Tuesday, August 11, 2009

The Big Picture: Evaluating Obama's Progress on Health Care

I'm finally back with my monthly grading of Obama's achievement of the eight big goals of his presidency. He has been in office for nearly 7 months at this point, and we're definitely past the initial phase, which was characterized by excitement, an air of invincibility, and the haplessness and cluelessness of Obama's opponents. The big underlying problems with our political system and our democracy - which had made me highly skeptical of the possiblity of incremental change that system before I was swept up in the promise of Obama - have definitely re-emerged. And these problems are ugly. We'll focus on health care today, as it is Obama's major issue. Tomorrow we'll do the other 7.

In this health care debate, we are witnessing the enormous power of corporations to dominate our society's decision-making through essentially bribing and extorting politicians and using their humongous war chests to flood the airwaves with their message. And this isn't just Republicans. The medical-industrial complex - the insurance industry, the hospital industry, Big Pharma - are currently donating millions of dollars to the key Democrats - the Blue Dogs who are the swing voters, the Democratic campaign committees. A classic example is that the extremely costly, profit-driven, incentives-for-quantity-not-quality hospital profiled by Atul Gawande in the New Yorker, which Obama has said is the embodiment of the problems in our current system, the source of the devastating cost overruns even as quality is poorer - that hospital, which any health care reform would clearly reform, is emerging untouched, even strengthened. In a coincidence, that hospital is hosting big-money fundraisers for the Democratic campaign committees. At the same time, Big Pharma said that it would go along with reform, but only if it didn't have to surrender any more thna $80 billion in potential revenue over the next decade. The implicit threat is that if this big-business-alliance doesn't get what it wants, it will spend untold sums to bulldoze any reform effort. That is very troubling for all future efforts to deal with the reach, and the consequences, of big corporate power. Is it even possible to hold them accountable?

More broadly, these industries have showered money on the key players to ensure that their interests aren't harmed, which means that any health care reform we get will primarily expand and improve insurance coverage - which would be a huge accomplishment - but it will not deal with the underlying problems that are causing health care to be so expensive even as our quality is inferior. The good news is the Massachussets model: Massachussets enacted universal coverage several years ago, with basic protections, and now that people (should) know that a reform rooted in cost/benefit analysis and comparative effectiveness studies can NOT take away their coverage. In short, people can be confident that efficiency will not be code for "taking away my necessary coverage" because that necessary coverage becomes a legal right. Unfortunately Massachussets hasn't actually moved ahead with the reforms to incentivize best-practices, quality-over-quantity, it's only recommended them, so we'll see if the well-founded assumption that they will be politically easier with enhanced insurance coverage proves true. Especially because those reforms, by definition, take away the profits from the medical industrial complex. Don't expect them to go quietly. So if we follow the Massachussets model, most of the uninsured will get coverage, insurance will be subsidized for the poor and working classes and even into the middle class, coverage will be protected against the nefarious practices of the insurance industry, and the ground will be laid for increased popular support for what should still be, given the power of big corporations over the political system, a very tough fight to change the incentives of medical care toward quality.

Last time we talked about the key policy priorities that would make for real improvement in insurance coverage. The first priority is the health insurance exchange - if you don't like the coverage you have, will you be free to choose a plan? Will there be real competition, among public and private plans, to be your insurer, which should make the insurance system far far more consumer-friendly than the current rigged system? Here's the Strike's take: "Progress has been stagnant. The House bill contains a National Health Insurance Exchange, which will make it big enough to compete with the employer-based market. The problem is, that people who already have insurance through their employers, even if they’re not happy about it, will not be allowed to join the exchange, at least temporarily. This could make the exchange, as you say, a dumping ground for the unemployed. It would be open to small businesses and individuals who don’t get insurance through work, and the subsidy rates will be high enough that it would allow almost everyone to have coverage. If the House version were accepted, it wouldn’t be perfect, but it would be a major accomplishment. The Senate HELP exchange is state-based, which does not give it the same sort of bargaining power." My takeaway is that this is the area where the Senate centrists/cowards/sellouts could do the most damage, and will unless they really feel the pressure to create a real exchange. It's very clear from their public statements that they don't want this exchange, for two basic reasons: one is that they fear the wrath of the insurance industry, which would necessarily lose its profits and power; the second is that an exchange leaves open the possibility that people's insurance will change, and while this will be for the better, this possibility of change, of losing what little you have in an increasingly insecure society with an ever-weaker social safety net, creates so much anxiety among the public that the centrists' Republican opponents will successfuly demogogue them as "the politicians who took away your health care".

The second priority is the definition of the minimum benefit package - will it provide real insurance against catastrophe, or be a Swiss Cheese illusion of coverage that takes your premiums but isn't there for you when you need it? Here's the Strike's take: "The second element I feel very, very strongly about. The House bill has a very stringent set of minimum benefits, including dental and eye care. The problem is that it will be under the direction of a Health Benefit Advisory Board, and the Secretary of HHS. If Republicans take back the White House by the time the bill is implemented, we may get standards that aren’t good enough. The HELP bill has a similar standard." Obama has focused on how health insurance reform will benefit people with existing coverage, prevent discrimination based on pre-existing conditions, lifetime caps, and basically all the practicees that so enrage people because they mean insurance isn't actually insurance, and you haven't been paying for anything. If Obama needs to ensure that anything is in the bill he signs, it will have to be a solid minimum benefit package. This is also a very hard one to oppose - except with this "euthanasia" argument, and the "taxpayer-funded abortion" argument, the right has found a way to attack even health care benefits, and potentially bring down the whole effort by sewing such fear in the electorate.

A third major priority is the subsidies to make health insurance affordable, both for the poor and for the working and lower middle classes, which is good on the merits, and critical for the plan's long-term political viability. Here's the Strike's take: "I’m satisfied with what the House bill does with subsidies to buy insurance. First of all, it expands Medicaid to cover people at 133% of the poverty line, which is more than what it is now, and it provides a subsidy (on a sliding scale schedule) for people making up to 400% of the poverty line. The HELP bill goes further on Medicaid, making it available to people making up to 150% of poverty, it also makes subsidies to people making 500% of poverty, but significantly limits that by saying payments can’t exceed 10% of a person’s income." However, this is another area where the Senate centrists may undermine everything in their purely ideological effort to reduce the supposed overall cost of the bill. Somehow, it's "better" to have a smaller official price tag for health insurance - which should be paid for by a surtax on the extremely wealthy - than to have hardworking middle class Americans have their insurance subsidized, and not be punished for making a few thousand more dollars by being denied that subsidy and potentially denied health insurance. Talk about a perverse incentive structure that may undermine support for health reform among the very swing voters critical to the popularity of the Democratic Party! At least in the eyes of the "reasonable" centrist politicians and media analysts, who say "Look" every other word to appear like they really know what's going on (and who we call the "Looks"), it's obviously, blatantly better to have the middle class denied affordable health coverage than to have multimillionaires pay a few extra thousand dollars, pocket change for them. Would this have anything to do with these Senators being multimillionaires themselves? With their families and friends and entire social network residing in the top .1%?

But the big struggle is over whether health insurance reform will even happen, or whether it will be undermined by the scare campaigns that tap into the deep anxiety, rooted in insecurity and instability and a fragile safety net, which we discussed above. These scare campaigns are disturbing not only because of their potential consequences, but also for what they tell us about the current condition of our democracy, how it seems impossible to find any common ground to do anything about the most pressing problems. We have a lot of pressing problems, and they can only be addressed through collective action, through that democratic belief that we are our brother's keeper, that your interest is my interest. What we're seeing out there now is this fear that any benefit to you will take something away from me, that there's no hope for anything better, only fear that things will get worse. Those kind of impulses are the eternal enemies of liberalism.

It's almost impossible to give a prediction right now of where this debate will go. There are some signs that these protesters are confined to the radical fringe, and through positive polarization are actually strengthening the cause of the President and reform, but that could just be wishful thinking, looking at a situation that should never have reached this level of anger, that has played right into the hands of the nihilists. The Strike has been covering this public debate very well, but I just want to reinforce that the big mistake liberals and especially Obama have made is failing to make it personal, make it real. Emotion and real stories with real people are the primary drivers of political change. It should be easy to do that with health care reform, when on the side of reform we have the thousands who die from lack of health care, the million bankrupted, and the promise of people's lives seriously improved by health care reform. Very surprisingly, Obama has not found his stride, has not connected emotionally, and this has opened the door to the emotional stories, the visceral fears and resentments, stirred up by the right. I asked Ezra Klein about why he has failed, and this was his puzzled, pretty depressing answer, "he's not good at selling it. He's good at explaining it. But those two things are different. Obama hasn't given a definitional speech on health care, the way he has on race, or greed, or Barack Obama. He's not elevated health care into a theme or a challenge or a story in the way he did with those subjects. I don't really know why that is."

The time is now, Mr. President.

We'll put the ball at their 45, because Obama has made it clear that this is his top priority, and I just can't see Democrats preventing him from having at least some accomplishment. But the reform will be much less than it could or should be, and the effort to achieve it has exposed some deep problems with our political system and its capacity to make necessary change. Obama's grade rises from a B to an A-. Yes, his selling effort has not been as good it needs to be. But in the past month, since our past grade, he has really put his all into it, and when we step back and gain some perspective, let's appreciate that the President of the United States is staking his administration on a serious effort at reforming the health care system, a pressing national problem and the most important liberal goal for 60 years. We should never take for granted this radical change from most of the past 40 years.

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