On Health Reform, Ask: Where Is the Opposition Coming From?

Politicians seek endorsements and favorable feedback for their ideas. It’s part of the job description.

Now, however, in the referendum-and-recall charged climate of California, avoiding opposition may be even more important than winning support.

“The more I think about it, the more I would be worried about the possibility of a referendum if I were trying to push through any kind of meaningful health care reform right now,” Robert Stern, president of the Center for Governmental Studies, said.

The reverberations from the statewide referendum on health care reform in 2004 are still ringing in politicians’ ears, and “you can be fairly certain they’re doing whatever they can to avoid generating the kind of deep opposition that led to the last one,” Stern said.

Options on the Table

Four California politicians — one Republican and three Democrats — are stumping this year for their visions of reform in a state that finally appears willing to do something about a health care system with spiraling costs and growing ranks of uninsured. Also in the mix are two Republican reform packages from the Legislature.

Republican Gov. Arnold Schwarzenegger, Senate Health Committee Chair Sheila Kuehl (D-Los Angeles), Assembly Speaker Fabian Núñez (D-Los Angeles) and Senate President Pro Tem Don Perata (D-Oakland) all have sweeping reform proposals on the table.

Assembly Republicans’ bundle of 18 proposals seeks to reduce the number of uninsured residents by two-thirds without relying on employer contributions or tax increases. Their plan, revealed earlier this month, promotes tax-free health savings accounts and permits residents to deduct all medical expenses from state income taxes.

Senate Republicans earlier this year proposed several changes that would provide incentives for uninsured Californians to obtain coverage while not requiring contributions from employers or health care providers.

Fear of Rejection

“Nobody’s talking much about what happened three years ago, but you can be sure they’re thinking about how to avoid a repeat,” Stern said.

In October 2003, about a month before he lost a recall election, Gov. Gray Davis (D) signed into law the Health Insurance Act of 2003 requiring large and mid-sized companies to provide health insurance for employees or pay a fee to the state. Spearheaded by the California Chamber of Commerce and invigorated by the election of a Republican governor who helped lead the charge, big business mounted a campaign to make sure it didn’t happen. Before the law had a chance to take effect, voters scrapped it through Proposition 72 in 2004.

“Referendums are very rare — as are recalls at the statewide level — but the success of both in the past few years … has changed the landscape of how legislation and reform gets done in California,” said Stern, who has been observing, researching and analyzing California politics for 35 years.

The Center for Governmental Studies, based in Los Angeles, is a not-for-profit, nonpartisan research and advocacy organization that studies and helps implement innovative approaches to improving social problems and the processes of self-government. The organization was established in 1983 by Tracy Westen and Stern.

Next month, the Center for Governmental Studies will begin publishing a new Web site examining and tracking California health reform proposals.

Nurses Union Steadfast for Single-Payer

Gov. Schwarzenegger, who knows what dedicated opposition can do to a piece of legislation, is facing opposition at two ends of the political spectrum. Many in the business community don’t like his plans to require employers to buy into his system, and at the other end, nurses are against individual mandates without a single-payer system.

Last time it was big business applying the brakes to reform it couldn’t accept. This time it could be nurses.

The California Nurses Association earlier this month sent thousands of mailers across the state with a blaring headline: “Insurance Companies Love It: What Better Reason To Stop the Politicians Health Care Plan?”

The single-sheet flier mentions no specific legislation or politician but attacks several features included in proposals by Schwarzenegger, Perata and Núñez. Individual mandates — called for by Schwarzenegger and Perata — requiring all citizens to have health insurance, will increase the costs of health care, reduce benefits to individuals and help insurance companies, the CNA flier argues.

CNA and its national arm, the National Nurses Organizing committee, earlier this month joined the AFL-CIO. In its campaign for health care reform, CNA plans to use the new affiliation, which was announced shortly after AFL-CIO endorsed a position statement in favor of a single-payer health care system.

CNA has been actively campaigning for two single-payer proposals — Rep. John Conyers (D-Mich.) HR 676 at the federal level and Kuehl’s SB 840 in California.

Other Stakeholders Must Be Swayed

Nurses are one of a handful of significant powerbrokers in the health reform process along with doctors, hospitals and employers.

“The way legislation happens, the way it is shaped and reshaped into something that can win enough votes to be enacted, involves a lot of foundation laying with power groups,” Stern said. “What’s going on right now in California health care is the various camps — the governor, Núñez, Perata and Kuehl — are out there meeting with lots of organizations and interest groups trying to find out what their bottom lines are for the myriad of details that go into these kinds of sweeping bills.”

“It used to be a pretty straight-forward process of trying to win active support,” Stern said. “That’s still the main goal, but now there’s another step in the process where politicians say to powerbrokers, ‘If you can’t endorse my plan, what can I do to make sure you won’t oppose it?'”

Stern said it’s a logical evolutionary step in state politics where it’s considerably easier to kill ideas than to make them thrive.

“Remember, you only need to kill a bill one place in California but you need to pass it [in] about seven places,” Stern said.

Keeping with that negative train of thought, Stern points out that “voters tend to vote ‘No’ when they’re unsure of anything, especially if it involves money. If there’s any confusion or doubt, I think the ratio is voters will say ‘No’ about 75% of the time.”

The threat of referendum effectively adds one more place where ideas can be killed.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.