Two seasoned political strategists, Paul Begala, and Stan Greenberg, spoke at “Health Action 2008,” a conference that Families USA sponsored in Washington last week.  There, they argued that the U.S. may be on the threshold of what Begala, a political contributor on CNN’s “The Situation Room,” called “a totally new deal.”  Greenberg, chairman and CEO of Greenberg, Quinlan Rosner, went a little further: “It is very possible that the whole conservative complex crashes.”

In an interview later that afternoon, Greenberg explained what he meant: “I think this election is going to mark an extraordinary defeat for conservatives.” Greenberg isn’t talking about the number of Congressional seats that the conservatives may lose: he is not forecasting a sweep for Democrats that equals the LBJ landslide. Instead, he’s predicting something more fundamental: that the right wing of the Republican party will be shattered. “There may be a fragmentation on the conservative side that changes what’s possible after the election.”

For many who came of age in the 1980s and the 1990s, this must seem unimaginable. For the past 28 years, the U.S. government has been held captive by the conservatives. Ronald Reagan sowed the seeds and George W. Bush harvested the fruit of a political movement bent on deregulation and smaller government while consolidating and preserving the wealth of the country’s richest citizens.

At the beginning of Bill Clinton’s first term, it seemed that the nation might be ready for deep changes, in large part because we had entered a recession that was threatening not just blue collar but white collar workers.  Middle-class and upper-middle class employees were afraid that they were going to lose not only their jobs, but their health insurance.  But as that recession eased, Bill Clinton’s first major initiative went down in flames.  A health care reform plan that would have signaled the beginning of progressive economic reform failed, in  part because Americans were no longer as anxious as they had been when Clinton captured the White House.  (Ezra Klein recently did a superb job of putting the death of the Clinton healthcare plan in context, explaining how a combination of “bad timing, political misjudgment and human error” conspired to kill what had been a “courageous effort” to pass health reform.)

But now, Begala and Greenberg say, the time is ripe for radical reform. They make their argument based both on the fact that the conservatives are in disarray and on what Americans now say when they talk to pollsters about healthcare reform.  In September, 62 percent of those polled said that “rising health care costs are a very serious problem in the economy”—up from 50 percent a year earlier. And, as the recession deepens, that number is likely to climb.

Paul Begala began his speech by pointing out how different this
election is from past elections. As others have noted: there is no
incumbent. “We Have to go back to 1928 to find an election without an
incumbent president or vice-president on the ballot,” observed Begala,
whose consulting firm, Carville & Begala, helped elect Bill Clinton.

And George W. Bush has no coattails. “Usually, after a two-term
presidency a vice-president or someone from his cabinet would be
running. But our president’s popularity rating is down to 33 percent—it
has been below 50 percent his entire second term,” Begala added.

During his eight years in office, Bill Clinton saw his popularity fall
as low as 33 percent “just once, in one survey,” Begala noted.  “In the
past, the public has been extremely loyal to sitting presidents, even
when they do incredibly foolish things.

“Ronald Reagan sold weapons to the Ayatollah of Iran, Begala says, his
voice cracking at the unbelievable absurdity of the transaction.  “No
One thought that was a good idea. (Well, okay, except perhaps Ollie
North, who as Begala recalled, later testified that he thought raising
money from the Ayatollah to support Nicaraguan freedom fighters was “a
neat idea.”)

As for Bill Clinton, “he had a girlfriend,” Begala pointed out. “And he
lied about it. No One approves of having an affair and lying about it.”

Still, Clinton’s popularity never sank like Bush’s. What is the moral
of this story, Begala asked–“that George Bush needs a girlfriend?”

“No, what this tells us is that we have given up on Bush,” said Begala, wiping his hands.  “We’re done with him.

It’s a new game, and rather than feuding over the mistakes of the
past, progressives should  be seizing the moment—especially when it
comes economy and health care reform, Begala declared. “The hardest
thing for people working on healthcare to understand is that this is
not 1994.  This is a completely different country. On healthcare, the
progressives are too cautious.”

Everyone talks about how badly would-be reformers were “burned” the
last time around.  And it’s true, he acknowledged, “a cat that sits on
a hot stove never sits on a hot stove again.  But it won’t sit on a
cold stove either. We need to be smarter than Mark Twain’s cat.”

“I think progressives need to remember that on the other side—they have
nothing to sell but fear,” Begala added. He then channeled a
fear-mongering conservative: “Oooo, Single Payer; Oooo, Socialized
Medicine,” he cried, crossing his arms over his eyes, and shaking his
hands over his head as if warding off  ghosts of the Cold War Past.

Stan Greenberg, who has been reading public opinion since the 1970s and
served as pollster both for President Bill Clinton and Vice-president
Al Gore, spoke next.  “What I do is, I try to help elections matter, to
help them have meaning,” said Greenberg, who, together with James
Carville, founded Democracy Corps in 1999.  “If I do anything in life,
I understand the dynamic of an election and the opportunity to create
mandates.”

He offered an example: “When the 1992 election was over, people
understood what it was about: ‘It’s the economy, stupid!’  This time
around, Greenberg is certain “there will be a mandate on healthcare.”
Moreover, he insists that “healthcare and the economy are one and the
same issue. Health care costs are a central economic issue.”

Just as in 1994, voters will be voting their pocketbooks. And this
time, it’s not likely that the recession will end quickly, or that the
public’s anxiety about losing health insurance will suddenly disappear. Health care costs continue to levitate, and employers are backing off.
Meanwhile, the price of oil climbs and the war in Iraq goes on and on.

The voters are angry, Greenberg continued. “They won’t elect someone
without taking them through all sorts of tests. The candidate who wins
will win on three linked issues: reducing the number of troops in Iraq,
making healthcare affordable for all, and energy independence.

“I believe that when we wake up after election day we will know that
these are the issues that matter,” he added, “though not necessarily in
that order. “

And when it comes to healthcare, “the public is open to fairly complex
plans for reform,” says Greenberg.  But the candidates are going to
have to take responsibility for explaining their plans, And then
explaining them again. And again.

“Among the mistakes we made in 1994,” Greenberg explains, “is that we
thought the media would do it. They won’t. They’ll write one story, and
then move on, looking for ‘new’ news. So the candidates have to find
ways to repeat, repeat, repeat.” And, Greenberg stressed, “They must
allay anxieties with facts.

“They also need to be aware that the conservatives’ proposals also sound good,” he cautioned. Rather than reforming the health care system, most conservatives would give people tax credits or tax cuts so that they can “be in the driver’s seat” and fund their own
health care.  “We know the consequences of these health care policies,”
Greenberg observed, referring to the fact that most of the middle-class
doesn’t have enough discretionary income to fund a health savings
account, and that tax cuts tend to be most valuable to those in the
highest tax brackets.

The conservatives’ plan will not broaden access by putting a brake on
healthcare inflation. It would simply reinforce a three-tier health
care system in which some Americans receive what they believe is good
health care, a second tier receives what they know is insufficient
care, and a third tier receives no care at all until they are
very, very sick.

This is what progressives need to explain to voters. They also need to
show how their plans dovetail with what the public values most. Here
Greenberg produced polls revealing what voters say they want.  (The
numbers come from a series of 14 surveys in eight battleground House
districts and six competitive Senate states that Greenberg Quinlan
Rosner conducted in November. The presentation also incorporates data
from a Democracy Corps National Survey that was done in May 2007. The
below charts are pulled from this presentation.)

First, Greenberg noted that there is strong support for reform.  Even when
asked “Would you support or oppose reforming our current health care
system to provide affordable health coverage for all Americans . . . if
it meant government taking a much larger role in our health care
system—and if it meant that you would have to pay more in taxes?” 44
percent  said they would support reform. The chart below refers to this group as “firm
supporters.”

“Conditional supporters” by contrast, initially said “yes” to reform,
but dropped their support in the face of greater either government involvement
OR higher taxes, while “firm opponents” opposed any reforms to our
current health care system.

Clearly, there are still fears of a “government takeover” and
progressives need to explain that their plans would let families keep
their private sector insurance if they choose. The majority of voters
also are still unwilling to pay higher taxes to ensure coverage for
all.  Nevertheless, Greenberg points out “44% support reform—even if it
means more taxes and more government involvement. Other voters just
need to be reassured that the government role will work for them and
that costs will be contained.” Here, I would add that money will be the central, recurring problem
in the fight for health care reform. As we have seen both in California
and in Massachusetts, the question of how we will pay for
reform—especially as the economy heads south—cannot be ignored. I will
be talking about this in my next post.

Greenberg’s polls also looked at the degree to which Democrats,
Independents and Republicans agree on the issues. When asked about the
biggest problem in our health care system, “costs are too high” ranked
first with all three groups.  By contrast, as the chart below shows,
only 34 percent of Independents and 24 percent of Republicans saw the
fact that  “there are too many people without coverage”  as “one of the
biggest problems.”

Instead, both Independents and Republicans were significantly more
worried about insurance companies.  Here, the polls showed that voters
were primarily concerned that insurers will refuse to cover them if
they are sick.  As Greenberg points out, progressives must allay fears
with facts, making it very clear that under their plans, insurers would
no longer be allowed to refuse coverage or raise rates if a customer is
sick. They could not “cherry-pick” healthy patients or shun the sick.

Pollsters also asked “Which Values Should Guide Reform,” giving those polled a choice among:

• Fundamental Right: Healthcare is a fundamental right – every American should be guaranteed coverage that can never be taken away
• Choice of Doctors: Every American should have a choice of doctors and hospitals
• Shared Responsibility: Individuals, businesses and government have a shared responsibility for covering health care costs
• Should be Private: America’s health care system should be private and market-driven, not government run
• Business Not Hurt: American businesses should not be hurt by health care costs

As the chart below reveals, more than half of all Republicans,
Independents and Democrats ranked having a “choice of doctors and
hospitals” either first or second among the values that should guide
reform.  “This is key, key, key,” says Greenberg.

Voters also believe that individuals, government and business should
share in the cost of care. But the majority of Independents and
Republicans are not convinced that health care is a “fundamental
right”—which explains why so many are not willing to pay higher taxes
to make sure that everyone is covered. Progressives will have to find
other ways to finance reform.

Greenberg then revealed what percentage of voters strongly support (left-hand number in each row) or totally support (second number) elements of progressive and conservative plans for health care reform.

PERCENTAGE WHO STRONGLY SUPPORT/TOTALLY SUPPORT ELEMENTS OF PROGRESSIVE PLAN

PERCENTAGE WHO STRONGLY SUPPORT/TOTALLY SUPPORT ELEMENTS OF CONSERVATIVE PLAN

Finally, Greenberg ranked the key elements that voters favor,
showing that the progressive messages generally outperformed the
conservative messages. As the chart below shows, the progressive
promises (in blue) meant more to voters than the conservative ones (in red). The lighter shade in each bar represents respondents who valued a promise “somewhat,” the darker shade are those who place “much” value in the promise.

As you can see, promises of Security (you cannot lose your insurance,) No
Discrimination (insurers are prohibited from discriminating and denying
coverage), Universal Coverage and Choice ( if they choose, families can
keep the private insurance they now have) meant more to voters than
conservative promises of tort reform, affordability (with a tax cut
making healthcare more affordable) individual choice (as to whether or
not you have to purchase insurance) and markets (letting free market
competition continue to try to solve the problems of our health care
system.)

Greenberg believes that when you look at voters values, fears and
priorities, it becomes clear that “the conservatives are out of touch.
Social conservatives are being devalued and de-linked. We can win this
debate,” he adds. “I’m not worried about the debate. I’m worried about
the programs.”

I’m not quite as confident as either Begala or Greenberg that the
conservative wing of the Republican Party will be pushed off the political stage—though it is true that
American political history is a history of pendulum swings. And after
years of conservative dominance, it is time for a “New Deal”—a “totally
new deal.” Perhaps we are entering a new era, where we will be able to
do things that we haven’t been able to do in the last 28 years.

The question is, how are we going to fund health care reform? I talked
to Don Berwick, head of the Institute for Healthcare Improvement about
that in Washington last week. In my next post, I’ll talk about how we
might persuade hospitals to put fewer heads in hospital beds.