show healthcare is more important to Democratic voters than Republicans. I watched 12 televised debates—seven for contested Senate seats and five for governor races—to gauge how the campaigns and parties position themselves on healthcare issues. I examined the questions asked by moderators, the timing of healthcare in the debate agenda, follow-up queries posed in response to candidate responses and the intensity of the differences between candidate views.

Medicare for All, Preexisting Conditions, Opioid Addiction, and Medicaid Expansion are the healthcare issues that have figured prominently in the debates. Senate debates devoted less attention to healthcare than gubernatorial contests: the Supreme Court confirmation of Brett Kavanaugh, gun control, tariffs, federal debt and foreign policy items were addressed in the Senate clashes contrasted to governors' debates in which Medicaid expansion and opioid addiction got more attention.

Three of the four issues lent themselves to sharply contrasting views between candidates and their parties: opioid addiction and drug abuse less so. So, debaters used their 60-second time allocations to drive home one key difference between their view and that of their opponents: 

1. Preexisting Conditions

Republican view: We will protect citizens against insurer denial of coverage due to preexisting conditions by passing new laws that require coverage but allow insurers to charge what they must to address their added risk. Bottom line: The ACA is still bad policy: we will repeal it. What's needed is health insurance reform.

Democratic view: Protections against the denial of coverage for a preexisting condition by an insurer is in the Affordable Care Act which Republicans have pledged to repeal (again). Bottom line: It's the right thing to do.

2. Medicaid Expansion

Republican view: It's dependent on a state to decide, as 33 already have. For those considering expansion, newly insured eligible enrollees should be required to work and maintain eligibility for the cost of the entitlement to be contained. Bottom lineThere should be no free rides. Medicaid waste and fraud should be addressed to protect taxpayers.

Democratic view: Low income families and kids need access to healthcare. They do not abuse the system; they depend on it. And the costs for Medicaid services which are coordinated by states and private managed care organizations, are substantially less than what's spent in costlier settings like emergency rooms and hospitals. Bottom lineIt makes fiscal sense to expand Medicaid to reduce overall health costs. The public believes access to health insurance is a fundamental right.

3. Opioid Addiction

Republican view: Drug addiction, including opioids, is a societal issue requiring a comprehensive approach including tighter controls on prescribing and access, coupled with increased funding for mental health and counseling. Bottom lineIt's a problem that needs urgent bipartisan attention.

Democratic view: It's a major problem requiring urgent attention. The solution should include penalties for manufacturers and prescribers who have abused the system for their financial gain. And funding for mental health, which has been cut, should be restored. Bottom line: It's not enough to say there's a problem. Action must be taken.

4. Prescription Drug Prices

Republican view: Drug prices are too high. Policies that promote price transparency, increase generic competition, remove gag clauses on pharmacists and "naming and shaming" companies guilty of price gauging are working. Bottom line: There no excuse for drug price gauging: current efforts are working.

Democratic view: Drug prices are inexcusably high because drug manufacturers put profits before patients. Lawmakers must hold them accountable. Importation of drugs, direct purchasing by Medicare, and more drastic measures should be taken. Bottom lineAccess to drugs should not be limited by a person's income.

Long on Soundbites, Short on Specifics

On healthcare issues, candidates lean heavily on focus-group tested "gotcha" responses and avoid specifics. Their answers tend to follow a formula:

  • Reinforce the underlying issue as a "real" problem by using a key statistic to demonstrate knowledgeability;
  • Convey sincere sensitivity about the problem by referencing a personal experience;
  • Assert a solution without offering specifics about how it might work or what it might cost; then
  • Attack the opponent's solution as unworkable, expensive, untested, or immoral.

It's a formula that works, especially in a debate format, and especially when terms and phrases are used to stimulate an emotive reaction from viewers: "government-run healthcare" and "liberal" were used frequently by the GOP Senate candidates to label opposing ideas and "drug company profits" and "far right" were popular as Dems characterized the ideas of their opponents.

Despite Its Importance, Healthcare Got Inadequate Attention

In every debate, candidates alluded to the critical and unique roles played by healthcare and education in advancing and protecting our society. It's political malpractice not to mention both. At 29% of federal spending, 34% of state spending, and 14% of household spending, healthcare deserved more attention in the midterms.

In these debates, not a word about Veteran's Health impacting 21 million, alternative payment models, the roles of mid-level clinicians or physician burnout, mental health parity, drug prices, physician shortages, total costs of care, workforce shortages, or price transparency. No reference to industry consolidation, the Amazon effect, the future of medical education or precision medicine. Nothing about retail clinics, telemedicine, social determinants, or reimbursement shortfalls. Just the four issues. Regrettable!

When the dust settles after November 6, a bigger issue will linger: how to engage voters so solutions to complex problems can be developed in a nonpartisan constructive way based on facts. The American electorate is vastly uninformed and ill-equipped to address the pressing issues in healthcare.

In these debates, healthcare did not get adequate attention. It is up to the industry to fill the knowledge gap so voters in 2018, 2020, and beyond understand the facts, trends, and implications of their actions.

Editor's note: This special to HealthLeaders analyzed the following Senate debates: Massachusetts (10/21), Tennessee (10/10), Indiana (10/8), Texas (9/21, 10/16), Ohio (10/20), California (10/17), Washington (10/20). And it analyzed the following gubernatorial debates: Michigan (10/12), Tennessee (10/12), Florida (10/21), Massachusetts (10/17), Arkansas (10/12).

Paul H. Keckley is Managing Editor of The Keckley Report, a healthcare policy analyst, and a widely known industry expert. For a full version of this column and his other reports, subscribe at

Get the latest on healthcare leadership in your inbox.