By John Ballard
I'm linking this splendid article in The Nation not because I think many of our readers will read it but on the outside chance that somewhere out in the Internets some policy wonk needs another push to do more homework.
As a layman I have done just enough homework about health care to be dangerous, having followed the issue since before Hillary Clinton's efforts crashed and burned way back when. Along the way I have come across two names that are not household words but whose analytical writing and insight are two of the anchors of the policy debate.
One, Alain Enthoven, whose views on healthcare will not make Progressives happy. He, nevertheless, an acknowleged expert, sometimes called the father of insurance exchanges. But this post is not about him. I only include the references by way of sharing what I have come across in my journey to learn as much as possible about a topic that some of the smartest people argue about. I learned long ago that when scholars argue it is best that laymen, particularly politicians, keep their mouths shut and pay attention.
The other, Paul Starr, literally wrote the book about health care in America, appropriately named The Social Transformation of American Medicine (1982)
Starr has now published a sequel to his first book and Bernard Avishai, in A Spoonful of Sugar: On the affordable Care Act, is my way of learning what Paul Starr says without reading the book. Some would say that's cheating, but I already admitted to being a layman, calling my knowledge just enough to be dangerous, so for that I don't apologize. (If I were twenty year younger I would have a different attitude, but one of the vices of getting old, I have discovered as a caregiver for other old people, is not having to get too disturbed about what might happen two or three decades out.)
Here are a few snips...
Starr learned his lessons the hard way. He closely advised the Clintons on health strategy in the early 1990s (he still knows and has debriefed key Congressional staffers). The centerpiece of Remedy and Reaction is a long section, full of illuminating asides, on the frustration of the Clintons’ plans. Starr shows that, even as Bill Clinton submitted his bill to Congress, some 70 percent of voters subscribed to the principles embodied in the legislation he proposed. Yet the bill didn’t come close to being enacted. True, Clinton was losing altitude by then, but to suppose his failure was largely a matter of leadership—you know, that he didn’t use his bully pulpit forcefully enough, the sort of gripe heard relentlessly on MSNBC, the Huffington Post and Daily Kos about Obama and the “public option”—is to suppose that willows really weep.
Obama’s actions were cannier than Clinton’s, but they also amounted to a profile in courage. When Obama came into office, Starr explains, only 11 percent of Americans thought reform would have a “negative personal impact,” but by August 2009 this segment of the population was trending to 31 percent. Both Rahm Emanuel and Joe Biden were urging retreat. Starr writes, “Obama not only resolved to go ahead; in September and again in the new year, the president took charge of the effort to steady the health-care initiative and prevent it from careening off the tracks.” Nor was the final bill anything less than what might reasonably have been expected, filling as it did the negative space left by four generations of government programs and serial compromises. Starting with clean sheets of paper was never realistic when one-sixth of the economy was at stake.
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Each era had its champions, but Starr is particularly good at explaining the permanent counterforces that were salient on Washington’s political landscape by the time Obama inherited it. First is the inherently conservative nature of Congress.----
The second, and even more important, counterforce is accumulated material incentives. The tax reforms and IRS clarifications of the Eisenhower years—during which modern medicine and research hospitals rose in parallel with employment in large corporations—enabled businesses to deduct nearly all sums spent on employee group health insurance. Accordingly, businesses began to offer employees healthcare as a matter of routine in order to lure and retain talent in a hot employment market.-----
A third counterforce is regional lobbying. Starr reminds us at the start of his book that “every dollar spent on health care is also a dollar that someone earns from health care.” ----
Fourth, and finally, are the politics of the not-quite-ideological sort: the egos of senators who expect to mark up bills (and slide in parochial advantages), Congresspeople who would not feel safe endorsing something that has not been demonstrated to work (which, for Obamacare, meant pointing to satisfaction rates in Massachusetts) and so forth. In this context, Starr emphasizes that Republicans under Obama became an all-but-monolithic party with a singular ambition: to regain the presidency. Starr implies, but does not say, that mainstream journalists have inadvertently colluded with Republicans by scoring politicians more on their electoral guile than on their public policies. Republicans have thus plausibly assumed that Obama would be blamed for any economic difficulties, even if they created or deliberately worsened them. Republicans were eager to subvert the administration’s healthcare plan, never mind that Bob Dole (and, more recently, Mitt Romney) had pretty much designed it.
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For the first African-American president, surely the cruelest charge from the left was that in pursuing healthcare the way he did, he had wasted an “FDR moment.” Unlike Obama, presumably, Roosevelt had summoned the courage to take a radical case to the people against Congressional resistance—to be transformational, not merely transactional. Starr’s review of the New Deal refutes that myth, reminding us that Roosevelt avoided a healthcare fight almost from the start, not only because he didn’t want to take on the doctors but also because he didn’t want to ruffle the feathers of Southern Democrats. Indeed, FDR’s entire reform strategy depended on holding together a coalition that required him to ignore, if not pander to, the grotesque racism of the South. He got Social Security (and other bills) passed by appealing to immediate and universal pocketbook interests, and with a larger Senate majority, which reserved the filibuster mainly for civil rights; to appease Southern Democrats, he agreed to exclude domestic servants and farm laborers (e.g., sharecroppers) from the initial Social Security program.
Toward the end he ties up his points with a reasonable (indeed, obvious) reference to how tax policy will be essential to what happens next, concluding with "Americans will soon decide whether or not to leave in place a president who, among other things, will leave the act alone. It would be a shame, Starr warns, if the president who husbanded this once-in-a-lifetime legislation to victory is beaten by a Republican claiming the need for “leadership” in the White House—a double shame if misinformed Democrats, nursing their “disappointment,” continue to help make that need seem plausible."
The more I read about health care reform the less enthusiastic I become, not because the future is bleak but because of indifference and outright hostility on the part of both professionals and citizens. Articles such as this should not need to be written.
