Monday, December 21, 2009

Theda Skocpol on health care reform, then and now

Anything that Theda Skocpol has to say about the politics of social policy in the US has to be taken very seriously, and that definitely includes her interventions in debates over the politics, political economy, and policy substance of the current health care reform effort. That makes it especially interesting to read and compare two pieces she wrote on this subject for Talking Points Memo six months apart, one in June 2009 and the other on December 19, 2009. Both are strongly and cogently argued, but their messages point in strikingly different directions. Perhaps they don't quite contradict each other, but at least they're in sharp tension.

I don't say that as a criticism. Actually, comparing Skocpol's arguments in these two pieces helps to illuminate some of the deepest, most difficult, and most genuinely intractable dilemmas involved in this whole political struggle. Some highlights:

=> "Robust Health Care Reform is the Moment of Truth for Obama and the Democrats" (June 24, 2009)
Fellow Americans, and fellow Democrats and Obama supporters, we are at a moment of truth, a pivotal turning point -- in the form of what happens in the next days and weeks with robust, universal health reform. A fork in the road socially, economically -- and politically. It could go either way depending on Obama and the Democratic officeholders many of us worked so hard to elect. They have the power to act, but will they use it -- or lose it?

If at this remarkable juncture Obama and the Democrats cannot enact a robust health care reform -- with a strong nationwide public option, cost controls, and nearly universal coverage -- I would not want to be in charge of fundraising and mobilization for them in the 2010 and 2012 elections! Most of us who supported them last time will of course not vote for a Republican.. But if Obama and the Democrats cannot act now on a once in a half century challenge and opportunity, they are not worthy of extra energy. [....]

Key leaps forward for U.S. public social provision -- Social Security, Medicare, etc. -- have NEVER happened through "bipartisan" compromises and they always happen in close votes. They have always sqweaked through after gargantuan effort, strong presidential pressure, and refusal to allow eviscerating compromises. Think of Social Security if the Clark amendment -- allowing corporate opt-out -- had passed in 1935. We would not have it. And conservatives and the medical and insurance establishments cried "socialism" in 1965, too. We would not have Medicare if we had listened.

Obama and the Democrats are coming off a historic, landslide election. They have all the popular support for robust reform they will ever have. Good policy design as well public desire for change and considerations of social justice and economic efficiency insist that they enact health care reform with a strong public plan in the mix. That is the only way to move toward cost control and guaranteed access with quality to all -- especially for Americans in lower economic strata or in rural states where one or two private insurers call the tune. [....]

The stakes here in political-economic terms are NOT between a "free market" and "government control." They are between two alternative uses of government regulations and subsidies: [....] So-called conservatives seeking "compromise" on health care reform want more subsidies for their buddies' profits, and want to force more Americans to buy inefficient products (through a mandate to buy private insurance). If Obama and the Democrats agree to such compromises under the name of "reform" they will have squandered the country's future economically -- and undercut their own political fortunes for the future.

Because let's not kid ourselves: WHATEVER passes this year will make the Democrats owners of the health care mess going forward. If they just throw more subsidies and piecemeal regulations into the current system, they will ensure galloping public costs for residual arrangements and for subsidies to private insurers who will easily find ways to avoid sick or costly patients. Businesses and citizens will grow more and more irritated as time passes, and will blame the Democrats. Rightly so. [....]
=> "Defend and Demand: The Progressive Way Forward" (December 19, 2009)
The 2009 health reform end game -- yes, the end of the beginning is in sight -- has been excruciating for progressives. Reforming health care in the real world in which we live means paying to include millions more Americans while fending off all of the tricks America's privileged, left and right, use to resist paying taxes; and it means finding ways to use public regulations and subsidies to put health delivery and finance on a more sustainable path for us all, while watching key mechanisms like the public option shrink and disappear to buy the votes of a few weasely "Democrats" in Congress who want to guarantee profits for private insurers.

Understandably, some progressives see what's left at the end of these struggles as not worth their support. But history tells us this is mistaken. We should take the many big steps forward that are on the table now -- above all the expanded entitlement, the regulations of private insurance, and the increased subsidies for the less fortunate -- and accept that true "health care reform" remains a multi-year, multi-election struggle. Social Security took several decades to become universal and adequate; Medicare did not include cost controls or key benefits for many years. Both programs moreover, had to be improved and defended at the same time, because conservatives attacked and tried to dismantle, even as liberals fought to improve and expand. The same will happen here.

So what should happen next for progressives? We have to DEFEND AND DEMAND AT THE SAME TIME-- and keep at it:

-- We must curb our doubts enough to celebrate what is good in the accomplishments and promises of this round in health reform, and make sure that those Congressional Democrats who fought for the best parts of this reform survive in 2010 and 2012. There is a huge amount of good in even the compromised Senate bill. It marks the accomplishment of a century-long struggle to say that all Americans deserve public help to ensure affordable health care coverage; and there are billions in subsidies to help many lower and middle-income people afford health care. [Etc.]
=> What changed in the meantime? Well, no doubt watching the health care reform effort make its way through the political meatgrinder this year has been a sobering experience. As John Maynard Keynes once said: "When the facts change, I change my mind. What do you do, sir?"

That doesn't necessarily mean that Skocpol's present position is the correct one, though I'm inclined to agree with it myself. But the crucial point is that morally serious political judgment has to take account of reality, with all its constraints and imperfections and ethical irrationalities, as well as ideals. (And has to do this without succumbing either to doctrinaire and unrealistic moralism or to spineless and unprincipled opportunism masquerading as 'pragmatism'--which, as Max Weber explained in his great essay "Politics as a Vocation," is not easy.)

--Jeff Weintraub

P.S. As I was finishing up this post, I noticed that Matt Yglesias also urged people to read and ponder Weber's arguments in "Politics as a Vocation"--and quoted one of the key passages, too. At moments like these, it's hard to avoid thinking about Weber's analysis of what it means to pursue what he calls an "ethic of responsibility" in politics. Matt ends on the right note:
[This] is perhaps a long-winded way of explicating Weber’s maxim: “Politics is a strong and slow boring of hard boards."
But we might also note what Weber says next:
It takes both passion and perspective. [....] [E]ven those who are neither leaders nor heroes must arm themselves with that steadfastness of heart which can brave even the crumbling of all hopes. This is necessary right now, or else men will not be able to attain even that which is possible today. Only he has the calling for politics who is sure that he shall not crumble when the world from his point of view is too stupid or too base for what he wants to offer. Only he who in the face of all this can say 'In spite of all!' has the calling for politics.

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