This article first appeared in the St. Louis Beacon, Oct. 5, 2010 - Republican and Democratic candidates in Missouri say doing something about health care is part of their pledge to Missouri voters.
The GOP candidate for the U.S. Senate, U.S. Rep. Roy Blunt, of Springfield, says he will work to repeal it if he wins the election. His Democratic opponent, Secretary of State Robin Carnahan, says she wants to improve it should she win. Just as Blunt has embraced his party's repeal and replace slogan, Carnahan has talked about the issue on the campaign trail in the context of her battle against breast cancer.
In the contentious 3rd district congressional race, U.S. Rep. Russ Carnahan, D-St. Louis, has been upfront defending the plan while his Republican opponent, Ed Martin, is promising to work for its repeal.
The issue is so hot among Republicans, argues state Sen. Jane Cunningham, R-Chesterfield, that the party will use it to unleash a sleeping giant electorate in November and send a message to Washington.
Still, questions remain about about how much attention both parties are really paying. While the GOP advocates "repeal and replace," there's little detailed discussion about the specific provisions the Republicans would introduce. And in general, the Democrats have tended to be more defensive about health care than celebratory.
In fact, one political scientist says the candidates aren't giving the issue nearly as much attention as he expected.
That's a surprising comment in light of the visibility of the health care problem in the congressional districts of both candidates. Blunt's 7th congressional district is thought to have at least 75,000 uninsured residents, more than in any other district in Missouri. In addition, the numbers in the 8th district, the home of the Carnahan family farm outside Rolla, are thought to be right behind Blunt's, with more than 68,000 uninsured. As if that were not enough, the two live in a state where the number of people under age 65 with employer-sponsored health insurance has plunged to 62 percent from 72 percent in a decade.
Nationally, the Census Bureau reports that the number of uninsured Americans under 65 has risen to 50 million from 45.7 million, the largest number since the bureau began counting them.
All these statistics speak to the ongoing instability of Missouri's health-care system in general, from the poor who rely on Medicaid to the middle class that once could count on coverage on the job. Even so, Blunt and Carnahan haven't lit much fire under the issue as they campaign to replace retiring U.S. Sen. Christopher S. "Kit" Bond.
Targeted messages on health care
Marvin L. Overby, a professor of political science at the University of Missouri at Columbia, says the two are basically preaching to the converted, using health care "in communications that are targeted at their supporters." Generally speaking, he says the issue "cuts more to Blunt's advantage," because the measure "has been framed as a massive, expensive government intrusion into the health-care market. As long as voters have that generic image in their heads, it will benefit Republican candidates."
Complicating matters, Overby says, are legal and constitutional issues, such as the anti-health reform lawsuit filed by Florida and 19 other states. A federal judge in Florida is expected to rule by Oct. 14 on whether the lawsuit will go forward. One key issue in the suit involves the individual mandate that nearly every American must have health insurance or face a fine. Missouri is not part of the lawsuit, but Lt. Gov. Peter Kinder, a Republican, is waging his own legal challenge to the health-reform law.
"I suspect that federal courts will eventually invoke the Constitution's supremacy clause to dismiss such state challenges," Overby says. "But they're good politics. In almost any year, there is political hay to be made from attacking the federal government. That is especially true in a year in which skepticism of Washington is waxing. The Blunt campaign can -- and has -- used this issue to try to portray Carnahan as an Obama-Pelosi-Reid rubber stamp who is ignoring the express wishes of Missourians."
Still, Overby says he's surprised that health care hasn't been more of an issue.
"It may be getting more play in some other parts of the state, but I've seen relatively few television commercials from either side here in Columbia highlighting the issue."
The general silence seems just fine to some voters. B.J. McGough of St. Louis feels both sides need to take a breather because of the exaggerated claims, such as a government arresting people without health insurance, that tend to rise whenever the public attempts a rational discussion about health care.
"There's no end to the quibbling," McGough says. "If I were a politician and had only 30 days or less left to explain myself, I wouldn't want to get into that discussion. We need to calm down and just wait for the benefits to take effect. This law will save the federal government billions, and I think it will work great."
But she's far from certain a majority of Missourians share her belief, saying many seem to embrace the GOP's promise to dismantle the law if it prevails in November.
"That makes me very sad. This law represents a giant leap, and it's working very well."
Carnahan's campaign press spokesperson, Linden Zakula, answered some Beacon questions about health-care reform and Proposition C by email. Blunt's campaign didn't respond by press time. Zakula says Carnahan wants Congress to "focus on fixing what is broken and not repeal the whole thing." Repealing the law, he says "would mean going back to letting the insurance companies make out like bandits and deny coverage for people with pre-existing conditions." Missourians who want to see change, Zakula says, "can't keep sending the same old people like Congressman Blunt back to Washington."
States challenge health-care reform
Even those states that opposed the law seem to be complying with it. As Florida's attorney general wages his legal fight, the state's insurance office is quietly doing all the paperwork to comply up to this point and reap the benefits. The same is true of Virginia and other states where governors or attorneys general have attacked the law.
Some states also have indirectly taken the emotional charge out of the individual mandate issue. For example, Florida's insurance department points voters to the National Association of Insurance Commissioners' explanation of the individual mandate.
NAIC explains the issue this way: "The key goal of the health-care reform law is to ensure that nobody can be denied coverage or be priced out of coverage due to a health problem. If you allow people to wait until they have a health problem to purchase insurance, the health-insurance market simply will not work. There would be a small number of very expensive choices for everyone. So, the law requires that everyone have minimum coverage, creating a larger pool of both sick and healthy individuals."
Still, the law has plenty of shortcomings, says Cunningham, the Chesterfield Republican who was the force behind Missouri's referendum in August.
"As you saw last week, the child-only plans are being dropped all across the country," she says. "People with pre-existing conditions will line up to get this coverage and force carriers to go bankrupt. So carriers have immediately dropped their child-only plan."
She adds that Missouri's 71-percent vote for Proposition C "sent shockwaves not only across the state but across this country about how this sleeping giant electorate feels about this issue. There were independents, Democrats and Republicans supporting Proposition C, and I think that's a tremendous boost to the Blunt campaign."
Stephen Smith, an anesthesiologist in West County, was among some medical doctors who sided with Cunningham during the Proposition C campaign. He was asked what people would do if the new health law is repealed and people have no health insurance.
"We've always had people who haven't had health insurance. For one reason another we provided for them. There is definitely a place for people who have no resources, including organizations, whether they are government or others, to help them."
He still believes health savings accounts are the best way to "put the patients back in the driver's seat" and help control health cost. He thinks Missouri voters will perceive Carnahan as being on the wrong side of the issue. On the other hand, he says even some opponents find good provisions in the reform law.
"I like the idea of insurance companies not being able to cherry pick," he says. "That's good but it comes with a price" because requiring insurers to cover sick people also raises insurance costs. "Allowing young people to remain on their parents' insurance until age 26 is also good, but it also comes with a price. It means we'll pay more for health insurance."
One woman's story
In this election year, Karen Hagrup has had trouble understanding the big political fuss about health care. Perhaps it's because she was born in Norway, had polio at age 3 and remains thankful for a health system that paid the bills for the many operations, the therapy and the medicine that helped to restore her health. She lives in St. Louis, is a naturalized citizen and taught at Truman State University and the University of Missouri at St. Louis before retiring. Her partner is B.J. McGough, interviewed above.
"It probably wouldn't have been possible (to have the operations in the United States) because my parents didn't have the resources to pay for them," Hagrup says. "In Norway, it was taken for granted that you get the medical services."
Her reaction to the debate over health reform?
"I don't like to live in a country and think people may be dying because they can't get the health care that they need and people callously say that we shouldn't take care of everyone. That kind of mind-set, I don't understand. And I don't like it."
Place her vote in the Carnahan column. But that may not be saying much if Democrats don't turn out in large numbers and if the sleeping giant electorate that Cunningham mentions rises again and flexes its political muscle in November.
Funding for health reporting is provided in part by the Missouri Foundation for Health, a philanthropic organization whose vision is to improve the health of the people in the communities it serves.
