07/21/2009 01:38 pm ET Updated May 25, 2011

Health Reform: Which 'Costs' Are We Talking About?

In my ongoing discussion on poll questions that push respondents to choose between reducing health care costs and increasing access to health insurance, I neglected this bit of helpful reporting from my colleague Marc Ambinder:

Earlier this year, the White House decided to base its health care messaging on the concept of cost -- the current system was unsustainable and wasteful. They did not focus their argument on access, which appeals to people without access but doesn't do much for people with insurance, or about quality, which is complex and not intuitively helpful for Democrats. Maybe the price of doing business with the insurance company was to focus on costs. Maybe they overcorrected from the Clinton model in 1994, which focused on "health security."

"We tried access and quality, with a tad of moral imperative, once before and it didn't work out so well. Its difficult no matter how you slice it," a senior Senate aide told me. A White House adviser conceded that "access is killer, no matter how you poll it."

While I cannot react to polling data we cannot see, this conclusion presumably reflects some sort of message testing, and not just the forced-choice variety of question I critiqued yesterday and last Friday. One thing that quickly gets confused in this discussion, however, is the kinds of "costs" we are talking about.

When Americans tell pollsters they want health care reform to focus on "costs" they usually mean their actual, out-of-pocket health care expenses: insurance premiums, deductibles, co-pays, the costs of prescription drugs and any other medical bills not covered by health insurance.

The survey I linked to yesterday, sponsored by the labor-business coalition known as America"s Agenda, included a test** of measures to "reduce costs" that speaks directly to these kinds of out-of-pocket expenses (emphasis added):

Now I would like to read you a proposal that is being considered to reform health care. This proposal aims to reduce costs and improve quality of health care in the following ways: make health coverage more affordable and accessible for all Americans; eliminate co-pays and deductibles for recommended chronic disease treatment prescribed by your doctor; eliminate co- pays and deductibles for recommended preventive services and emphasize disease prevention including reducing obesity and smoking; ensure that doctors have accurate and updated information on the most effective treatments; and ensure that patients receive highly-coordinated, personalized treatment plans based on the latest medical evidence.

While the America's Agenda poll did not test this proposal against alternatives, I would not be surprised to see Americans with health insurance react more positively to it than anything else we could dream up, especially if the alternative is framed in terms of providing "access" to those presently uninsured (in other words, to somebody else).

When policy makers have talked about the "concept of costs" in recent months, however, the focus has been much different. At best, the discussion focuses on issues affecting the larger health care system (e.g. systemic "cost containment" or how to "bend the health care cost curve"). At worse, it focuses on the price tag for the health reform proposal itself. But either way, the discussion is removed from the every-day expenses faced by those with insurance.

Most Americans are not following this debate closely (only 24% told the Pew Research Center in June that they are following it "very closely"). Those that are have heard about a trillion-dollar-plus reform package and talk about taxing health care benefits or finding other forms of tax revenue to pay for it. And then there's the fierce debate about whether those remote, systematic changes will really "bend the curve." Put it all together, and it is easy to see why Americans are not responding to all the recent "messaging" on costs the way they do to the benefits promised by America's Agenda poll question, why they may doubt that reform will really bring down their own out-of-pocket costs.

Lost in all of this process coverage, of course, is discussion of the tangible benefits to individuals. Yes, as Mickey Kaus argues, "it's possible to take polls that show something very different" about whether costs matter most (see also, again, my column and previous posts on this subject). But in crafting a strategy, it is also important to consider more than just which paragraph gets the most positive response on a survey.  A strategist needs to think about how the poll-tested arguments might translate into the reality of the legislative process and the way the media covers it.

**Update: America's Agenda has also posted a filled-in questionnaire as well as a video and powerpoint of the presentations by pollsters Celinda Lake (D) and Bill McInturff.