1726 M St., NW Suite 500 Washington, DC 20036 Phone: 202-776-9066 Fax: 202-776-9074

1. Health Care and the 2008 American Presidential and Congressional Elections Presented to the Second National Congress on the Un and Underinsured by Celinda Lake September 24, 2008 1726 M St., NW Suite 500 Washington, DC 20036 Phone: 202-776-9066 Fax: 202-776-9074 www.lakeresearch.com

2. Context: The Electoral Climate The mood of the country is decidedly sour, and voters are ready for a change. However, the presidential race remains tight and is by no means over.

3. Voters’ outlook has been strongly and consistently negative over the last year, with almost eight in ten now saying we are on the wrong track. Lake Research Partners/Tarrance Group for all questions up to July 2007 and December 2007, 1,000 registered likely voters, MoE +/-3%. Oct. 07-Apr 08 (except Dec 07) are from AP/Ipsos nationwide surveys of the same question. May 08 from LA Times. June and July 08 from CBS, and August 08 from ABC.

4. Much of the souring national mood rests on the slumping economy. It is by far the most important issue—more important than the next three issues combined. Health care has recently been a lower priority as people worry about gas prices and the credit crunch. In deciding who you would like to see elected President this year (2008), which one of the following issues will be most important to you?...Terrorism and national security, the economy and jobs, health care, the war in Iraq, gas prices and energy policy, illegal immigration, or something else? NBC/WSJ Poll. June 2008. 1,000 Registered Voters Nationwide

5. Though the economy is the top concern overall, rising health care costs are a key component of voters’ economic anxiety. Traditionally, health care costs are a top economic concern, but this summer’s sharp increase in energy prices has brought that issue to the forefront. Thinking about your own situation, what current economic issue is most important in determining your vote for President? GWU Battleground. August 2008. 1,003 Likely Voters Nationwide

6. The vast majority of voters are insured. However, some key constituencies view health care as a voting issue. • 94% of voters in 2006 had some members of their household covered, 79% had everyone covered.* Of those, 79% were swing voters. • Core health care voters supporting progressive reforms include Democrats, Democratic women, and African-Americans. • Older women and seniors are the most attentive voters on this issue. They need to be reassured that reforms will not adversely affect the quality of their health care. *SEIU/AHC polling by Lake Research Partners, November 2006.

7. A snapshot taken between the parties’ conventions shows Obama with a small lead in a tight race. The post-convention picture is beginning to emerge, and all signs point to the race staying tight. Presidential Ballot Gallup Daily Tracking. August 31-September 2, 2008. N=2,767 likely voters nationwide.

8. Barack Obama is more trusted by voters on the economy, and especially on health care. AMONG ALL VOTERS GWU Battleground. August, 2008. 1,003 Likely Voters

9. Voters’ Attitudes on Quality, Affordable Health Care for All Americans

10. The Strategic Situation • Based on focus groups and survey findings, advocates of health care for all Americans are in a position for a successful health care debate in the 2008 elections. • Voters are feeling more urgency about national health care reform and the need to fix the system but are also becoming more tax sensitive as the economy continues to flounder. • Voters assign negative characteristics to the health insurance industry, and tying stories of increasing profit margins and denying people coverage elicits anger that can be channeled into support for reform and discredit of attacks.

11. As the economy continues to get worse, voters have become more tax-sensitive. However, a solid majority favors health care for all Americans even if it means raising taxes. Do you favor or oppose providing access to affordable, quality health care for all Americans even if it mean raising your taxes? Do you feel strongly or not strongly about that choice?* Oppose Favor 69% September 2007 28% February 2008 27% 64%

12. Voters are becoming more comfortable with a government role in health care reform, possibly as a result of the presidential campaign. Do you favor or oppose providing access to affordable, quality health care for all Americans even if it mean a major role for the federal government? Do you feel strongly or not strongly about that choice? Oppose Favor 28% 66% September 2007 February 2008 23% 69%

13. Voters strongly identify the health insurance industry with negative traits of putting profits ahead of people and being greedy, uncaring, and bureaucratic. Terms like reliable and unreliable are more middling.

14. Among all voters, banning the practice of denying coverage due to “pre-existing conditions” is the highest scoring feature of progressive reform, but especially among women. Now, I'm going to read you the individual components that are in the health care proposal I just read you. For each one, please rate how favorable you are toward that item on a scale of 0 to 5, where 5 means it is a very convincing reason to support the initiative, and 0 means it is a not at all convincing reason to support the initiative. If you are not sure, please say so. • Among Women • Very Convincing • 65% • Total Convincing • 80% • Mean Score • 4.2 14

15. Health Care Reform Proposals A progressive health care reform plan beats out a conservative plan both in focus group and survey research.

16. Text of Candidate A’s Progressive Plan Americans would be guaranteed to have a choice of health plans they can afford, either from a private insurer, or from a public plan. Everyone would pay on a sliding scale based on income. To maintain quality and allow fair cost comparisons, health insurance companies and the public plan would be required to provide at least a standard, comprehensive package of benefits including preventive care and all needed medical care. Employers and individuals could choose to keep their current health plans. The public plan would be paid for through a modest payroll tax on employees and employers and by rolling back tax breaks for those who make over $200,000 a year. Small businesses would also pay a lower rate. No insurer could deny coverage or charge higher premiums to people with pre-existing conditions.

17. Text of Candidate B’s Plan The proposal would level the financial playing field for all health purchasers, so individuals and families can purchase their own health insurance with a universal refundable tax credit of 2,500 to 5,000 dollars in place of the current employer sponsored health insurance tax exclusion. Access to Health Savings Accounts would be expanded and improved by streamlining rules and regulations, allowing families to maximize the value of health services tailored to their needs. Families would be able to purchase health insurance nationwide, across state lines, to maximize their choices, and heighten competition for their business that will reduce overhead, administrative, and excessive compensation costs from the system. Low-income families would receive supplemental aid through their state's Medicaid funds and states could choose to allow the use of private insurance in Medicaid.

18. When asked to choose between the two plans, a majority opt for Candidate A’s progressive plan including 2-in-5 who say they strongly support it. 55% 28%

19. Focus group participants liked that under Candidate A’s plan they would have choices in their health care and that they would not have to fear being denied.

20. Responses to Candidate B Plan • Focus group participants like the personal responsibility and choices offered in Candidate B’s plan. • They are also skeptical about how Candidate B’s plan will be paid for and if regular people can afford coverage.

21. Republican men and independent men are the most likely to support Candidate B, but both groups are still net supportive of Candidate A. Margin for Candidate A Candidate B Candidate A +51 +36 +11 +37 0 +23

22. White women solidly support Candidate A’s plan but the margin of support is smaller among white men. Margin for Candidate A Candidate B Candidate A +16 +37 +26 +13

23. The best messages center on the guarantee of health care and criticize the harsh and unfair insurance industry. • Guarantee: We need an alternative to the harsh and unfair practices of the health insurance industry. The right approach recognizes that we are all part of the solution. We need a guarantee of quality, affordable health care for all of us. We need to set and enforce the rules so insurance companies put our health care before their profits. We need to be able to keep the health care that we have and we need the choice of a public plan, so we’re not left at the mercy of the same private insurance companies that have gotten us into this mess. • Guarantee with government: We need an alternative to the harsh and unfair practices of the health insurance industry. The right approach recognizes that we are all part of the solution. We need a guarantee of quality, affordable health care for all of us. We need government to be an advocate for us and set and enforce the rules so insurance companies put our health care before their profits. We need to be able to keep the health care that we have and we need the choice of a public plan, so we’re not left at the mercy of the same private insurance companies that have gotten us into this mess.

24. Best Messages (Cont.) • Can’t keep up – rules: If you work hard, pay taxes, and play by the rules, you ought to have access to quality, affordable health care, but it’s getting tougher and tougher today to make ends meet and afford good health care. Health insurance premiums are going up three times faster than workers’ wages or inflation. None of us should be left behind. As Americans we can and must provide a real solution. Candidate A’s proposal is a common sense plan to make sure we all have access to the highest quality health care in the world. • Can’t keep up – struggle: No matter how hard we work and struggle to make ends meet, it’s getting tougher to get good affordable health care. Health insurance premiums are going up three times faster than workers’ wages or inflation. None of us should be left behind. As Americans we can and must provide a real solution. Candidate A’s proposal is a common sense plan to make sure we all have access to the highest quality health care in the world.

25. A “Big Government” attack on Candidate A’s plan raises doubts among 55% of voters. Candidate A’s plan sounds good, but it just won’t work. It will be just another big government bureaucracy like the IRS and the DMV, operating inefficiently and costing taxpayers hundreds of billions of dollars. We will end up paying higher taxes and getting low quality health care with long waiting lines to get treatment and lots of red tape and paperwork. Instead of a big government program to bring socialized medicine to America, we need to give consumers more of their own money back, and more options to choose the health insurance plan that’s right for them. 65% Doubt Does that raise SERIOUS doubts, SOME doubts, MINOR doubts, or NO real doubts in your mind about the health care proposal from Candidate A?

26. The attack on Candidate B’s plan is farther reaching, raising doubts among over three quarters of voters. Candidate B’s plan is misleading. Candidate B doesn’t tell you that with those Health Savings Accounts you will need to buy a health care plan with deductibles of 11 hundred to 11 thousand dollars. He doesn’t tell you that even if you do manage to get a tax deduction or credit it will pay for only a quarter to a half of your cost of health insurance. And his plan doesn’t do anything to regulate insurance company practices, like not covering pre-existing conditions, denying claims or restricting your choice of doctors. And there’s nothing in the plan to control skyrocketing premiums or insurance company profits. We don’t need a plan that leaves us on our own with the insurance industry. We need a guarantee of quality affordable health care for all of us. 77% Doubt Does that raise SERIOUS doubts, SOME doubts, MINOR doubts, or NO real doubts in your mind about the health care proposal from Candidate A?

27. As voters learn more through the survey, Candidate A gains some additional support and Candidate B’s support erodes – margins grow from 27% to 32% to 38%. Margin for Candidate A Candidate B Candidate A +27 Initial Post-Attack +32 Final Post-Messaging +38

28. Attacking the Conservative Message Several direct attacks on the conservative plan proved effective.

29. “Market” Attack on the Conservative Plan Every time the market fails to solve a problem, we hear, "Just eliminate regulations and the market will correct itself." That's what we heard with the mortgage industry, the oil companies, and the big corporations that are outsourcing American jobs. Just look at what the "free market" has brought us on health care: Millions of people can’t get insurance or are afraid to change jobs because they have some "pre-existing condition"—which we all have if we just live long enough—and millions of parents who work full-time have no insurance for their kids. Insurance companies have complete control over the size of premiums, deductibles, co-pays, and how much they’ll pay, and the rest of us have no choice but to take what they offer. They spend a fortune on “administrative costs”, wasting doctors' time filling out paperwork and denying people coverage for tests or procedures their doctors say they need. Drug companies charge whatever they want for new medications and lobby Congress so Medicare can't even negotiate lower prescription drug prices. We don’t need more of the same, we need leadership. MEAN DIAL RATING (0-100) = 62 POST-CANDIDATE RATING (0-100) = 71 * 29

30. “No Regulation” Attack I’m not sure exactly what problem this plan was supposed to fix. It does nothing about the 50 million working Americans and their families who have no health insurance, or for the other 50 million middle class Americans and seniors who spend more than 10% of their income on health care. It does nothing to control skyrocketing premiums and out-of-control insurance or drug company profits, or to prevent insurance companies from imposing huge co-pays and deductibles that force people to choose between their mortgage and their medication. It does nothing to stop insurance companies from denying people coverage because they have “pre-existing conditions” or making arbitrary decisions about what to pay or not to pay. And hidden in the fine print is a huge tax increase on the middle class, because it taxes working people on their employers’ contributions to their health insurance, encouraging companies to drop their health benefits. It’s a great plan if you’re the CEO of an insurance or drug company. MEAN DIAL RATING (0-100) = 62 POST CANDIDATE RATING (0-100) = 66 30

31. “Taxes” Attack This is nothing but a huge tax increase on the middle class. Hidden in the fine print is that if your employer pays for part of your health insurance, you’ll get taxed as if that’s income. The last thing we need is a big tax increase on people who work for a living. And what do we get in return? A tax credit that doesn’t even cover what most of us already pay, high deductibles before any coverage kicks in at all, huge out of pocket expenses, and cuts in prescription drug benefits to middle class seniors on Medicare. It does nothing to curb the record profits of the insurance companies or stop them from discriminating against people on the basis of age or “pre-existing conditions,” and it gives incentives to employers to drop coverage for their employees. It puts us all out there on our own, buying plans with terms dictated by the insurance industry, with no choice but “take it or leave it.” It’s no surprise that no one in Congress is proposing this plan for themselves. MEAN DIAL RATING (0-100) = 62 POST-CANDIDATE RATING (0-100) = 66 31

32. Strategic Summary • The best message strategy is strong initial positioning which helps protect us against attacks. • Positive messages saying what you will do about the problems test better than negative messages talking about the problem. • Stating our goal as providing access to the highest quality health care in the world and providing affordable, quality health care to all who work hard, pay taxes, and play by the rules remains our core positioning. • Candidate B’s plan is vulnerable even before it is attacked. People worry about the cost, bureaucracy, and being left on their own with the insurance companies. • Charging further that Candidate B’s plan was written by insurance companies to help them is very damaging.

33. Message Research Dial testing that captures voters’ moment-to-moment responses to conservative and progressive health care messaging

34. Every progressive narrative tested substantially outperformed the conservative message (below). Families should be in charge of their health care dollars. Rising health care costs are a problem, and the best way to bring them down is to increase competition among health care providers and put an end to these million dollar lawsuits that drive up insurance costs and put doctors out of business. The best solution to our health care problems is to let the free market work, foster more competition, and help people deal with the rising costs of coverage with health savings accounts that allow people to manage their own health care decisions. The last thing we need is the government taking over health care and creating a massive bureaucracy that will cost us billions of dollars a year. Sure, we have problems, but what the naysayers always seem to forget is that Americans still have the best health care in the world. Europe and Canada have government run health care, and their patients come here for treatment due to long waits and poor quality care. The answer to our health care problems is a freer market, not socialized medicine. MEAN DIAL RATING (0-100) = 55 POST-CANDIDATE RATING (0-100) = 51 34

35. A populist message about “people who work for a living” being able to take their kids to a doctor scores very well. I believe that people who work for a living ought to be able to take their kids to a doctor, and people who are retired, ill, or temporarily out of work shouldn’t risk losing their life savings because of one illness. We’re not just talking about poor people. We’re talking about middle class Americans who are getting squeezed. Too many people have to think twice before switching jobs or starting a business because they’re worried they won’t be able to get insurance. We need comprehensive reform, not a band-aid. That means putting government to work for taxpayers again, not for special interests, by requiring insurance companies to put more money into patient care and less into efforts to deny it. It means preventing insurance companies from excluding patients because of “pre-existing conditions” and overriding doctors’ decisions about what their patients need. It means giving us choices among plans so we can decide what’s best for our own families, including the choice to keep our current doctor. It means limiting the amount anyone has to spend out of pocket, so no one loses their life’s savings because of a sick child or a hospital bill. And it means giving small businesses tax breaks to offset the costs of covering their employees, and requiring big businesses to offer coverage to their employees instead of sticking middle class taxpayers with the tab. * MEAN DIAL RATING (0-100) = 71 POST-CANDIDATE RATING (0-100) =74 67% of respondents rate higher than the conservative message *Top Testing Message 35

36. A “family doctor for every family” is a powerful opening that provides an effective avenue into talking about the un and underinsured with the largely insured electorate. I believe in a family doctor for every family. It’s not right that hard-working Americans are struggling to afford health care and prescription drugs, while we’re strangling small businesses with the cost of their employees’ health care. The market hasn’t solved this problem, and it’s not going to as long as big insurance and drug companies are profiting at our expense. But we don’t need to replace managed care bureaucracy with government bureaucracy. We need common sense reform that gives people more choices, not less, including the choice to stay with the doctor they have now. We need to make insurance companies compete with each other to keep costs down and quality up, and give people the option to buy into the same plan members of Congress get, because if it’s good enough for Congress, it’s good enough for the people they represent. And we need government to set high standards to keep deductibles low, stop insurance companies from cherry-picking patients by excluding people with “pre-existing conditions,” and guarantee preventive care like cancer screening that cuts long-term costs and saves lives. MEAN DIAL RATING (0-100) = 69 POST-CANDIDATE RATING (0-100) =74 67% of respondents rate higher than the conservative message 36

37. “Cost” Attack ATTACK We need to make health care more affordable, but trying to add nearly 50 million uninsured people to the system all at once with a big new government program is a recipe for disaster. It will cost billions in taxes, and hospitals and doctors will be even more overloaded than they are now. It punishes families and businesses who are already working hard to pay for health care by adding billions in new taxes and raising their costs. (MEAN = 55; POST CANDIDATE = 54) * 37

38. “Cost” Top Response TOP RESPONSE Middle class Americans are having a harder time making ends meet, and we need to cut both their taxes and their health care costs. If that means cutting the profits of insurance companies and requiring big businesses to contribute to the health insurance of their employees, my sympathy is with people who work for a living. Health care premiums have nearly doubled for the average family in the last seven years at the same time as insurance company profits have more than doubled, and if we don’t do something now, our costs will double again. And that’s not even counting the billions we already pay in federal and state taxes for expensive emergency room visits for people with no insurance who end up driving up costs because they don’t get preventive care. It’s time to put some money back in the pockets of working Americans and give them peace of mind about the health of their families. Maybe we should build a few less hospitals in Iraq and start investing again in doctors, nurses, and hospitals right here in the United States. (MEAN =71; POST-CANDIDATE = 75) 38

39. “Government/Bureaucracy” Attack ATTACK This isn’t health care “reform,” it’s socialized medicine—another big government bureaucracy like the IRS or the DMV, operating inefficiently and costing taxpayers hundreds of billions of dollars. It’s just one more step toward government intrusion in yet another place where it doesn’t belong. We’ll all end up paying higher taxes and getting substandard health care, with long waits to get treatment, and lots of red tape and paperwork. Keeping health insurance in the private sector is the only way to guarantee that we have the best health care in the world. (MEAN = 51; POST-CANDIDATE = 52) * 39

40. “Government/Bureaucracy” Top Response TOP RESPONSE If you want to see what bureaucracy and red tape look like, try reaching a person on the phone the next time you call your own insurance company, and try getting them to explain why they won’t pay $800 of some medical treatment your doctor ordered. We need leaders willing to take on the insurance companies, by setting clear, high standards for what’s covered, preventing them from requiring patients to jump through hoops just to get insured, and saving billions by cutting administrative costs and moving to electronic medical records. We need leaders who will hold insurance companies accountable, guaranteeing us all more choices, better care, and no more of those 45-minute phone-calls to the insurance company. And if we stopped wasting doctors’ time with paperwork so they had more time for patients, and stopped forcing people who used to have insurance into emergency rooms for basic care, we wouldn’t have to worry about overloading our system. (MEAN = 68; POST-CANDIDATE = 74) 40

41. Strategic Recommendations The strongest messages are built around the experience of middle class voters and their increasing concerns about being able to get quality, affordable care for themselves and their families. Since the vast majority of voters are insured, it is better to start with arguments about cost and then move to access rather than the other way around. For example: “Today it is getting harder and harder for Americans who work hard and play by the rules to afford health insurance, and over 47 million can’t afford insurance at all.” The value of choice is central to a progressive message. Don’t be afraid to animate anger to galvanize support for progressive reform. The conservative alternative is highly vulnerable to the argument that we have already seen what the “free market” can do, and it has failed, leaving tens of millions without care and an equal number with insurance that works fine until they need to use it. In addition, the conservative alternative does nothing to rein in costs or insurance companies whose profits have skyrocketed as the average American pays more for less. 41

42. Strategic Recommendations It is crucial to answer attacks head on. Populist language about reining in insurance and drug companies resonates with voters, but the concept of big, inefficient government remains well branded by the right and will take time to rebrand. It is crucial to speak to Americans in clear language that addresses their interests, their concerns for their families, and their values, and to know what is happening in people’s minds when we use language such as “universal health care,” “health care as a right,” or “S-CHIP” If we want people to hear us, we have to speak their language. 42

43. Health Care and the 2008 American Presidential and Congressional Elections Presented to the Second National Congress on the Un and Underinsured by Celinda Lake September 24, 2008 1726 M St., NW Suite 500 Washington, DC 20036 Phone: 202-776-9066 Fax: 202-776-9074 www.lakeresearch.com

44. APPENDIX

45. All messages generated solid ratings, with the strongest response to the “Guarantee” message.

46. Similar messages test well with swing voters1, but they are even more supportive of government involvement.

47. Attacks on Candidate B’s plan are consistently effective, though no message is a silver bullet.