Dan Gorenstein: After months of campaigning and debate, we’ve finally had our first election night!

Newscast: There’s still no winner of the Iowa Democratic caucuses.

Newscast: This is the third straight cycle we’ve seen challenges in Iowa.

DG: And it was a bit of a train wreck.

News clip: Chaos continues to hang over last night’s first-in-the-nation presidential contest.

DG: We’re recording this episode at 6 p.m. eastern on the day after Iowa, and we still don’t have a winner. 

By the time you hear this, a winner may have been called.

Either way, over the next month, Democratic voters in nearly 20 states and territories will vote or caucus for the person they want to take on President Donald Trump this fall.

And according to polls, health care is their top issue.

Today, we take a closer look at those polls and hear from some voters about how health care is influencing their vote in 2020.

I’m Dan Gorenstein, and this is Tradeoffs.

Ashley Kirzinger: Our goal isn’t really to predict anything in an election, especially at this stage. What these polls are especially good at is explaining what people are experiencing on a day-to-day basis. 

DG: Ashley Kirzinger is a pollster with the Kaiser Family Foundation, which has conducted surveys on health care stretching back over the last three decades.

Ashley has managed dozens of polling projects over the past 5 years, with interviews from more than 70,000 Americans. She has already run over 15 polls in the lead up to this year’s race.

AK:  What we are trying to do is to really provide insight into what is driving voters opinions and decisions. And when we ask Americans what their top worry is and we give them a list of things that families worry about, you know, being able to afford a place for them to live, being able to afford their groceries, being able to afford their health care ranks at the top of that list. And that’s not something we see in other countries.

DG: Two-thirds of Americans say they’re very or somewhat worried about being able to afford an unexpected medical bill, and more than half feel that way about their annual deductible. 

Ashley says health care has been among voters’ top issues for the past two decades. 

AK: Since 2000, really, health care has ranked among the top three issues for voters. However, it frequently fell behind issues such as the economy.

Barack Obama campaign ad: Financial system in turmoil and John McCain erratic in the crisis…

AK: and terrorism.

George W. Bush ad: John Kerry has repeatedly opposed weapons vital to winning the war on terror.

AK: It really wasn’t until 2018 that health care kind of took over this top spot on the list of issues that we ask about…

News clip:A big concern for some under the House GOP health care plan is that people with preexisting conditions could have to pay more for coverage or worse be denied coverage…

AK: The ACA’s protections for people with preexisting conditions were under threat.

News clip: I lay awake at night wondering what’s going to happen? How is this going to affect me?

DG: So Ashley, there’s no doubt health care was huge in  2018. What about 2020? What’s your polling tell you about this year? 

AK: When we asked people what is the one thing that’s going to motivate them to vote in 2020, you can guess what they say. About one in five voters say that defeating President Trump is the one thing that’s going to motivate them in 2020, compared to about 8% who say health care is the one thing that’s going to motivate them. But as candidates are on the campaign trail, they’re not going to be talking just about President Trump. They’re going to be talking about issues. And voters are telling us right now that health care is their top issue in the election. 

DG: As we record this, we still don’t know who won in Iowa, but Ashley, it’s clear health care was top of mind for people. 

AK: That’s right. We have two polls, we have an entrance poll that was done by Edison research and we have the AP VoteCast which was done the week leading up to the Iowa caucus. In both of these, health care was the top issue for Democratic voters in Iowa. Four in 10 voters said that health care was their most important issue. This was followed by about one-fourth of Democratic voters who said climate change was their most important issue. This is consistent with what we have found at KFF in our polling leading up to Iowa. We have found that Democratic voters say that health care is top of the mind, they want to hear the candidates talk more about health care, and so this is something we expect to see a consistently throughout the Democratic primary.

DG: So, Ashley, in addition to the big picture you’re giving us, we also wanted to hear from a few individual voters who will be voting in the coming weeks and months.

And we asked our producer Ryan Levi to talk to some people and dig into the nitty gritty with them. Ryan, thanks for joining us. 

Ryan Levi: Happy to be here. 

DG: When you think about some of the folks that you’ve talked about, who’s a person that you’ve spoken to that you think is really sort of helps us better understand how health policy is influencing their choice as a voter?

RL: So there’s one guy, Clayton McCook.

Clayton McCook: I’m originally from Texas and went to high school in northeastern New Mexico, and I’ve called Oklahoma home for nearly 10 years now.

RL: He’s a 42-year-old equine veterinarian.

DG: He’s an equine veterinarian?

RL: Yes. So if you if you have a horse that that’s feeling a little under the weather, take him to Clayton. He’ll be able to sort you right out. 

DG: Excellent. Thank you. 

RL: He lives just north of Oklahoma City, and for him, prescription drug prices are really kind of motivating him.

CM: My oldest daughter, Lily, was diagnosed with Type 1 diabetes in 2012 when she was 3. And since that time, we’ve seen the price of her insulin literally double. And so that’s a huge concern in our family.

RL: So when he’s looking at the candidates, he’s really zeroing in on their prescription drug plans.

CM: I think they need to be talking about price controls at the federal level. You know, I’ve gone through a lot of their plans and just about all of them are, if they’ve addressed it, they are in favor of direct negotiation between the pharmaceutical manufacturers and Medicare. But I’d like to see them go a step further. 

RL: He even mentioned, you know, just setting a flat cap on what drugmakers are able to charge for their products. But at the same time, he is really you know, he considers himself a practical person, a pragmatist, a realist. 

CM: I appreciate some of the really bold and sweeping policies that are being put forth by some of the candidates. However, having been a close observer of politics for most of my life, I have some concerns that those may most likely are not going anywhere.

RL: So while he really would love to see some bold moves on prescription drugs to lower some of these costs. He really finds himself leaning…

CM: More towards the candidates like Vice President Biden, Sen. Amy Klobuchar. Their approach seems to be more in line with how I see things going.

DG: So, Ashley, clearly Clayton is balancing this idea of electability with his health care priorities, namely high prescription drug prices. Based on your polls, how big of an issue are prescription drug prices?

AK: When we ask people, what is it about health care that’s important to them, it really is about their health care costs. It’s those out-of-pocket costs, whether it’s their deductibles or their co-pays, including co-pays for prescription drugs.

DG: So this own personal health care cost issue, this has become much more of an issue than overall total health care spending by the federal government. 

AK: Exactly. It outranks any other health care issue, including implementing a national Medicare for All plan, even though that’s something that we’ve heard a lot about during the Democratic primaries. In terms of  prescription drug prices, it’s not people’s direct experiences with prescription drug costs that’s really driving this as an issue. But they’re hearing a lot about exorbitant prescription drug prices and they do not like pharma. And so they see these kind of high prescription drug prices affecting really disadvantaged populations like older adults or those who are really sick, including some family members or friends who they’re hearing stories from.

DG: Ashley, you say a lot of people are like Clayton, worrying about their personal health costs. The reality is lots of us get our insurance from our employers.

Did you talk to any business owners, Ryan? Do they share their employees concerns or what are they thinking?

RL: So one woman I talked to was Nancy Clark. 

Nancy Clark: I own a small marketing and branding firm in New Hampshire.

RL: And she’s been doing that for about 20 years or so.

NC: I have this deep rooted philosophy that health care is a right. And as a small business owner, it’s my responsibility to provide that.

RL: Over that time that she’s been doing that, she really looks to the time of the Affordable Care Act, when it was first enacted as really kind of a peak time for her as a small business owner when it comes to fulfilling that duty, fulfilling that obligation.

DG: And in our country, since the Trump administration has taken office, the ACA has withered a little bit, right? There’s been some fraying at the edges.

RL: For sure. 

DG: What has her experience been?

RL: Not great. She says at the beginning, the ACA made getting insurance more convenient, it gave her more choices of insurers and helped lower costs for her and her employees. And she says in the last few years, there are fewer insurers to choose from and more out of pocket spending for her employees. 

DG: So Ashley, when it comes to the polling that you’ve done, how important is the ACA as Democrats begin to sift through the Democratic primary field?

AK: What we see is that Democrats are really rallying behind the ACA in ways that perhaps we hadn’t seen during the first couple years of its implementation. About eight in ten Democratic voters have a favorable view and they tell us that maintaining protections for people with pre-existing condition is their top priority.

DG: So, Ryan, to just wrap up with Nancy for a quick second, where is she at when it comes down to actually picking candidates?

RL: It’s really all about the ACA for her.

NC: Normally I would vote for fresh ideas and new ideas, but I can’t reconcile the health care and how strongly I feel about it. So I have to take what I’m thinking is the safe vote to try to get the Affordable Care Act back on track. So for that reason, I think I’m really leaning towards Biden.

DG: We called Nancy back late on Tuesday afternoon to see if the Iowa results changed her mind, and she said the strong showing from Pete Buttigieg has pushed her to take second look at the young mayor before she votes next week. 

DG: We were talking about exit polls, Ashley. One that caught my eye showed 6 in 10 caucus-goers supporting Medicare for All. This is obviously a small snapshot of views on the issue. What is your latest polling telling you about what’s really been one of the hottest topics in health care?

AK: What we’re seeing is that a majority of the public favor both Medicare for All and a public option, with a slightly larger share of the public favoring a public option. However, when we asked voters, OK, so what does Medicare for all mean? They really don’t know. One of the great examples that we saw in our focus groups is that there was a woman there who was like very pro-Medicare for All. And she did a great Oprah impersonation that was like, “You get Medicare! You get Medicare! You get Medicare!” 

Oprah: You get a car! You get a car! You get a car!

AK: But once they hear that they have to pay more in taxes or maybe they don’t get to get Medicare, then they’re like, “Oh, wait, what’s Medicare for All?” In our most recent tracking poll, we’ve actually seen that there has been a slight uptick among the general public and a more significant uptick among Democrats. So 53 percent of Democrats now know that individuals would not pay premiums under a Medicare for All plan. Forty percent say that they now know that they would not be able to keep their current health insurance plan, which may not seem like a lot, but you have to understand, that’s an uptick from 24% just six months ago. 

DG: So, Ryan, let’s talk about one more voter. Is there any voter that you spent time with who really is a big sort of Medicare for All booster?

RL: Yes. So I talked to Khahlidra Hadhazy. She’s a 39-year-old real estate agent, lives in New Jersey, has a couple of kids. 

KH: Health care is the most prominent issue in our family. It’s something that we deal with on a daily basis.

RL: You know, she talks about, you know, being kept up at night. Her husband has Crohn’s disease, you know, it’s a pretty serious chronic condition. One of her daughters has a chronic eye condition. So she’s really concerned about what’s going to happen to them and how she’s going to care for them and be able to pay for their care.

KH: Having the security of like a single-payer option where your guaranteed health care and that’s one less thing that you have to think about allows you to focus on other things. And I really wish that we lived in a country that offered that.

RL: She thinks it’s really important that the country expands access and it gets to a place of universal coverage. And one of the things she talked about was making sure that everyone can go to a doctor that they feel comfortable with and not having costs be part of that.

KH: I know as a woman of color, I’ve been to doctors, that I’ve felt uncomfortable working with, that I don’t want to see because I don’t like the way that person spoke to me. I don’t think they took what I was saying seriously. And I shouldn’t have to be forced to go to a doctor that I’m not comfortable with, because that’s the only doctor who takes my insurance.

RL: And she thinks that in a Medicare for all system that piece of the problem goes away as well.

DG: And which candidates, as Khahlidra like sifts through her options, she’s all Bernie all the way?

RL: She’s a big Bernie person. She said she was Bernie back in 2016. She said she’s also, as one would guess, Elizabeth Warren as well.

KH: I feel like if you have the candidate that has the most sort of radical position on covering everyone, that when push comes to shove and they’re having to compromise, that their compromise won’t result in such a watered down policy, where someone who’s already in the middle, their compromise would to me not be strong enough.

DG: Ashley, I’ve been really curious, in general, how intense are people’s health policy opinions? Are there a lot of Medicare for All or bust folks out there?

AK: In our January tracking poll, we asked people, you know, do you favor Medicare for All? Do you favor a public option? And we found that very few, it’s 6 % of the public overall say that they favor a Medicare for All plan, and so that’s the only way that they see forward. Forty-eight percent favor both a public option and Medicare for All.

DG: We’ve spent a lot of time talking about Democrats, which makes sense. They’re having a primary. The Republicans aren’t really having much of a primary. What are your polls showing about Republicans? What matters to them most about health care? 

AK: It’s health care costs, still. Democrats, while health care costs are their top personal issue, they kind of see any kind of change to the health care system need to be balancing both health care costs and increasing access for all people to be able to get coverage, to be able to go see a doctor. Republicans are prioritizing health care costs, especially prescription drug costs. Republicans tend to skew a little bit older. They’re the population that’s more likely to take more prescription drugs. They’re seeing this to be a significant cost burden for them. And so this is something that they want President Trump and Congress and any president to really take action on.

DG: Are there other topics in health care we haven’t talked about yet that are also driving people? 

AK: Well… 

DG: We haven’t talked about abortion.

AK: No, we haven’t talked about abortion. But it’s not yet driving people, which is the interesting thing. So we know that the Supreme Court decided not to take on the Texas vs. U.S. case, which was the case that was challenging the constitutionality of the pre-existing condition protections, but they are going to be hearing arguments on the Louisiana case.

News clip: The Supreme Court has agreed to hear a controversial abortion case with enormous stakes for those who support a woman’s right to choose.

News clip:This will be the first abortion case heard by the Supreme Court since President Trump appointed Justices Neil Gorsuch and Brett Kavanaugh.

AK: That is a case that’s going to be in the news. We’re going to be hearing a lot about it. Our poll that we just released two weeks ago found that reproductive health care is not ranking as a top priority. It’s like 6% of Democrats saying it’s the top issue in this election and 7% of Republicans. So it’s not yet ranking to the top. But as the year progresses and we imagine that we will hear a lot about this Louisiana case, we could see that playing a larger role.

DG: When you look back four years from now, right, the next presidential cycle, what do you think’s going to stick for you, that you’re going to remember from this presidential cycle from what people have actually said to you? I guess that amounts to what have you learned, Ashley?

AK: I hope that I’m able to look back and say health care costs were at a breaking point and Congress was able to address this because it ranks so high among voters across the partisan groups. I hope that’s what I’m able to say. But there’s no crystal ball there. Hindsight’s 20/20. I’m not sure, but that’s my biggest takeaway so far in the 2020 election. I know that a lot of the Democratic conversation has been Medicare for All versus the public option. But what we’re seeing over and over in our polls, regardless of how we ask the question, it all comes down to health care costs. 

And I think what was so interesting about the stories of these voters that Ryan shared is that all of them, at the end of the day, it’s concerns about health care costs. 

DG: Obviously, 2020 is largely a referendum on President Trump.

But for many Democrats and some independents, the issue that stands out more than any other is health care. 

People are scared about whether they can afford to get sick. 

When it comes to comparing candidates, whether they’re offering sweeping changes or more incremental ones, voters are looking for the person they can trust to deliver real relief from rising costs. 

I’m Dan Gorenstein and this is Tradeoffs.