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Borde-nough: Debating healthcare

Published: August 28, 2009
Section: Opinions


As Americans engage in what passes for a debate on the future of health care, attention has come to focus on the question of whether any changes will include a so-called “public option” for health insurance coverage. Given the size of the Democrats’ Congressional majorities, it is hard to explain why President Barack Obama’s health care proposals – which until recently consistently included a public plan – have stalled in Congress unless at least some Democrats disagree with him.

But one may wonder whether unbridgeable policy differences really exist, or whether, alternatively, a lack of bridge-building enthusiasm is the real problem. With his election a memory and his reelection still well over the horizon, Obama seems to be engaging in a form of political opportunism with respect to his universal health insurance promises that reflects poorly on him.

A clue as to the nature of this opportunism emerged two weeks ago, when Secretary of Health and Human Services Kathleen Sebelius revealed that the “public option” was “not an essential element” of the president’s health care plans. CNN and other commentators recognized Sebelius’s statement as newsworthy, but spun the retreat from Obama’s earlier promises as an essential compromise, a “necessity for any legislation to pass” in Congress.

That analysis misleadingly minimized the extent of the president’s leverage over the legislative process in this instance. Obama won a large victory at the polls less than a year ago. He heads a party that controls big majorities in both houses. At a time when government employment looks unusually attractive to job-seekers, and when state governments cannot finance projects, Obama commands more public jobs and dollars than anyone. The president does not control Congress, but the idea that he was forced to drop a key part of his plans conceals behind the language of necessity a judgment that achieving universal care is not worth the political cost.

Candidate Obama let it be known in no uncertain terms that he wanted coverage that would reach the country’s 45 million uninsured and millions of underinsured persons. President Obama has until recently been adamant that (as he put it in a speech to the American Medical Association on June 15) there “needs to be a public option” for an “affordable, basic package” of health insurance “that will give people a broader range of choices and inject competition into the health care market.”

Presumably, nothing that has happened since June has eliminated these concerns. What has changed is the administration’s calculation of the political benefit to be realized from pulling the strings and calling in the favors necessary to make universal coverage a reality. Now that the flesh of detail must be attached to the bones of the universal care proposal, the president has sensed that there’s no longer easy political capital to be gained from simply smiling for the cameras and declaring himself in favor of some benign, vague idea with the uplifting name of “universal health care.”

Obama has stopped leading the push for universal insurance from the front and taken cover behind bet-hedging statements like Sebelius’s. He once endorsed government intervention to offset market forces that were leaving tens of millions of Americans to rely on the existing health care “public option,” that of waiting until they have a serious enough condition to go to a hospital and seek the emergency care mandated under existing federal law. While people differ heatedly on the details, the idea of a legal right to coverage is popular. It probably won Obama many votes in 2008, not least from those whose only coverage is of the get-sick-enough-for-an-emergency-but-try-not-to-die variety.

What is unpopular is the idea that Americans with adequate insurance will see the quality of their health care decline, or the health insurance component of their pay from employers taxed, or that they will lose their coverage altogether as employers seize upon the new public option as an easy justification for dropping their own plans. Universal insurance legislation need not cause these problems. Funding for a plan for covering the uninsured does not necessarily have to be diverted from resources now allocated to health care for others. Candidate Obama rightly assured Americans that this was so, and attacked his opponent’s plan to tax employer contributions to employee health benefits.

But after Sebelius’s statement, President Obama appears content to offer no public plan, and instead to rely upon nonprofit cooperative insurance trusts. White House Press Secretary Robert Gibbs demonstrated how far the president has retreated from his campaign promises by asserting that “the bottom line is, do individuals looking for health insurance in the private market have choice and competition?” The administration has yet to explain why the proposed trusts would voluntarily wade into the high-risk pool of the currently uninsured and offer affordable coverage options that someone without a forked tongue might say reflect “choice and competition.”

Anyone could have predicted that universal health care would face serious opposition if the proposal’s enemies succeeded in convincing the wider public that universal coverage could come only at the expense of the health coverage currently enjoyed by other Americans. Obama needed to make clear that this would not happen by crafting his plans in such a way that they did not penalize insured Americans. Such sources do exist. Parts of the federal budget unrelated to health care could be used. Provisions to discourage employers from dropping existing plans could be enacted, and taxes could be raised so as not to specifically penalize Americans with employer coverage.

Maybe he foolishly planned to fund his program from one of these unpopular sources, and must now rethink. But the president is smarter than that, and he knows that universal health care is a sure loser if the public thinks that it would hurt the majority who do have health insurance.

Similarly, maybe when Obama used to speak of a public option, he really meant non-profit trusts. Certainly he’d like the public to think that: on Aug. 20, he claimed that Sebelius’s statement about dropping the public option was nothing new, but that “she’d been saying this all along.” But that also seems unlikely. The distinguishing feature of the proposed public option is not that it will be non-profit. Many health plans are already organized that way. What’s important is that it would be, in a sense, non-market: it would provide insurance to people that the existing insurance market has let down. The proposed trusts will be much more exposed than the public option to the market forces that currently leave many people uncovered.

With years separating him from his reelection bid, Obama can safely assume that his supporters will settle for less than universal health coverage, or at least forget by 2012 what they can’t forgive. Even his party’s Congressmen have a year to spare before facing the voters. Rather than push for universal health care, Obama may substitute an insubstantial policy change that he can sell to the public as an achievement. Presidential concern for maintaining a winning image is nothing new – consider “Mission Accomplished” and the George W. Bush’s administration’s other war rhetoric (and cross your fingers and hope that Obama’s hasty August 20 judgment that “a successful election” took place that day in Afghanistan was not similarly wide of the mark despite low turnout in much of the country, fraud, vote-buying, and intimidation). But an incumbent who enticed voters by stressing that he would be different should not display such continuities, or renege on a promise that more effort could fulfill.

Indeed, now that he faces opposition to his domestic plans, Obama seems to be taking additional cues from his immediate predecessor in office. Pouring Cash for Clunkers into the auto market and encouraging banks to resume taking bad mortgage risks look great as long as the money lasts, but will do no more to promote sustained economic growth than, say, handing taxes back to the rich no-strings-attached, or brutally destroying Muslim countries to make work for contractors. And Obama, like Bush, has discovered both the distraction of overseas adventures and the convenience of minimizing his own responsibility for them. “We must never forget,” he told an ex-military audience on August 17, that Afghanistan “is not a war of choice. This is a war of necessity.”

Just as CNN and other commentators have indulged the president by claiming to see the “necessity” of dropping the public option, Obama himself now claims absolution from responsibility for the Afghan War from a public that must pay to give him the resources and powers of a “war president.” If the best that our centuries-old democracy has been able to do in its most recent presidential polls is to reelect a wannabe tyrant and then replace him with a photogenic demagogue, the president’s assessment of the Afghan election may be quite accurate.