Matt (pizzuti) wrote,

Healthcare Reform Post-Mortem: What Happened, and Where we Are Now

Two comments; first: Yeah! We did it! Change!

And then: what the hell happened?

We had a popular new Democratic president with outstanding rhetorical skills, elected with the biggest percentage of voters in 20 years - largely on plans to reform healthcare - allied by the biggest Democratic majority in congress since 1976 - and in spite of that it took a year-long, caustic and fierce battle to the brink of political suicide to enact a bill that is so moderate and incremental that a liberal Republican could have thought of it. Indeed it has key elements John McCain supported in 2008 and looks somewhat like what Mitt Romney enacted in Massachusetts.

I'll say it again: "Obamacare" is moderate and incremental. It doesn't go as far to cover everyone as we will need to go in the future, and some will say it doesn't even go far enough for now. Yet we've come out with a country more divided, with a more fearful status-quo, than we have seen since the Civil Rights era.

Lets create a scale of government involvement in a healthcare system for perspective. A totally government-run and non-optional healthcare system where all doctors and healthcare workers are government employees - say Cuba's system - is ranked as 100 in government involvement. A totally unregulated "Ayn Rand's Dream" free-market system where you only get what you can personally pay for even if you're dying, and providers can set whatever price they want, will be a 0 in government involvement.

That would mean "Obamacare" moved us from about a 25 to a 35. Most of the developed world is between 50 and 90.

The National Health Service in the U.K., in which the government employs all doctors but a small minority of citizens still choose private plans and there are small fees for most services, would be a 95. Canada's government-insured system where the government pays for care but you get it from private doctor's offices and hospitals, would be about a 60 with some government and some market. A private insurance system that contains one "public option" letting people buy insurance from the government if they want - a true balance letting individuals opt for a government or private system - would be about a 45. Switzerland's system with compulsory health insurance from nonprofit private companies (banned by law from earning a profit on their services) would be about a 40. America's pre-2010 system, which guarantees care in worst-case scenarios where you are broke but dragged to the hospital bleeding, and provides mostly-free care to seniors, some poor people and veterans - but is mostly market-run and leaves many uninsured - would be about a 25. The new system, when fully initiated after 2014, will ensure that anyone can some level of routine care if they want it and enforces penalties to encourage everyone to do so, but from private companies that earn lots of profit for providing care. It's a 35.

The changes will make a big difference for many uninsured and under-insured Americans, but the post-"Obamacare" American healthcare system is still one of the most right-leaning and market-oriented systems in the developed world. And yet the more conservative 40 percent of the country is treating it like the plague.

So, what the hell happened!?

One word: politics.

To some extent there are Americans who would prefer our healthcare system to be closer to a 10 or 15 in government control, so of course they're going to be bothered by any change that makes the system more universal or more regulated. But they're a fringe that doesn't manifest highly in polls - perhaps no more than 25 percent of the country - so what's going on with these caustic remarks from independent voters, and this anger at Democrats for passing the bill?

Americans have a cultural preference for balance. Some libertarians and liberals are drawn to ideological consistency, but the the crucial bloc that usually decides which direction the country moves in prefers a system that draws a little influence from any two sides of opposition.

The manifestations of a desire for balance are clear and predictable in our recent history: Americans like divided government, and the party that has control of the White House will inevitably, eventually lose seats in Congress. We like Republicans who come from liberal states and Democrats who come from conservative states. Americans usually elect a new president from the opposite party from the last one, and there haven't been three presidents in a row from the same party since 1928 when Herbert Hoover followed Calvin Coolidge and Warren Harding. Candidates always win votes by proving "bipartisan" credentials and a willingness to hear out the other side, whether the sentiment is genuine or not.

Sometimes Americans' view of "balance" is skewed by privilege or history. For example, the word "feminist" means a belief that women should have equal rights and opportunities compared to men, but most people consider feminism an "extreme" word - though equality would suggest feminist ideals represent a perfect balance. A lot of Americans think 25% representation from women in Congress is reasonably diverse and sounds about right, even though a straightforward analysis would consider it blatantly lopsided. Similarly, it is hard to find middle ground when it comes to issues involving race and sexual orientation when history is full of white and heterosexual dominance - most peoples' compromise position ends up looking more like milder forms of prejudice, rejecting past generations' attitudes but still making life harder for minorities than it is for most people. They like black people as long as most of the black person's friends are white, though they'd never have the same standard for white people. They're OK with gay people as long as the gay person doesn't act "too flamboyant," etc. (It's especially hard for people to find balance when the unfairness tilts in their own favor.)

Americans try to find the middle ground, so when they hear two parties taking two perspectives on a single issue, they assume that both are somewhat right and somewhat wrong, and shoot for the middle. The debate over healthcare reform was no different, and Americans wanted something both Democrats and Republicans would like.

To this cause, Republicans found a brilliant winning strategy to have an unfair amount of influence in the debate. That is: keep crying "government takeover!" and "socialism!" and "leftism!" on healthcare no matter how many items Democrats give up on to move their policy in your direction, and most voters will keep trying to find the "middle" and decide the Democratic plan is too liberal, too much, too fast, or whatever. While all the while the voters are unaware they are moving to the Right compared to where they were months ago. In the end you come up with a product that is centrist or even center-Right, that people would have loved in the beginning, but they still end up thinking it's an overreach by the left and conclude we need more Republicans in government. A win for Republicans, right? Current polls would say so. That's why the first strategy of Republicans in congress was to unify their caucus against the bill, ensuring that not a single one of them voted for it, giving the appearance that the finished bill was totally unpalatable to anyone who isn't on the far-left.

My guess is that this Republican strategy will backfire. They drooled over polls saying a majority of Americans oppose the bill, but a portion of those Americans opposed it because they wanted a more liberal and more far-reaching bill, which surely doesn't make them Republican allies.

Significant numbers of other hesitant voters will be lost too. The problem is that keeping up the current rhetoric is painfully exhausting, and when the venom finally does die down, there will be less to distract voters from the bill itself, which is hardly leftist at all, and certainly not a government "takeover." Meanwhile, the people the Republicans rallied to put out on their front lines - the Tea Partiers and the reactionary wing of Congress - are not an example of "balance" that defines most Americans, who will be at a loss to figure out who represents a reasonable counterpart to Obama and to moderate Democrats.

Newspapers will publish "what's in it for you" stories listing some concrete things that the bill has to offer:

Many Americans age 23-26 will suddenly find themselves covered by their parents' health insurance plans again; a huge benefit to them, and a big relief for their parents too. Many Americans who are just a little older will find themselves finally able to buy insurance due to generous subsidies that decrease with income. Those with pre-existing conditions will suddenly be able to get coverage and others will be saved from being dropped. A bunch of seniors with poor drug coverage will get checks for $250 to help them pay for it, and it's hard to be oblivious to a check in the mail. Employees in small companies will be more likely to get health coverage since their company will be assisted by the government if they provide it and fined by the government if they don't - those who do want to provide coverage will likely be grateful. People seeking individual plans will be able to choose from plans available to people in other states, putting some pressure on insurance companies to keep rates lower and stay competitive.

Most importantly, it will be illegal for insurance companies to deny coverage to those with existing conditions, so it will be possible for people with HIV or diabetes to buy health insurance individually. And it will be nearly impossible for insurance companies to randomly drop you, as they have done to many customers before when those customers got sick. And everyone will be required by law to buy health insurance or pay a fine, something they may resent at first but will likely get used to and be glad they have.

Most people will find these changes to be good, and enough of them will be personally helped that they'll end up liking the bill. And the fact that Republicans unanimously opposed it won't make Republicans look very "balanced."

If I have to make a call, I'd guess that two weeks from now this "unpopular" bill will be seen as a positive step by a slim majority of Americans. The wording a poll uses will matter a lot, but I think that by November around 55 percent of Americans will like the bill, which will be a huge victory for Obama and Democrats. I could be wrong, and Republicans could have a surprising endurance in keeping up their current rhetoric, but my guess is that a small upward tick will result in a few of the more moderate Republicans backing off and providing the "balance" that Americans need to re-position themselves more in favor of healthcare reform.
Tags: politics
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