A Spoonful of Sugar: On the Affordable Care Act
It is hard to read Remedy and Reaction, Paul Starr’s remarkable chronicle of the hundred-year effort to legislate universal health insurance in the United States, without recalling Robert Gibbs’s tortured quip that Democrats who’ve denounced the Obama White House for having knuckled under to Republican principles or intimidation “ought to be drug-tested.” Nobody with a sense of history—that is, nobody who reads Starr’s book—could doubt how sensible and brave was the president’s effort to drive the Patient Protection and Affordable Care Act of 2010 through Congress. Nobody with a feel for the present moment should doubt how imminent is the threat to the act, how urgent it is for progressive Democrats to rally around Obama—and without all the condescending qualifications that “independents,” who flock away from allegedly weak or incompetent leaders, interpret as contempt.
Starr, who teaches at Princeton and, with Robert Kuttner and Robert Reich, founded The American Prospect, has written 300-plus pages of tightly woven policy description, narrative and polemic; but one needn’t be a wonk to benefit from the tutorial or detect an occasional sigh between the lines. Literary scholars speak of a pathetic fallacy, the idea that inanimate objects have intentions and feelings. Starr makes clear that various political commentators have been susceptible to a somewhat different fallacy, pathetic in its own way, that America’s desires can be fathomed through polling and that the president must somehow be at fault if a desire is not fulfilled, as though flawed legislative institutions, entrenched political forces, conflicting popular incentives, regional rivalries and sheer corruption do not shape political outcomes.
Starr learned his lessons the hard way. He closely advised the Clintons on health strategy in the early 1990s (he still knows and has debriefed key Congressional staffers). The centerpiece of Remedy and Reaction is a long section, full of illuminating asides, on the frustration of the Clintons’ plans. Starr shows that, even as Bill Clinton submitted his bill to Congress, some 70 percent of voters subscribed to the principles embodied in the legislation he proposed. Yet the bill didn’t come close to being enacted. True, Clinton was losing altitude by then, but to suppose his failure was largely a matter of leadership—you know, that he didn’t use his bully pulpit forcefully enough, the sort of gripe heard relentlessly on MSNBC, the Huffington Post and Daily Kos about Obama and the “public option”—is to suppose that willows really weep.
Obama’s actions were cannier than Clinton’s, but they also amounted to a profile in courage. When Obama came into office, Starr explains, only 11 percent of Americans thought reform would have a “negative personal impact,” but by August 2009 this segment of the population was trending to 31 percent. Both Rahm Emanuel and Joe Biden were urging retreat. Starr writes, “Obama not only resolved to go ahead; in September and again in the new year, the president took charge of the effort to steady the health-care initiative and prevent it from careening off the tracks.” Nor was the final bill anything less than what might reasonably have been expected, filling as it did the negative space left by four generations of government programs and serial compromises. Starting with clean sheets of paper was never realistic when one-sixth of the economy was at stake.
Starr’s great fear is repeal of the Affordable Care Act, which would not only deny healthcare to more than 30 million people but would cast doubt on whether “Americans will ever be able to hold their fears in check and summon the elementary decency toward the sick that characterizes other democracies.” Obamacare, in short, was healthcare reform’s best—and last—shot, and it would be unconscionable for liberals to remain cavalier about its defense, or Obama’s, for that matter. It’s past time to discard the misguided assumption that in a better economy, or with more of “a fighter” in the White House, something like a Canadian-style single-payer system might have been (or might sometime fairly soon be) enacted.
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Don’t be put off by the title of Starr’s book, which sounds like a bland article in an academic journal. Starr presents the fate of very complex proposals with consistently graceful prose. Why have so many Americans wanted universal healthcare for so long and not achieved it? Why may opponents yet “react” against the “remedy”? The difficult truths are scattered over generations of political tussling.
The story begins with the Progressive Era, when proposals for government-sponsored healthcare were heavily influenced by, of all things, Otto von Bismarck’s sly welfare legacy: the chancellor of Germany had introduced health insurance in 1883 as a way of co-opting proletarian leaders. Soon came the Coolidge-to-Hoover retrenchment. FDR’s New Deal never seriously mooted universal healthcare—more on this presently—but the Truman administration did, proposing a single-payer scheme modeled after Social Security. This went down to defeat. The Eisenhower years focused on expanding employer-based insurance. The Kennedy and Johnson administrations finally delivered Medicare and Medicaid. Nixon attempted to advance “health maintenance organizations,” and later, seeking to regain popularity during Watergate, he proposed an employer mandate and a “public program for those not otherwise insured,” a formula many Democrats would now embrace but rejected then.
In retrospect, the saddest chapter was the ridiculously damaging Jimmy Carter–Ted Kennedy fight over universal coverage (Carter opposed it), which roiled Congress and paved the way for Reagan’s reactionary “revolution,” after which single-payer would never be seriously considered again. Then came the Clintons’ letdown, though one triumph was the launch of the State Children’s Health Insurance Program (or S-CHIP) in 1997, sponsored by Kennedy and Orrin Hatch. These advances were followed by the Bush years, in which S-CHIP expansion was twice vetoed but an (unfunded) prescription drug plan for seniors was unexpectedly passed. Finally, Starr tells us the story of the fight to pass Obamacare, which in context feels like a satisfying climax.
Each era had its champions, but Starr is particularly good at explaining the permanent counterforces that were salient on Washington’s political landscape by the time Obama inherited it. First is the inherently conservative nature of Congress. From its inception, the Senate was designed to give disproportionate power to the more sparsely populated states. During the twentieth century, the arrangement favored Midwestern and Western rural states—bastions of Republican “self-reliance”—and the Democratic Jim Crow South. Universal healthcare, at least since the 1930s, meant creating a system of coverage for the working poor, a category that inescapably included urban laborers and Southern blacks. Getting legislators from the West and South to support this—or, if they did (as with the Robert Kerr–Wilbur Mills initiative for seniors in 1960), getting Southern and Western governors to opt in—was hopeless.
More recently, the extension of the filibuster gave a virtual veto to forty-one senators hypothetically representing less than a quarter of the population. We somehow manage to forget that Obama’s supposedly impressive majority in the House in 2009 and 2010 was of no account—none—without a supermajority in the Senate, which Democratic leaders nominally enjoyed for only five months in 2010, and which even during that brief interlude relied on “moderates” whose views were indistinguishable from those of leading Nixon-era Republicans. (If they had enjoyed a Senate supermajority, the Obama administration would have gotten not just a “public option” but a second round of stimulus, a cap-and-trade energy bill, tighter bank regulations and immigration reform with the DREAM Act attached.) The House was hardly more responsive to Democratic presidents for much of the twentieth century. It was more reflective of the general will than the Senate, but its business was dominated by powerful committee chairs with seniority—again, for much of the story Starr tells, Southern Democrats. The fact that representatives face voters every two years makes them chronically susceptible to being lobbied (and threatened) by the healthcare industry triumvirate: the American Medical Association (AMA), the insurance industry and pharmaceutical corporations.
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