Monday, May 11, 2009

We're Screwing Up the Health Care Debate

Daily Kos: by eugene

What is Success?

Successful health care reform is not "something that gets Obama's signature." Instead success is something that solves the core problems. So that means we must define what the core problems are, and therefore what our goals should be, before we can assess any possible solution.

Problems and Goals

  1. Problem: Health care is unaffordable. Goal: Guarantee no American ever has to worry about whether they can afford treatment again. The #1 problem, and therefore #1 goal of reform, is that too many Americans cannot afford to get the health care they need. All other problems stem from this one. This has a massive, even catastrophic ripple effect throughout society and the economy, from epidemic disease, untreated illnesses, and the economic consequences of all of this. Any health care reform we produce should make health care affordable to everyone, not by an insurer's promise, but through a clear regulatory and financial mechanism. Many of us believe the only way to achieve this is through single-payer. I am open to other options, but they must demonstrate the guarantee of affordability that we all know single-payer ensures.
  1. Problem: Health care is unavailable. Goal: Guarantee every American has access to the appropriate level of health care they need within or a reasonable distance from their community. This is often a consequence of #1, but also stems from other sources. Many places in America do not have enough doctors, even if you are ensured. I live in such a place - Monterey, California. We are a wealthy community but few doctors accept new patients, and many common insurance plans are not accepted by a surprisingly high number of doctors - ob/gyn in particular. Some "reformers" dismiss this issue or view it as unimportant, but it affects a hell of a lot more people than is generally realized, especially if you're not in the upper middle class or higher. As with #1, single payer guarantees availability. Other options might too, but they must demonstrate this can be done as a consequence of the system they propose, and not out of a promise. In particular, any reform must guarantee that anyone with insurance can get care whenever they need it - care on demand. This requires, among other things, that any "public option" be accepted by any health care provider.
  1. Problem: Costs are rising. Goal: Ensure that costs are handled in a way that does not undermine goals 1 and 2. This is not necessarily a bad thing, but it is something that must be dealt with. Single-payer offers the benefit of ensuring low overhead costs, and because of its mechanisms is likely to produce more preventive care, saving money in the long run. Again, it's possible this could be solved through other means, but that must be demonstrated and not promised. The recent news of health insurers offering $2 trillion in cost savings should not be taken seriously since it is a mere promise, and not backed up by either laws or procedures.
  1. Update [2009-5-11 11:31:46 by eugene]: As explained by DrFerbie in a comment below: Problem - The Healthcare system impacts the entire economic viability of the United States.  Goal - Create a healthcare system which contains costs, fosters the ability of employees to change jobs without the the threat of loss of insurance, manages expenses for companies and levels the competitive playing field with foreign competitors. (Note: I'd intended to build this out of point #1, but DrFerbie is right that it should be specifically included here.)

I believe these to be the three primary problems that any health care reform must solve. Many of us single-payer advocates have constructed a rich language to advance these causes - such as the argument that health care is a human right. I fully agree with this, and believe that health care should be provided on demand without out-of-pocket costs of any kind. But I acknowledge those are frames to a solution to the three four problems above. I'm open to other frames and other solutions - but they must address the above problems and meet the above goals. If they fail to do so, they must be rejected out of hand.

The Politics of Reform

What is happening to us right now is that we are being told that the right solutions to the problems have to take a back seat to "political realities." In other words, we cannot merely craft something that is sensible and workable and implement it. Instead we must be willing to accept something potentially flawed and unworkable if it is what can pass the Congress and get Obama's signature - or so we're told.

This is an unusually bad approach to both health care reform and to maintaining our political majorities. The reason is it assumes that the short-term is all that matters, and that building prosperity, solving health care reform for decades to come, and building a lasting progressive political majority do not matter at all.

Too many people are stuck fighting the last war. Their frame of reference is 1994. "If only we could have gotten something passed," they say, "we'd have been OK." This is a debatable interpretation of history, but it also defies both common sense as well as the present political situation.

The truth of the matter is this: Obama's current popularity is likely to ensure victories in 2010 and probably 2012 (though we must not take these victories for granted - we must produce them, they don't fall in our laps). But beyond that, it's quite unclear what will occur. Despite the rhetoric of a dying Republican Party, they are wealthy and clever. After two more defeats they will start to figure things out, just as Democrats did after 2004.

That's why the medium-term matters so much. If we lose Congress in 2014 and the White House in 2016 without having written into stone a health care reform the way we did Social Security in 1935 and Medicare in 1965, we will have failed. Republicans will return and dismantle the short-term benefits, such as they were.

Further, a health care reform that does not fix the problems or meet the goals outlined above is likely to produce political failure through its own failure. There is no surer way to destroy the gains of the last two election cycles than to fail to actually solve the problems facing this country or to not fulfill our promises and our hopes.

By the mid-Teens we need to be watching a health care system settle in and produce real benefits. We probably have some space, actually, to see some short-term bumps, since it would take a massive shift in fortunes for us to be in jeopardy of losing in 2010 or 2012. After that, though, we need to be able to point to measurable results, especially towards the end of Obama's second term.

This isn't an abstract concern. I take this from the experience of the Labour Party in Britain, which is about to experience a severe defeat, perhaps along the lines of 1979, at the next general election. Under Tony Blair and Gordon Brown Labour proved able to provide short-term economic growth. But they failed to produce a newer, more stable system and method of producing that growth - they ignored the medium-term and the long-term. When the economic "boom" of the Labour years started unraveling in 2007, the party's political fortunes took a severe hit, and Brown seems incapable of recovering ground lost to the Conservatives.

This is particularly stunning given how pathetic the Tories looked in the years after Labour's 1997 victory. Anyone who followed British politics between about 1997 and 2005 knew that the Conservative Party had become a joke - disdained by the public and under the control of inward-focused ideologues who cared more about enforcing adherence to an unpopular right-wing party line than in appealing to the public. William Hague and Iain Duncan Smith are just the British versions of Eric Cantor and Michael Steele.

And yet the Conservative Party now enjoys a massive poll lead over Labour - between 18 and 22 percentage points according to the most recent data.

Labour totally failed to provide for the medium-term. And that in turn is because they failed to provide any truly new basis for the British economy, failed to provide any truly lasting and self-sustaining reforms.

There is every reason to believe the same can happen here in the United States to the Democratic Party - particularly on health care, but on broader economic policy issues as well. In fact, health care IS the economy - the competitiveness of US businesses, the ability and willingness of consumers to spend money - is dependent on Americans no longer worrying about the cost of or ability to access health care.

True Political Reality

I'm sure some will still argue that merely stating the above truths won't flip Specter's or Nelson's or Baucus's vote.

And yet we must remember that there are other ways to flip their votes without crafting a reform package that will fail to meet our long-term health care and political objectives.

The normal rules of politics have not been suspended. Those Senators are not immune to pressure. They are not immune to a public movement, any more than FDR was immune to a public movement on Social Security. When he was elected in 1932 he said he would not implement government-operated old-age pensions. So Dr. Francis Townsend and many others started a movement to demand government do precisely that. By 1935 FDR had embraced the reform as his own, labeled it "Social Security" and ensured it not only passed, but would last for a very long time. Its success helped solidify a decades-long Democratic political majority.

Baucus, Nelson, Specter, and the others all have their pressure points, their weaknesses. Good politics involves identifying and exploiting those weaknesses.

True political reality isn't throwing up your hands at the Senate's 60-vote cloture rule (which itself can be changed). True political reality is understanding that certain elemental political facts are never in suspension, especially in a liberal democracy. Senators can be moved by public pressure, properly conceived and applied.

What You Can Take Away From This Diary

  1. The health care reform debate MUST be oriented around problems and their solutions - NOT around whether we can get a label ("public option") signed by Obama. If labels were all that matters, Bush's Healthy Forests plan would have been a brilliant plan.
  1. "Political realities" dictate the approach laid out directly above. If we do not follow that approach, we run an unacceptable risk of failing to solve the basic health care problem and blowing up the Democratic majorities we worked hard to win.
  1. A successful health care plan does not rely on promises to achieve its goals. Nor, in fact, does it rely on Democratic control of government (although it can produce it!).
  1. You may not agree with my listing of the problems and their solutions - and I encourage you to propose alternatives or modifications in the comments. But you need to start debating health care from that kind of basis, especially on this blog.

Health care reform is, I believe, the most important battle we will fight in Obama's first term. We have NO room for error. We MUST get it right.


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