One could go on at literally exhaustive length about the ins and outs of the current “health care debate” in Washington, but I’ll try to avoid that. The media and the blogosphere have provided a constant play-by-play in terms of both substantive policy and, even more, political strategy. (Jonathan Chait at TNR has been particularly diligent. Meanwhile, much of the MSM seems content merely ringing premature death-knells for reform.) Me, I’ll just try to provide a few observations from a mile-high view.
Obviously, Obama’s pre-compromised approach to health insurance reform represents one of the larger political mistakes of his administration so far, as I’ve mentioned. He should have led with a pitch for single-payer, and should never have allowed Pelosi and Reid (or his own advisors) to take it off the table. Single-payer is the best way to guarantee access, expand the risk pool, increase bargaining power, maximize economies of scale, improve outcomes, and reduce costs. The health system with the highest customer satisfaction and lowest administrative costs in America is Medicare, which (shock!) happens to be a government-run single-payer system covering 100% of Americans age 65 and up. It’s been (ahem) known to work in other countries, too.
Letting the discussion be informed by evidence about what actually works apparently wasn’t in the cards, though. Instead we’ve had dueling committees on both sides of the Hill, with the most “progressive” position being a publicly managed insurance option competing with private insurers in a better-regulated “market.” Now, this might not have been a bad fallback position… the fact is, like it or not, there are serious institutional obstacles to a reform as dramatic as single-payer—most notably a very well-heeled private insurance industry, as well as quite a few citizens who, however myopically, say they’re satisfied with their private insurance and wouldn’t want to change it. And pragmatically, while it may be the most effective solution, it’s not the only one. Single-payer could have been negotiated back to a mere “public option,” the Democratic majority could pass something decent even as the GOP could claim it beat back “socialized medicine,” and everyone would be happy. But starting with the public option as your bargaining position virtually guaranteed that it would be watered down.
That the GOP is being obstructionist on this is no surprise: in its current politically diminished and ideologically marginalized status, the party reflexively opposes anything proposed by Obama or the Democrats. Even the usual Republican stance of protecting business over citizens can’t really explain its opposition in this case; most businesses would benefit greatly from health care reform, through reduced costs and increased competitiveness in the global economy. Only one particular business sector (basically the health insurance and pharmaceutical industries) would get its ox gored here. Nevertheless, today’s GOP is what it is.
So where’s the hypocrisy come in? Well, the real problem is conservative Democrats… the roughly 50-55 “Blue Dogs” in the House, and a smaller but still critical number in the Senate. Many of them have echoed the same kind of incoherent rhetoric coming from the right. From Republicans, it’s understandable as a tactic… but these Dems repeat it as if they actually believe it, all cognitive dissonance aside. The most commonplace yet flabbergasting argument—and you can read and hear both sides of this coming from the very same people!—is that:
(A) you just can’t trust a government-run insurance system to be efficient or effective, and
(B) a government-run system would have such an unfair competitive advantage over private insurers that it would drive them out of business.
I hope I don’t have to spell out the logical contradiction there.
Some opponents try to square this circle by protesting that whether or not it’s actually effective, a government plan could somehow win out through lower costs because it “doesn’t have to make a profit.” I heard right-wing blowhard Dennis Prager make this very argument the other day (on NPR, of all places). This is a truly staggering bit of rhetorical spin, because the thing is, taking profit out isn’t a bug, it’s a feature.
Ask anyone you want what they’re looking for in a health care system. Whatever else they may describe, I guarantee you, no one who’s not cashing checks from the health insurance industry gives a flying fuck whether that industry gets to make a profit. I certainly don’t. Drive the insurers out of business tomorrow, for all I care. But if they’re going to continue to exist, the least we can ask is that they compete on a level playing field, without the government setting policy to prop them up and guarantee that profit.
It’s as simple as this: the only way to expand health care access anywhere remotely close to “everyone” is with some sort of guaranteed or mandated coverage at some level—national, employer, individual, you name it. And the only way to reduce costs while doing this is to have (at the very least) a robust public option among the coverage choices… because otherwise you’re creating a completely captive market and leaving it at the mercy of the private insurers. Anyone doubt that every bit of potential cost savings in that scenario will be paid out in the form of executive bonuses?
As Paul Krugman has recently underscored for us, health care is the kind of “product” where market competition alone quite simply doesn’t work, even when the customers aren’t completely captive. Economists understand this well, and there are several reasons for it, key among them the fact that the demand for health care simply isn’t under consumer control like it is for more fungible or optional commodities: you never known in advance how much you’re going to need, or why, or when, you don’t get any choice in the matter, and it’s next to impossible to comparison-shop. It’s a problem even before you introduce devious practices like rescission (about which former Cigna exec Wendell Potter has testified so eloquently).
Still, lots of folks in the Beltway seem infatuated with preserving a “market” approach.
Much of the current political play-by-play is irrelevant: whatever any single Congressional or Senate committee is doing, whatever “deals” it’s cutting, doesn’t necessarily reflect the version of the bill that’ll be voted on in the full chamber, especially after amendments… much less the final version that’ll emerge from the conference committee. Still, the current dynamics give us some insight into how folks on the Hill are thinking.
There’s been much noise about the effect on the national debt… this, from lawmakers who never raised a peep about throwing money down a hole for overseas military adventures. In particular, it’s apparently been a stumbling block for Max Baucus’s Senate Finance Committee, which is trying so hard to be “bipartisan” that it has yet to report out a bill. This is shortsighted in multiple ways. For one thing, the CBO cost estimates that have precipitated so much alarm relate only to the costs to the federal government. That’s the CBO’s job, that’s what it covers. They neglect to address savings to the health system as a whole. And really, who cares if we’re taking a little extra money out of one pocket for Uncle Sam to channel along, if we’re putting even more money back in the other pocket? Thus Baucus’s proposed “compromise” that would save the federal budget $100 billion over 10 years (a pittance) at the cost of reducing coverage from 98% to only 95% of the population, and making it less affordable to the rest, is idiotic: penny wise and pound foolish.
For another thing, as Obama took pains to point out in his last press conference, it’s delusional to think that keeping the status quo, or anything close to it, will be cost-neutral: premiums are expected to double over the next decade (just as they did over the last one), forcing more and more people out of their coverage and possibly into bankruptcy, creating new (and avoidable) costs to public health and the economy, both direct and indirect, that will have to be borne by (who else?) the government. It’s akin to polluters who claim the economy is better if they’re not required to behave sustainably: all they really do is externalizing their costs, pushing them off to be borne in less obvious ways by those who aren’t actually responsible for them.
All told, there’s been too much compromising already, a predictable result of the strategy described above. Even in the best versions of the bill, the main House version and the Senate HELP committee’s version, the public option (while preserved) has been made needlessly complicated, and access to it has been artificially constrained. Meanwhile the White House has firmly backed an unnecessary deal with PhRMA, led by GOP stalwart and corporate flack Billy Tauzin—drug industry support in exchange for accepting only token cost reductions. PhRMA has also been remarkably influential in Baucus’s Finance Committee.
Of course, even that’s not enough for the obstructionists, in defiance of all reason. They want to block a public option entirely, and want to go beyond even that to keep costs high by (among other things) blocking the government’s ability to negotiate better rates… just as was done with Bush’s budget-busting Medicare prescription drug benefit. Many of them clearly want to make things worse. Either they’re willing to sell out the public for the sake of their own donors and narrow base (or just for a chance to defeat and humiliate Obama), or they’re just plain batshit crazy.
Right now, they’re busy spreading misinformation. The U.S. Chamber of Commerce (again, clearly neglecting the actual interests of most American businesses) has launched a multi-million-dollar ad campaign to discredit a public option. And the lunatic-fringe Teabaggers and other right-wing astroturf operations are working aggressively to disrupt Representatives’ public meetings during the August recess.
I was talking to a Democratic political strategist at a conference last weekend, and he put forward a sobering account of how his Congressional clients are affected by confused public attitudes on this issue. His clients are predominantly Dems from the South, and apparently many of them have seen polls indicating that majorities of their constituents—Democratic constituents—are falling for the reactionary line here, afraid of changes to their coverage and/or the possible effect on the federal budget. To the extent that that’s true, it’s understandable why progress has slowed down on the Hill.
(Of course, I’m sure it’s strictly a coincidence that the Blue Dogs happen to get 25% more campaign money from the health insurance industry than typical Dems…)
Here’s why I’m not entirely pessimistic about the final outcome, despite all the obstacles. What the Blue Dogs need to recognize, and most of them probably do, no matter how craven and self-serving their political calculus, is that it’s better for their political futures if the Democratic party succeeds in passing a health care bill this year, and if that bill actually does at least some of what’s promised. For a few of them, the true ideal may be for that bill to pass without them having to vote for it, so they can enjoy the collective credit as Dems while still telling center-right constituents back home that they opposed it on some pretext or another. But if the whole enterprise goes down in flames, the currently ascendant Democratic brand—and thus their own careers—are highly likely to go down with it. We all remember what happened in the 1994 elections, after the debacle of ’93 when Clinton’s health care reform was defeated.
Moreover, those cherry-picking polls mentioned above are simply not representative of public opinion as a whole, which still strongly favors serious health care reform—including universal coverage, tax increases on the wealthy, and a public option, and supports higher government expenditures to make it happen. Remember, folks, we need to get beyond the myth that this is a “center-right country.” And although delay thus far may have served the interests of opponents, the August Congressional recess now upon us presents a chance to drive real public opinion home to wavering lawmakers.
At the grass-roots level, organizations like HCAN (Health Care for America Now) are organizing rallies around the country (they had a very successful one here in Chicago on Tuesday) and directing supporters to those very Town Hall meetings the reactionaries are trying to undermine. Some events within range of me are already fully booked. People care about this issue.
Pushback is appearing even in the mainstream media: the other night MSNBC’s Keith Olbermann called out the Blue Dogs with a powerful commentary about health care, reminding them and his viewers that they were elected to provide change and leadership, not protect their own careers; to serve the public interest, not line their pockets. Single-payer is making it back into the discussion in the establishment-bound pages of the New York Times, of all places, and has even been scheduled for a debate and vote on the House floor (which, however symbolic, at least broadens the scope of the debate).
One key thing to remember—and repeat to our Senators and Representatives—is that an even worse outcome than no bill would be a bad bill, one that masquerades as reform without really controlling costs or offering a public option. Many members of the Congressional Progressive Caucus have already taken a stand against a watered-down bill, and a coalition of activists led by blogger Jane Hamsher of Firedoglake.com is urging members to take a formal pledge to reject any bill without a serious public option, and carefully tracking results… and providing a calendar you can use to find Town Halls in your area. All it will take is 40 House members drawing a line in the sand to make sure that any bill that passes is a bill worth passing.
(Reactions to this have been mixed. At least one “progressive” member has a staffer who apparently thinks the Congressional left is doing more than enough, that its key priority is to back the president in order to preserve its ability to achieve “meaningful progressive legislation.” Of course, that begs the question of what they’re keeping the powder dry for. If they can’t hit the target on health care reform (or the already fumbled cap-and-trade energy/climate bill), what other “meaningful progressive legislation” is coming up that could possibly be more important?)
Obviously, President Obama backstopping the progressive members on this with a veto threat would be tremendously helpful. His administration’s approach to the issue has been too tepid by far… no doubt influenced to some degree by the advice of Rahm Emanuel’s brother (the doctor, not the Hollywood agent)… but there’s at least some indication that he’s willing to draw a line in the sand on a public option.
Obama, Congress, and all advocates of health care reform need to realize: whatever kind of bill passes, the GOP is going to excoriate it as “socialism,” while the Blue Dogs will sit on the fence trying to avoid blame but share credit. These outcomes are as predictable as the sun rising tomorrow. They need to look back at how LBJ got Medicare passed (and for that matter the Civil Rights Act!) back in 1965. Johnson could be a sweetheart or a sonuvabitch, but either way he knew how to twist arms and get things done—the same qualities for which Rahm Emanuel was supposedly made Chief of Staff. And the Democrats have a triumvirate in Washington right now, for heaven’s sake—they have no excuse for letting something this important slip away. The White House and the Dem leadership need to get behind a serious bill that will actually help solve people’s problems, enforce some party discipline, and force it down the fucking throats of the opposition. Do that, and posterity will thank them for it, no matter what the 28-percenters say today.
We should have done this 30 years ago, or 60, like every other developed country. If we don’t do it now, the problem will only be that much worse and more painful to solve another decade down the line. The American political system has a tendency to let problems fester until they’re huge and unavoidable (just look at the foot-dragging reaction to climate change), but we have before us an opportunity to be better than that. Let’s seize it. I’ve written before about holding legislators’ feet to the fire. The time to do that is now: this month. This is when it matters.Tags: Blue Dogs, Congress, Democrats, health care, House of Representatives, insurance, Medicare, Obama, Paul Krugman, Rahm Emanuel, Republicans, Senate