The Problem With Obama's Health Care Argument

[Christopher Hayes]

Fascinating, frustrating times here in Washington. Here's my latest:

http://www.thenation.com/doc/20090803/hayes

July 28, 2009

As I write, the Senate Finance Committee has yet to release its
version of healthcare reform legislation, and Harry Reid has announced
that the Senate won't vote on any healthcare bill until after the
August recess. This is worrisome. The future of progressive politics
and the nature of the American social contract, not to mention the
lives and health of millions of our fellow citizens, is up for grabs.

Strangely, though, you wouldn't really know it from listening to the
pronouncements emanating from the White House. Instead, they're
focused with laserlike precision on "bending the curve." Testifying
before Congress in June, Council of Economic Advisors chair Christina
Romer said she wants "to focus on slowing the growth rate of
costs...the so-called curve-bending that can last for decades." Office
of Management and Budget director Peter Orszag emphasized in a recent
interview that "the legislation that emerges from this process has to
contain key provisions that will bend the curve over the long term."
And even before he took office, President Obama said that "the key is
going to be medium-term and long-term, how do we bend the curve so
that we start getting these deficits down to a manageable level?"

In this case the "curve" is the projected increase of healthcare
expenses over the next several decades. Healthcare currently accounts
for 17 percent of GDP (more than in any other industrialized nation),
and its share is growing. This predicted inflation in healthcare costs
will drive up the cost of Medicare and Medicaid, which if allowed to
grow at the current rate will eventually bankrupt the government.
Therefore, reforming healthcare is crucial to keeping America solvent.
This is true and right and compelling enough, so far as it goes.

But in politics there are two kinds of issues: those that make your
cheeks flush and inspire passion, and everything else. The integrity
of our bodies, the care loved ones will or will not receive when they
fall ill, the fear and misery that beset millions of people who are
cruelly left to a prison of nagging illness because they don't have
routine care--those are in the first category. Long-term fiscal
deficit projections are decidedly in the latter.

In its healthcare messaging, the White House has taken an issue more
intimate and immediate than perhaps any other in a voter's life and
transformed it into an abstract, technical argument about long-term
actuarial projections. It's a peculiar kind of reverse political
alchemy: transforming gold into lead.

Of course, there's a certain logic to the White House approach:
despite widespread public support for reforming the healthcare system,
a desire for more choices and pervasive insecurity about the stability
of coverage, a majority of people think that their health insurance is
just fine. The trick then is to promise two contradictory things: that
healthcare reform will change the system while leaving your healthcare
intact. In what at first appeared a deft bit of jujitsu, the White
House settled on the long-run-cost argument as the way to pull this
off.

But now we're seeing the problems with this approach. For one,
converting a moral and political argument into a technical and
accounting one ends up ceding veto power to the accountants at the
Congressional Budget Office. In a Beltway version of Revenge of the
Nerds, every time a Democratic bill comes out of committee it's sent
to the CBO to be "scored"--that is, to evaluate how much it will cost
and how much it will "bend the curve" on future costs. So far, the
results have been mixed. CBO head Doug Elmendorf has been skeptical
about the gains to be had from measures like health IT and wellness
programs, and both the House and Senate bills have been scored as
revenue neutral over the next ten years. In another context that would
be great news, but since healthcare is being sold as a way to reduce
the deficit, revenue neutral doesn't quite cut it.

The other problem is broader than just these pieces of legislation.
Obama has inherited a shared political vocabulary in Washington (with
phrases like "fiscal discipline," which he himself employs) that
shapes the contours of the possible and semantically militates against
progressive politics at every invocation. If "fiscal discipline" meant
that politicians support tax increases on the wealthy or cuts to the
military budget to pay for programs, it would be a useful concept. But
what "fiscal discipline" means in Washington is cutting government. It
means no taxing and no spending. It means "pain" and "sacrifice" and
gutting the welfare state. When politicians say they're "fiscally
conservative," what it actually means is they're conservative. Full
stop.

Even with his mandate and the broad social forces moving America
toward a progressive majority, Obama doesn't have the time (and may
not have the inclination) to undo three decades of accumulated right-
wing, antigovernment rhetoric. So in order to strike while the iron is
hot, he's attempting to use the language of fiscal conservatism to
pull off a marginally progressive shift in the social contract.

But the rhetoric of "fiscal conservatism" also empowers the enemies of
reform. When "moderate" Democratic senators on the Finance Committee,
Max Baucus and Kent Conrad, finally unveil their secretly crafted
version of healthcare reform, which reports indicate will include
neither an employer mandate nor a public option, they can claim it
fulfills the president's goal of "bending the curve." By cutting
subsidies and reducing the number of Americans covered, their plan
could still manage to come in under the magical $1 trillion mark.
Since the CBO's Elmendorf has been intimately involved in crafting the
bill, that seems assured. What Congress could end up with, then, is a
bill that costs less than others but doesn't, you know, provide
universal healthcare.

The policy argument the president is making is sound: more government
intervention, a public option and broader coverage will reduce costs
in the long run. But this causes so much cognitive dissonance that
mainstream media figures are incredulous. And that skepticism, along
with industry propaganda claiming that a public option will limit
choices, is, not surprisingly, showing up in public opinion. A recent
Washington Post/ABC News poll found support for Obama's healthcare
agenda at 49 percent, down from 57 percent in April.

So what to do? If there's a silver lining to the fact that Congress
will enter its August recess without a bill, it's that the White House
and advocates of real reform will have a chance to modify their pitch.
If there was ever a time for Obama's vaunted and much-anticipated
grassroots army Organizing for America (OFA) to do its thing, it's
now. Since it's closer to the actual lived experience of voters, OFA
may have superior instincts about what kinds of messages resonate.
Recently it undertook an effort to compile stories from people about
their experiences with a broken healthcare system, like this one:

I am 36 years old and have Blue Shield HMO health insurance coverage
through my employer. In January 2009, I was diagnosed with metastatic
(stage 4) breast cancer.... My doctors prescribed a medication that
targets and removes the cancer throughout the body like a "smart
bomb"; however Blue Shield of California denied coverage of my
doctors' recommended treatment. Blue Shield also denied a radiation
procedure that would target and remove the two lesions in my brain. In
both cases, Blue Shield denied the original requests and subsequent
appeals I filed on the grounds that the treatments are not a medical
necessity. I have learned that insurance companies will use "medical
necessity" as an excuse to not cover treatment when it appears that
the patient is "too sick" (read: not worth it).

Stories like this strike me as a whole lot more potent than talk about
"bending the curve."