On 2010-03-12, at 2:50 PM, Doug Henwood wrote:
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> On Mar 12, 2010, at 2:33 PM, Somebody Somebody wrote:
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>> More seriously, if Americans come to accept and like this bill, it could help rehabilitate notions of public responsibility and solidarity in this country. Okay, maybe that's just me dreaming.
>
> Probably so.
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(Someone we know?)
March 08, 2010 Why health care reform is not a "huge progressive victory" by Seth Ackerman
http://www.tinyrevolution.com/mt/archives/003226.html
Ezra Klein says progressives should see the health care bill as a “huge progressive victory.” He makes a number of points to support his claim, but I think these are the main ones: The bill is the most ambitious piece of social legislation since the 60’s. The plight of the uninsured has been a liberal rallying-cry for decades. The exchanges, regulations and subsidies in the bill will “create the core structure of a universal health-care system in this country.”
To me, these are all reasons why the Democratic bill is not a huge progressive victory. In fact, it’s closer to being a huge progressive defeat.
Let’s start by asking why there have been no large-scale advances in social legislation since the 1960’s. The first thing I’ll note here is that the last big, ambitious measure, Medicare, was a government-run single payer program that displaced or preempted private health insurance coverage for about one in ten Americans. That’s why the AMA, Ronald Reagan, and the nascent conservative movement spared no effort to decry it as socialism.
Yet none of that prevented Medicare from passing in 1965 with 13 out of 32 Senate Republicans voting in favor. Nor did it stop the bill from winning the support of half the senators from the Deep South (5 out of 10, or 7 out of 14, depending on whether you count Texas and Florida). And what about the Mark Pryors, Blanche Lincolns, Ben Nelsons, Mary Landrieus of the world? In 2009, we were told they fought the Senate bill’s mildly progressive elements because they represented states that are “obviously” too conservative to support even such tepid liberalism. But in 1965, three of the six senators from Arkansas, Louisiana, and Nebraska voted for or pledged support for single-payer Medicare, a.k.a socialism.
Clearly something has gone terribly wrong since 1965. The ideological barriers against solving national problems through public provision rather than through the logic of profit maximization have increased enormously. That’s not an original thought, and there’s no need to rehearse the long list of possible historical reasons – the fraying of liberalism, the chain reaction of race, rights and taxes, etc., etc.
But surely if we want to determine whether or not this is a historic progressive victory, we need to ask what exactly the health care reform effort has done to stem this ideological regression, since it clearly lies at the root of an unending string of progressive defeats. And the answer comes straight from the lips of Barack Obama, who has repeatedly told the country that this is a great bill because (1) it’s not an unrealistic and impractical foreign-inspired government-run program; (2) it doesn’t turn your health care over to government bureaucrats; and (3) it relies entirely on the principles of business competition and consumer choice (usually abbreviated to “choice and competition”).
But still, what about the millions of people who’ll now be getting health insurance? Covering the uninsured has been a liberal cause célèbre for years - how can anyone deny that’s a major progressive victory? First let’s all remember that millions of elderly people got prescription drug coverage due to a bill passed by a Republican Congress and signed into law by George W. Bush. Medicare prescription drug coverage had been a Democratic rallying cry for years. Yet I don’t recall a single person claiming that Bush’s Medicare expansion was a huge progressive victory, and in the end 95% of House Democrats voted against it in a close vote.
Second, besides being a moral issue, the health care crisis was – to put it bluntly – a great issue for progressives. And not just for progressives, but for progressive ideas. Everyone could see the dysfunction of a system where people go bankrupt because they get sick or stay in jobs they hate just so they can keep going to the doctor. And there was always a feeling that time was on the side of health care reform: Most people who paid attention to this stuff knew that universal coverage in some form was inevitable. It was just a question of how. (The insurers certainly understood this, which is one reason why they agreed not to fight this bill.) The status quo wasn’t just bad, it was unsustainable. A reckoning was sure to happen, and when it came the obvious solutions would all be progressive-inspired. After all, if America is the only country without universal coverage yet spends more than every other country; and if all those other countries’ systems are more public and less private – well, the solution (or at least the right direction to go in) seemed obvious.
So health-care reform was not just a goal in itself. It was also a lever to revive liberalism, so that all the othermyriad problems in this country could also be addressed. That’s why this issue was so cherished by the left. Now that lever has been pulled – only to bring about a moderate-Republican bill, sold on explicitly conservative grounds, that has been unpopular almost from the beginning.
But what about the reform itself? This is Ezra’s point three – the “structure” this bill is creating. Let’s do some arithmetic: Health spending equals the average price of health care services times the quantity of services purchased. To cut the growth of health spending, you either need to force people to consume less health care – i.e., cut services – or reduce the rate of medical inflation, which in the U.S. is way above the rates of other advanced countries. The overwhelming preponderance of evidence shows that by far the larger cause of our outrageous health spending is higher prices, not higher levels of health care use. The bill cuts Medicare payment updates to pay for itself, but I haven't seen any evidence that the underlying rate of growth of health spending will significantly decline as a result of this bill. By “significantly,” I mean enough to change the long-term budget forecast from “disaster” to “not-disaster.”
Countries where health care prices are negotiated centrally with the government at the national or provincial level – for example, because they have a single public payer for health care – pay much lower prices and their medical inflation rates are lower. (Here's a good article about price vs. quantity; it's a pdf.) Yet this plan does nothing to change the status quo in the U.S. It includes some pilot-project-type programs to see whether Medicare can cut some services without reducing quality. (We are assured this will never affect the quality of health care for the elderly, but it surely won’t be tested on Lloyd Blankfein.) But the “structure” left in place is still based on private health insurance – i.e., decentralized price determination, or what Obama likes to call “choice and competition.”
But it gets worse. The decentralized private payment system will inevitably start crowding out the public insurance we already have, especially Medicare. With continued double-digit medical inflation, the slow-motion dismantling of Medicare isn’t a possibility, it seems like an eventual certainty. (Just look at the current deficit hysteria, which is now being propitiated by the White House and its independent commission.) We are on a moving train going in the wrong direction; instead of turning the train around, this bill tries to solve the problem by having us all run towards the caboose.
This is not an argument about whether Obama “pushed hard enough” on this or that, or whether Harry Reid sold out such-and-such. The obsession with this kind of short-term thinking is the whole reason why we’re in this mess. It’s quite possible Obama couldn’t have gotten elected if he'd proposed anything more ambitious than the “Demo-plan.” And once in office he may not have been able to get his Demo-plan passed without dropping the more liberal features.
But all of that is beside the point. Whether or not a better health reform plan could have passed at this precise moment is a secondary issue. The larger question is what this bill tells us about this precise moment. Obama came into office with every whim of history leaning in his direction: a discredited Republican predecessor, a crisis of deregulated finance that reached a crescendo literally weeks before the election (what luck!); the largest Democratic majorities in decades (in a sense, even larger than the 1965 majorities; not counting southerners, the Democrats had 47 Senate seats in 2009, versus 40 in 1965). Such a clear shot will not return for decades.
And the result: The Democrats shot their historical wad on health care by re-introducing Bob Dole’s bill from 1994 and justifying it as a free-market solution. How is that a “huge progressive victory”?