The Secret History of Medicare
The overwhelming conventional wisdom about health care reform is that if reform is defeated in 2009, it’ll stay defeated for a good long time. Proponents won’t just be able to regroup twelve months later, make their case again, wage another election, and bring it back up in the next congress. I don’t particularly question that wisdom, but it is worth noting that this “get it right the first time” approach to legislative change is at odds with the way past major health reforms got done. Here, via David Leonhardt, is how we got Medicare:
— In 1960, as a Senator and Presidential candidate, John F Kennedy backs a Medicare legislative proposal that falls four votes short in the Senate.
— In 1962, now-President Kennedy backs Medicare in a State of the Union address and a 20,000 mass rally in Madison Square Garden simulcast on three television networks; the bills falls short by two votes.
— The bill is reintroduced in 1963 after the midterms and dies again.
— In 1964, Lyndon Johnson was able to ride the sympathy wave to pass the Civil Rights Act, but Medicare still couldn’t pass.
— In 1965, Medicare finally passes following a landslide election.
This is just totally different from the “win an election, try at reform, and if you fail give up for 20 years” model that Bill Clinton pursued and that people generally seem to feel applies in the Obama era. Instead, the fight went on-and-off for five years across three different elections and a presidential assassination. The idea was that reformers had a proposal that they thought was a good idea and that they thought was a popular idea; when they lost they didn’t blame themselves for having failed to persuade the opposition to stop opposing reform, they blamed the opposition and tried to win the next election.
Of course this doesn’t work if you get crushed in the midterm elections.
52 Responses to “The Secret History of Medicare”
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September 3rd, 2009 at 12:30 pm
That would be of some consolation if Obama and the Democratic Party had really tried hard to pass the current bill.
They seem to have conceded all the ground even before any serious negotiations began.
Although generally it’s a good idea to learn the lessons of history, it is foolish to work on the assumption that some magical power always repeats history.
September 3rd, 2009 at 12:32 pm
Matt, this is dumb.
First, you imply that Barack can do this in his second term, while failing on the issue might *cost* him that second term. And then you get a GOP fella totally unwilling to pass health care, which means you have at best 4 and at worst 8 more years till you get a Democrat back in the White House, and *then* you have to have a Democratic Congress, which could be either at the start of the new President’s term, but could as easily occur only after the midterms, but probably not until the new guy’s been reelected, which means, yes, fourteen years later.
Moreover, Medicare, the Voting Rights Act, and a lot of other progressive legislation happened because LBJ, *not JFK* had huge majorities to work with, and enormous political capital, because of a rather major disaster that happened to JFK
The bills got passed in large part *because* JFK got shot.
September 3rd, 2009 at 12:32 pm
Of course this doesn’t work if you get crushed in the midterm elections.
Well, yeah, that’s the point. The corollary to “nothing succeeds like success” is also true: nothing fails like failure. If congress fails to pass a bill that can be realistically labeled “health care reform” and that people quickly begin to think of as something that will improve their lives, then Obama will be seen as having failed to achieve one of his key campaign promises.
That will kill the Democrats chances of holding on to their majority for long and will certainly make it impossible for them to expand it.
Frankly I have very little hope at this point. The bills being considered (and which are all but certain to be watered down further) are so tepid that no one is excited about them except for those who are excited about defeating them. And, as an accounting gimmick, none of the bills under consideration even begin to phase in until 2013. This is political madness. Republicans will have three or four years to rail against Obama care even after it passes before anyone even feels a single positive effect from the bill.
The reason Kennedy and Johnson could try and try again on Medicare was that the idea was simple and it was something that masses of people could get behind. The current “health care reform” is a patchwork of regulations and subsidies that no one understands. You can’t define it. You can describe it. You can’t say why it would make your life or anyone else’s any better. So why get excited about it?
September 3rd, 2009 at 12:34 pm
This might be something for right wing nutjobs to keep in mind when they bring guns to presidential events or make comments about hunting tags for Obama.
September 3rd, 2009 at 12:35 pm
Referring to that period as some type of precedent is ill judged.
The events of November 22, 1963 loom large in that story and let us hope NOTHING like that happens again.
September 3rd, 2009 at 12:35 pm
— In 1965, Medicare finally passes following a landslide election.
Um, the landslide election didn’t result from the fact that Medicare didn’t pass. It occurred because the former President was assassinated.
I’m curious how Matthew thinks something similar occurs without some similar event now.
September 3rd, 2009 at 12:37 pm
Is that where that stupid little meme came from? Right now, it doesn’t make sense to me. They say it like passing health care reform depends on a specific planetary alignment.
September 3rd, 2009 at 12:39 pm
Of course this doesn’t work if you get crushed in the midterm elections.
Getting kneecapped by the hardliners of your own party on your biggest legislative priority is a *great* way to get crushed in the midterm elections and lose control of at least one house of Congress.
That makes the hardliners more relevant – they have stronger ideological control over the new minority party, just like hardline right-wingers do now. And since action is impossible, there’s no need for messy unsatisfying compromises! It doesn’t advance their agenda, of course. But it feeds their egos.
September 3rd, 2009 at 12:40 pm
I think this analysis depends in part on how you define your terms. Some people, for example, might argue that from a broader perspective Medicare was somewhat like the SCHIP of its time: a low-hanging fruit measure as compared to truly comprehensive reform.
And of course in 1997 the original SCHIP was defeated in the first attempt, before finally passing in the second attempt. And then Congress twice tried to expand SCHIP in 2007, and Bush vetoed it twice. It was finally expanded in 2009 once Obama took office.
So we already had a couple recent examples of low-hanging-fruit measures (SCHIP and SCHIP expansion) taking some time and some back-and-forth to finally get passed. But again one might argue that these sorts of limited measures aren’t really indicative of the dynamic when it comes to broader healthcare reform measures.
September 3rd, 2009 at 12:43 pm
THIS is the “wave” year that Johnson had. No, not a wave of sympathy because of an assasination but a wave of disgust at the republican agenda.
So unless you are planning for a catastrophic political event to happen in the next couple of years which would create another wave your analysis is flawed.
September 3rd, 2009 at 12:44 pm
Interesting post. What I take from this bit of history is that liberals in the House should kill the bill it stinks. It would be possible to try again in a couple of years, once it is clear that the “do nothing” policy is not sustainable for health care. Better that than give universal health care a bad name with a bad bill.
As for elections, how do Republicans go from ~30% approval rating to winning back Congress and the White House? It won’t happen that soon.
September 3rd, 2009 at 12:46 pm
The problem that progressives have with the “Obama process for healthcare reform” (TM rahm) is not that it is incremental.
Let me say that again, Matt, incremental is not bad.
What is bad is selling out to the healthcare industry for campaign finance and selling out to intransigent Republican indealogues in the name of the ever elusive bi-partisanship.
Once more: Incremental, not bad. Sell-out, bad.
Also, this is not 1965. In case you haven’t noticed, things have changed a little in the political arena.
Hey, I have an idea. Maybe you and Megan and Ross and Ezra can open your own DC Kewl-aid shop.
September 3rd, 2009 at 12:50 pm
LBJ didn’t win in a landslide just because of JFK’s assassination. He won big because enough voters felt in their guts that Goldwater was nuts. It also didn’t hurt that LBJ knew exactly where every political body was buried in D.C. and his fellow pols knew LBJ would uncover them if crossed. Wilbur Mills knew that, and Johnson knew he could make a deal with Mills also. I’m not sure Obama’s relationship with Max Baucus is on the same level.
It’s hard to say if Obama can pull something similar off, but let’s not doubt that it wasn’t just a matter of try, try, and trying again that finally got Medicare/Medicaid passed in Congress back in 1965.
September 3rd, 2009 at 12:50 pm
The permanent election campaign didn’t exist in anything like its current form during the 1960s. That changes the dynamics of the legislative calendar. You also had a very different Senate, where “blaming the opposition” meant dealing with Dixiecrats. The raw numbers for the Democratic majority in both chambers didn’t change a huge amount between 1960 and 1965.
Also, yeah, the whole JFK getting shot thing kinda sorta mattered too.
September 3rd, 2009 at 12:52 pm
To put it another way: how much money did it take to run a Senate election campaign in the early 1960s?
September 3rd, 2009 at 12:52 pm
In 1965, Medicare finally passes following a landslide election.
We can entertain all sorts of “maybes” about the future. The problem is that it is hard to believe that there will ever be a better time than now, in the foreseeable future, to pass health care reform. We just had a presidential election that produced a result that, if not exactly a landslide, was still convincing and resounding – certainly much more convincing and resounding than Kennedy’s squeaker. And we have huge House and Senate majorities that are unlikely to last. Now is the time to go for it.
Matt, you have written several posts over the past several months that seem to be designed to lay down markers of excuses for failure before the failures actually occur. It’s like you’re already writing the “Plan C” copy for some come-from-behind 2008 re-election campaign. I suspect that every time a Republican strategist reads something like this from a top progressive blogger, he thinks, “We got ‘em.” You have a prominent position here, and we really need you to help lead instead of lagging behind in the armies of the diffident.
September 3rd, 2009 at 12:54 pm
I think the more relevant history is Clinton’s failed healthcare reform in 1994 — in which Democratic leaders lost control of Congress for 12 years because the rank and file concluded they were fuckups and stayed home in disgust. The people whose careers were destroyed were the Democrats who obstructed reform.
People ask how minority Republicans can come back?
They come back by manuvering Democratic leaders into being weak sellouts that grassroots Democratic voters won’t support.
September 3rd, 2009 at 12:56 pm
from “The Steeple Jack” by Marianne Moore
September 3rd, 2009 at 12:57 pm
It would be possible to try again in a couple of years, once it is clear that the “do nothing” policy is not sustainable for health care.
The problem with this strategy is that the next couple years aren’t really going to make the status quo look that much worse. Specifically, for anyone capable of projecting the current trends into the future, it is already abundantly clear the status quo is not sustainable. But for those not able or not willing to project current trends into the future, the next couple years won’t make that big of a difference: most people will still have insurance they mostly like.
So for this strategy to be even plausible, you really need to give it a lot more years for things to get worse–I’d guess at least around 6-8 more years, and maybe more. And the damage that the status quo will cause in 6-8 more years, or maybe more, is a heavy price to pay, and who knows what politics will look like at that time. Moreover, in that same period you could perhaps do some reform now and re-reform later, and end up way ahead.
So I really think the case for actually scuttling reform now in the hopes of improved political conditions arising in a timely fashion is extremely weak. Of course if you actually think the reform bill would make things worse than the status quo, then that is sufficient grounds to oppose it on the merits (versus for strategic reasons).
September 3rd, 2009 at 1:07 pm
And the damage that the status quo will cause in 6-8 more years, or maybe more, is a heavy price to pay, and who knows what politics will look like at that time.
The frog-in-a-pot metaphor pisses off James Fallows, but people get used to being fucked over in annual increments.
The economic truism applies that if something is unsustainable, it ends. How and when it ends, who knows? Presumably there’s a death spiral for private insurance at the point where rising premiums and out-of-pocket costs start impinging on the mortgage payment or the grocery bill, but that’s an ugly prospect.
The Naderish idea of waiting for a better moment is silly. Especially with the Supremos apparently ready to give corporate cash free rein over electoral messaging.
September 3rd, 2009 at 1:08 pm
The ironic thing is this: if Dems would have passed a public option Medicare bill that became effective immediately, the Republican Party would have simply disappeared. People like to not worry about medical bills. They like to not be shackled to a bad job because of insurance. They’d really like health care to not take 16cents of every dollar. They’d like to live longer and feel better.
Opposition to single payer/public option is not just stupid and evil, it’s bad politics.
September 3rd, 2009 at 1:11 pm
DTM, typo, I meant: “liberals in the House should kill the bill if it stinks”. We don’t know yet what the final bill will look like, and can only rely on various “leaks” and “reports” of what Obama, Reid and Pelosi have in mind, or what they can get.
But it doesn’t look good. Of course, health care is not something easy to reform, with the highest stakes possible: life and death, and suffering, and rationing, no matter what you do. And perhaps even a bad bill would help some people, especially the poor.
But I believe a bad bill would hurt more people in the long run, cost a lot more (taxpayer money given to the insurance companies and pharma), and kill any hope of real reform (strong public plan or single payer, or a mix/good compromise).
September 3rd, 2009 at 1:11 pm
pseudonymous in nc,
Obviously I agree. I think the bottomline is that the progressive Democrats in Congress should negotiate the best possible bill they can with the conservative Democrats in Congress. And then they should pass it, because the alternatives suck.
September 3rd, 2009 at 1:11 pm
I think this analysis depends in part on how you define your terms. Some people, for example, might argue that from a broader perspective Medicare was somewhat like the SCHIP of its time: a low-hanging fruit measure as compared to truly comprehensive reform.
By that standard, “truly comprehensive” reform has never passed, and there is no evidence that it ever could pass, and plenty of evidence that it can’t pass all at once.
The only way to eat that elephant is in pieces. Insisting that you must swallow the whole thing at once and incrementalism is unacceptable only guarantees that it won’t get eaten at all.
What is bad is selling out to the healthcare industry for campaign finance and selling out to intransigent Republican indealogues in the name of the ever elusive bi-partisanship.
I would really like to know where this idea is coming from. Knowledgeable people who have read the fine print (e.g. Ezra Klein) agree that that’s not what the bills under consideration do. But someone who positions themselves on the left is absolutely, regardless-of-the-evidence convinced that Congress’s plans are worse than the status quo and must be killed even at the cost of losing Congress for another decade. (But, of course, they can’t cite any provisions in the bill that actually are worse than the status quo – only repeat the same vague slurs.) It seems like the kind of position that could only be taken by a right-wing mole, because it’s so obviously destructive of the left’s agenda.
September 3rd, 2009 at 1:14 pm
Obama is a DLC democrat.
The only way to get him to be progressive is to FORCE the issue. Threaten nonsupport for democrats and then follow up.
The DNC and others are very nervous about their melting support. A lot of upset about the wimpish democrats is not getting aired by the media. Strong, loud protest is needed now.
September 3rd, 2009 at 1:18 pm
I would trade Obama for single payer, a carbon tax and EFCA.
September 3rd, 2009 at 1:26 pm
someone who positions themselves on the left is absolutely, regardless-of-the-evidence convinced that Congress’s plans are worse than the status quo and must be killed even at the cost of losing Congress for another decade.
I’m not sure that that’s an accurate representation. The regulatory elements can be seen as treating the symptoms, and to that extent, improving on the status quo, but a potential giveaway to the people who brought you the pre-ex exclusion, rescission and the settle-at-the-courtroom-steps approach to litigation is distasteful (in the bank bailout sense), doesn’t address the basic structural failings of American healthcare, and probably doesn’t end up feeling like reform for the majority of people currently dealing with rising premiums and out-of-pocket costs.
September 3rd, 2009 at 1:27 pm
But I believe a bad bill would hurt more people in the long run, cost a lot more (taxpayer money given to the insurance companies and pharma), and kill any hope of real reform (strong public plan or single payer, or a mix/good compromise).
I guess here is where I would turn your own strategic reasoning against you. The worst case scenario right now appears to be something like that we get all sorts of regulatory reforms for employer-provided health care, an expansion of Medicaid, and a subsidized national exchange for everyone else. Within this exchange we would only have highly-regulated private options, maybe including some new large nonprofit options such as co-ops, but no public option.
OK, so I think the argument goes that regulation and maybe these nonprofit options would prove insufficient to control the cost of the insurance options in the subsidized exchange. I don’t think that is necessarily going to be the case because that model has had some success in other countries, but it isn’t a bad bet.
So assuming that failure of the regulatory cost controls happens, then what happens next? The subsidized exchanges are themselves going to be an entitlement shared by a large politically-potent group (politically potent because they will be mostly working-to-middle-class people). So, actually dismantling the exchanges isn’t going to be a viable political option. But with regulatory controls having proven inadequate to control costs, the only remaining alternative will be to then do something like institute a public option, or in fact maybe even a total public takeover of the national exchange system.
In short, I don’t think there is any real chance of the worst-case bills actually killing future reform, and I think it is actually a better bet they will speed along future reforms by creating this middle-class entitlement. That said, I see no reason to waste time and resources getting to that point if we can actually do better right now. So, progressives should definitely push as hard as they can for a public option–and personally, I still think they will succeed.
September 3rd, 2009 at 1:32 pm
By that standard, “truly comprehensive” reform has never passed . . .
Well, no duh. It is a simple fact that truly comprehensive health care reform has never passed in the United States, which is why we find ourselves with such an inefficient and unsustainable system.
. . . and there is no evidence that it ever could pass, and plenty of evidence that it can’t pass all at once.
Probably correct, which is why all these measures have to be evaluated in part by how they fit into a prolonged strategy of reform, as opposed to just what they immediately accomplish. And I think the calmer voices on the reform side understand that and are having that discussion, which nonetheless leaves plenty of room for debate.
September 3rd, 2009 at 1:35 pm
Or to put it another way, incremental change needs to be actually in the right direction. Binding and gagging the sheep ^H^H^H^H^H voters and handing them over to the insurance companies- which is what mandates unaccompanied by a meaningful public option would do- is regress, not progress. Also political poison for the Democrats.
Even the feel-good story about a Plan B of just passing new insurance regulations doesn’t stand up to even modest scrutiny. Even assuming the regulations were actually enforced, how would they prevent the insurance companies from jacking up everybody’s premiums to pay for the influx of sicker customers to whom they would be unable to deny care? Taking money out of the pockets of millions of middle-class voters and giving them nothing in return is not exactly a recipe for political success.
Oh well, the only consolation is that the coming 2010 debacle will relieve us of the presence of many of the obnoxious Blue Dogs in the House.
September 3rd, 2009 at 1:36 pm
My concern with depending on the regulatory approach is that –under a future Republican President — we will end up with something like the Five SEC investigations of Bernie Madoff.
Civil servants executing a public option will be accountable to the public and to their Member of Congress. Regulators are not.
90 percent of Americans don’t know who the fuck Chris Cox is even though he has put $24 Trillion of their money on the Craps table.
September 3rd, 2009 at 1:37 pm
Voters who see their share of the premiums on their employer-provided insurance skyrocket, with no benefit for themselves, vote the Democrats out of power. That’s what.
September 3rd, 2009 at 1:37 pm
The worst case scenario right now appears to be something like that we get all sorts of regulatory reforms for employer-provided health care, an expansion of Medicaid, and a subsidized national exchange for everyone else. Within this exchange we would only have highly-regulated private options, maybe including some new large nonprofit options such as co-ops, but no public option.
Only if you consider that case worse than “We get nothing and the Democrats lose both houses of Congress in 2010″. (That’ll help pass future, more ambitious reform, for sure.)
Which some people apparently do (or claim they do). What are they smoking?
September 3rd, 2009 at 1:41 pm
Reality. What are you smoking? How about actually making the mental effort to deal with the predictable consequences of the “pass anything” “strategy” as I outlined them above.
September 3rd, 2009 at 1:44 pm
Re chris at 33: “Only if you consider that case worse than “We get nothing and the Democrats lose both houses of Congress in 2010″
———
I think the swine flu will have a disruptive effect — I don’t think the healthcare system crafted by the insurance companies is going to hold up well. Democrats should be planning to dump this on Republicans as a consequence of past Republican sabotage of healthcare reform.
It is fucking unbelievable that the WHite House lets Huckabee et al get away with attacks re “rationing” and does not lift one fucking finger to remind Americans that Republicans fought Medicare every step of the way and that they did NOTHING to provide healthcare to 45 million Americans during the 12 years they had power.
You know what REALLY loses elections? Not having a fucking spine. Look at the 2004 John Kerry campaign.
September 3rd, 2009 at 2:09 pm
Voters who see their share of the premiums on their employer-provided insurance skyrocket, with no benefit for themselves, vote the Democrats out of power. That’s what.
Voter will more likely do that without reform as well, so this is more of a partisan argument in favor of more effective reforms as opposed to a partisan argument in favor of keeping the status quo. But I would agree these are good arguments for progressive Democrats to use with conservative Democrats in their negotiations over the final form of the bill.
Only if you consider that case worse than “We get nothing and the Democrats lose both houses of Congress in 2010″.
I meant the worst-case among the plausible scenarios including bills actually being passed. I don’t actually think not passing a bill at all is a particularly plausible outcome at this point, but in any event it wasn’t within the scope of that statement as I intended it.
September 3rd, 2009 at 2:10 pm
Let me see if I have this straight:
1) Democrats “pass anything” and then people get pissed and vote them out of power.
2) Democrats refuse to pass anything, nothing changes, people get pissed and vote them out of power.
Theoretically, there’s the pipe dream of passing a really good bill that makes lots of people happy to keep Democrats around, but regardless of where you choose to place the blame for that – Obama, Republican intrasigence, Blue Dog betrayal, etc. – the Democrats aren’t going to get such a bill passed.
If the consequences of doing what they can, or doing nothing at all, is that the Democrats are inevitably screwed, why not at least get the “pass anything” bill for the trouble? A bill that prevents insurance companies from refusing to cover people with preexisting conditions and from rescinding coverage when it gets expensive is still a big step forward for lots of people.
September 3rd, 2009 at 2:19 pm
It’s not a step forward if it drives even more people out of an even more unaffordable insurance market. I can’t fathom how people think regulaltions without effective cost controls can possibly work. Do you imagine that the insurers are just going to eat the cost of covering a bunch of new, sicker people whom they’ve been working overtime to avoid covering up to now?
September 3rd, 2009 at 2:29 pm
Let’s refresh everybody’s memory on just how far backward we’ve traveled in the past 9 months.
September 3rd, 2009 at 2:45 pm
I can’t fathom how people think regulaltions without effective cost controls can possibly work. Do you imagine that the insurers are just going to eat the cost of covering a bunch of new, sicker people whom they’ve been working overtime to avoid covering up to now?
As I understand it the risk-spreading mechanism and minimum loss ratio regulations are designed to help address this issue.
September 3rd, 2009 at 2:46 pm
Don’t revise history. After 1994, any health care reform was in the hands of Congress and Newt Gingerich.
Not comparable to the 60s when the Dems had the power to bring legislation forward. During the GOP control of Congress, the Dems were locked out.
September 3rd, 2009 at 2:55 pm
I imagine that the employer and individual mandates that will vastly increase the number of new healthy people they cover will more than compensate for the new, sicker people. The much-derided “trigger” option (that’s apparently Olympia Snowe’s preference, rather than a public option or co-ops) would (in theory, anyhow) act as a restraint on the amount of outright robbery the insurance companies could get away with.
And then for the sake of argument let’s assume none of that works and we’re all getting strip-mined by Allstate: don’t you think that that would generate enough anger to pass a reform package you’d be happier with? The principal problem to reforming our public health system from a public-relations standpoint is that people who have insurance are largely satisfied with it – at least, satisfied enough to be frightened that any change will be for the worse. If, despite the presence of safeguards, an incremental reform leads to more people being less happy with their coverage, that ought to lead to more radical reforms.
In the meantime, people who are sick right now and don’t have coverage, or who get sick but would currently lose the coverage they do have, would at least have some kind of insurance to make sure they don’t wind up bankrupt because of poor health.
September 3rd, 2009 at 2:55 pm
By “risk-spreading mechanism” are you referring to mandates to force healthy people, who are currently going bare, into the insurance companies’ pools? That might “work”, to some degree, but if those people aren’t given a cost-controlled public alternative it’s a recipe for a huge political backlash among voters on whom Obama was particularly dependent in 2008.
September 3rd, 2009 at 3:28 pm
Aaron:
Tell that to the people whose credit lines were eradicated and APR raised to 30% the week after the new credit card rules passed. The same banks who only months before had used the threat of crisis to politely request trillions of dollars.
These corporate hucksters and banksters will fistf*ck literally any poor or middle class American they can get their hands on before the hammer comes down. And that, of course, is assuming the hammer will ever actually come down.
The President and a Congress are likely to throw away a public option that 72-78% of the American people support in order to secure funding for the 2010 elections. Trust me, there’ll be plenty of anger to go around once self-identified Democrats realize their hides have been sold. (Bye-bye, Blue Dogs!)
September 3rd, 2009 at 3:56 pm
By “risk-spreading mechanism” are you referring to mandates to force healthy people, who are currently going bare, into the insurance companies’ pools?
No, a risk-spreading mechanism is a reinsurance scheme whereby the insurance companies that ended up being required to issue policies to a disproportionately risky pool of people could get compensation from the insurance companies that ended up being required to issue policies to a less risky pool. I actually don’t know the exact details of the risk-spreading mechanism in, say, the Tri-Committee Bill, but apparently it does have one.
Anyway, when you combine that sort of scheme with minimum loss ratios (where minimum loss ratios are the amount of your premiums you have to pay out in medical claims), you are helping to minimize the incentives for insurance companies to try to jack up their premiums to make up for any high-risk people they are compelled to insure.
[I]f those people aren’t given a cost-controlled public alternative it’s a recipe for a huge political backlash among voters on whom Obama was particularly dependent in 2008.
I think it should be noted that most people won’t have access to the public option, at least initially, because they won’t be participating in the national exchange: instead most people will still get insurance from their employer, Medicare, or Medicaid.
For the people in the exchange, I agree that in the long run controlling costs will be important, and I agree the public option would likely help do that. But I again think it is necessary to think through how this will play out: initially, at least for people getting subsidies, the insurance they can get in the national exchange will undoubtedly be cheaper than what they could get under the status quo system. Over time, those costs may start to spiral out of control if various other cost-control measures fail, but will they then blame the people who gave them access to the exchange in the first place?
I tend to think not. Instead, I think they will just demand bigger subsidies and/or more effective cost control. And since bigger subsidies would require higher taxes, I think the more likely outcome is more effective cost controls.
By the way, although this kind of argument is not terribly trustworthy, I do think it is worth noting the Republicans are ultimately fighting the national exchange itself as much as the public option specifically. And I think that is because they rightly see it as creating an entitlement that will prove very popular, and open the door to more sweeping reforms in the future.
Again, none of this is intended to undermine the claim it would be a very good idea to get a public option in the national exchange. But I think people are being overly dismissive of how important the subsidized national exhange itself is to the likely future course of health care reform.
September 3rd, 2009 at 4:08 pm
I don’t see how that compensates for the fact that eliminating pre-existing condition exclusions, etc. makes the OVERALL pool in the total private health-insurance market significantly riskier than now. Neither, it seems, do the insurance companies, which is why they very much want a (subsidized) mandate to top up their coffers. I wouldn’t be surprised at all if they ordered their Congressional minions to kill any plan lacking a mandate. (Come to think of it, how’d that get INTO Obama’s plan in the first place after he campaigned against it in the primaries? Hmm.)
September 3rd, 2009 at 4:18 pm
I attribute the whole “reform every 20 years” thing to the Chattering Class getting most of them political lessons in the 1990s, and having little knowledge of political history before then. Clinton didn’t give up on health care reform because of some desire to only do it once a term – he gave up on it because he had simply no chance to get it (or almost anything else) done with a hostile Congress breathing down his neck.
September 3rd, 2009 at 4:26 pm
I don’t see how that compensates for the fact that eliminating pre-existing condition exclusions, etc. makes the OVERALL pool in the total private health-insurance market significantly riskier than now.
Combined with the minimum loss ratios, it helps make sure that this issue is dealt with systematically and doesn’t become a pretext for jacking up premiums more than necessary to cover these costs. But you are right that if total claims systemwide actually go up, eventually somebody has to pay for those claims.
Of course no system can avoid that outcome, so now you are getting into the issue of “rationing”, meaning measures to actually control the total amount of claims being paid. That said, I think this issue is a little overstated. Insurance companies don’t want to take these people because they can’t possibly profit on them. But that doesn’t mean they are going to add a lot to the bottomline on a systemwide basis.
September 3rd, 2009 at 5:31 pm
Matt, you have written several posts over the past several months that seem to be designed to lay down markers of excuses for failure before the failures actually occur. It’s like you’re already writing the “Plan C” copy for some come-from-behind 2008 re-election campaign. I suspect that every time a Republican strategist reads something like this from a top progressive blogger, he thinks, “We got ‘em.” You have a prominent position here, and we really need you to help lead instead of lagging behind in the armies of the diffident.
Matt’s just a blogger and my theory is that he’s baiting gullible people like you because he knows people will freak out if played like a violin. If true that’s really funny but kind of mean.
or he’s just preparing for the worst while hoping for the best b/c you can only influence events so much.
Concerning the Petey type Prolier-than-thou people, just off the top of my head I remember them arguing the stimulus was way too small b/c Obama was a centrist sellout and the economy was going to tank which would show the Obamabots what dupes they were. That didn’t come to pass. Same with Obama’s failure to nationalize the banks. We faced Armageddon because of Obama’s weak spine, supposedly.
So if they’re wrong again on health care reform, I won’t be surprised.
September 3rd, 2009 at 6:21 pm
Another way our current time is different from the early 60’s is that this time we won’t have the luxury of waiting decades before we implement further reform. Even using the most optimistic estimates, the current proposals don’t sound likely to provide enough cost savings.
Going back to an earlier post of Matt’s, this is another reason some of us are so anxious for a public option. Not only is it the best chance we have to achieve adequate savings this time around, but it will also be the easiest way to implement further reforms while protecting consumers/citizens from their corporate overlords.
September 3rd, 2009 at 6:58 pm
Kill a Kennedy and see a doctor!
September 3rd, 2009 at 8:25 pm
Re: Um, the landslide election didn’t result from the fact that Medicare
That is the first time I have ever heard that claim. People punished the GOP for Oswald’s actions? Why? I don’t recall reading anything about Republicans high-fiving over Kennedy’s murder, or doing anything else that would have seriously outaged the electorate.
And you are by the way leaving out the little fact that the GOP ran a candidate who (justifiably or not) was deeply unpopular with the electorate, who was in fact considered a nutcase extremist (Yes, we should so lucky to have Goldwater-type extremists today!)
Re: The problem with this strategy is that the next couple years aren’t really going to make the status quo look that much worse.
One thing we have going now and will have going in the near future: the Big Money people want reform. Even Big Insurance wants some kind of reform (albeit with no public option), because the current system is costing them as well. So my bet is still on some manner of reform going through.
Re: Voters who see their share of the premiums on their employer-provided insurance skyrocket, with no benefit for themselves, vote the Democrats out of power.
Are living in an alternate reality? Hello– voters have been seeing the above (often with less coverage too) for the last 25 years!