Health care reform after the Summit - Andrew Sullivan assesses the prospects

In a (London) Sunday Times column yesterday, Andrew Sullivan combined a post-mortem on the bipartisan Health Care Summit with an overall assessment of the issues at stake in the health care reform fight and the prospects actually getting something accomplished. I don't agree completely with all his points, and some of the ones I do agree with aren't new or surprising. But overall this is an intelligent, perceptive, and fair-minded overview of the current state of play.

As Sullivan himself notes from time to time, the tone of his columns is sometimes calmer and more reflective than that of (at least some of) his blog posts. Calm and reflective are the keynotes here--but certainly not bland or wishy-washy.

As usual, it's worth reading the whole thing, but here's main body of his discussion ... with some remarks of my own interspersed:

Well, I did my best to watch the healthcare summit. I really did. But it was a bit like watching the cross-country skiing in the Olympics. Everyone seemed to be trying very hard and you knew that someone in the end would presumably win, but before any real resolution occurred you had nodded off.

Barack Obama was Barack Obama: smooth, unruffled, on top of the facts, open to civil debate. The Democrats were almost uniformly awful, a sad sack of shiftless saps. [....]

Not entirely unfair, though there were some exceptions.

The Republicans did better than expected.

True, but only because expectations had been so low. After the televised question-and-answer session between Obama and the House Republicans on January 29, the Republicans realized that Obama came off looking very good in that exchange, and this time they were better prepared. Also, they were careful to keep most of their real crazies (I name no names)out of the discussion.

Sullivan, who has never quite shaken off the traces of his Thatcherite past, continues to hope (or fantasize) that he can find some genuine "fiscal conservatives" on the Republican side. Once again, reality intrudes on wishful thinking.

There was even one intellectually honest moment when one of the younger ones, Paul Ryan, actually seemed to be sincere about opposing the bill on fiscal grounds. He made several good points, mainly that Congress did not have a good record on cutting Medicare — which was a core component of the bill to prevent it from breaking the bank. And then one remembered that in 2003 he had voted for the biggest entitlement programme since Lyndon Johnson — free pills for the elderly for ever — with not even the faintest attempt to pay for any of it. The total future cost of that Republican bill dwarfs the current one. But when George W Bush was president, the Republicans were massive spenders and borrowers. Their sudden conversion to fiscal rectitude occurred miraculously on January 21, 2009.

Why dwell on the past, one might ask? Because the Republicans have now established a very clear long-term record. When there is a Democratic President, they will reflexively oppose any constructive measures (back in the early 1993, let us recall, Bill Clinton's economic plan, which really was fiscally responsible, passed Congress without a single Republican vote) and make noises about fiscal rectitude, while in practice being most committed to lower taxes for rich people and corporate welfare. Then, when they get back into power, they decide it's time to abandon these pretenses (in the immortal words of Dick Cheney, "Reagan proved deficits don't matter") and throw a party. At this point, why should anyone be foolish or gullible enough to take them seriously?

=> Now Sullivan zeroes in on the crucial point (also highlighted by Jonathan Cohn a few days ago):

The one helpful thing to emerge from the day’s torpor (I hope Obama had a cigarette afterwards for his sanity’s sake) was that we now have more public clarity on the critical issue. The Democrats want to provide basic private insurance to the 40m or so working poor who don’t have it. The Republicans don’t want to.

As a friend of mine correctly put it, that's the moral heart of the matter.

Both parties want to stop the cruelty of denying people access to health insurance because they have a pre-existing condition,

At least, most Congressional Republicans say they do.

but if you do only that, then the insurance companies will take a big hit and hike premiums even more, rendering even more people without insurance. So you have to have a way to get the companies to agree to this by giving them 40m more customers to outweigh the costs. Only the Obama plan does that. The Republicans have nothing.

Correct.

What some Republicans--including both politicians and policy analysts--really believe is that most health care shouldn't be covered by insurance at all. We should simply buy ordinary medical services on a straightforward fee-for-service basis, treating them as we do other ordinary commodities like widgets or loaves of bread or kitchen appliances, and at most reserve insurance for catastrophic or emergency care. Along with most analysts who have thought about health care more fully and systematically than I have, I happen to think this is a disastrously wrong-headed approach. But, at all events, it's something that Congressional Republicans almost never do more than hint at, with very rare exceptions that the news media generally ignore. For understandable reasons, most Republican office-holders are not quite willing to come out and say honestly to the public: "We think we can restrict costs by taking away your health insurance."

I have to say I think this is a reasonable, sensible centrist bill whose flaw is that it doesn’t do enough to control costs.

Again, this strikes me as a fair summing-up. Whether or not one likes the result, the Democrats' health care reform package, as it has come together over the past year, definitely represents a centrist, gradualist approach to reform rather than a radical overhaul of the system. It's also true that some of its main flaws are connected to this fact--since the existing system is such a mess, starting from it and trying to improve it incrementally will necessarily introduce complications and require compromising with existing dysfunctions. But, all things considered, reasonable arguments can be made that at this point a centrist, gradualist approach toward reforming the health care system is the most sensible, not least because the more simplifying alternatives are either not politically feasible (e.g., a single-payer system) or highly undesirable (e.g., radical marketization).

The trouble is no one knows how to do that without brutal rationing,

Could be. But some other countries somehow manage to provide health care that is, overall, at least as good as that provided by the American system (I use that formulation to be diplomatic and uncontroversial, but in some cases it's almost certainly better) with dramatically lower costs. So why should that be impossible for us here in the US?

but the bill does contain sensible pilot schemes to test out new models and it increases patient choice through healthcare exchanges. Among the most promising cost controls once envisaged: mandating that the elderly get to talk to their doctor about end-of-life decisions. Getting more people to agree in advance that they don’t want their lives extended a few days or hours at massive expense would free up resources for the young. But this was quashed by Sarah Palin’s hysteria about “death panels”.

=> Now to the immediate politics of the matter:

What will happen now? It’s pretty clear to me that the Republicans will not cooperate at all. But the summit once again showed Obama as a reasonable guy listening to the other side. This matters. Polls show the public favours him over the Republicans 2-1 when asked who is making the most effort to find practical solutions to public problems. His polling is still resilient with just under 50% approval ratings. In a brutal recession that’s not so bad.

Can he force his bill through the House and Senate with what’s called “reconciliation”, which requires just a one-vote majority in each chamber? That requires strong discipline among Democrats in vulnerable seats and a brutal process of procedural obstruction by the Republicans. In this, critically, the interests of Obama and his party divide. The Democrats in the House face re-election in November; he doesn’t until 2012. But, equally, failing to get anything done could be as damaging electorally as getting something somewhat unpopular done. You need your base to turn out in mid-terms and failure to do anything could mean more bad news for Democrats rather than less. I also think the massive support for the bill among Hispanics would be a critical long-term gain for the Democrats.

I suspect the bill will pass — but I sure wouldn’t bet much money on it.

I feel a bit more optimistic than that right now, but he's right that the outcome remains highly uncertain. If this whole effort does end in legislative gridlock and total debacle, should we draw any larger conclusions about the dysfunctionality of the US political system? Sullivan is, basically,inclined to look on the bright side. I offer the remainder of his discussion without comment, except to say that it's worth pondering, whether or not one fully agrees:

If it fails, does this mean we could face such deadlock in the world’s largest democracy that we are threatened with what one British economics commentator has described as “a financial crisis so horrific that actions by the British or European governments would be swept away like beach huts in a tsunami”? Er, no.

People forget that the American political system is designed to stop anything getting done. Civil rights bills, even after Kennedy’s assassination, were filibustered for 37 days straight. Bill Clinton’s healthcare bill failed; Bush’s social security reform failed. The Senate, with its arcane procedures, is a brick wall against change — just one senator can, in effect, stop everything. Rural states with barely anyone in them have two senators each, while the national capital, Washington DC, has none. The population represented by senators who favour health insurance reform dwarfs the population represented by senators who don’t. As Churchill once said: “Americans always do the right thing after they have exhausted every other alternative.” And that’s what the founders wanted. This isn’t a bug; it’s a feature.

After the appalling imperial presidency of Bush, Obama is trying to restore constitutional balance and order. While Dick Cheney, the former vice-president, had contempt for the rule of law, Obama is a stickler for it. His seeming passivity is actually what used to be called constitutionalism, which is why I still see Obama as a One Nation Tory rather than a liberal radical. If he squeezes this bill through, no one will now believe he rammed it through. He tried. Just as, if he imposes sanctions on Iran, no one will be able to say he didn’t try all he could to bring Tehran around. And this strengthens his position in the long run, when not all of us will be dead.

If he fails and the Republicans sweep in this November, he can pivot to long-term fiscal debt and ask the right to propose serious spending cuts. Or he can propose tax reform and watch them try to obstruct that. He has great leeway in foreign policy; he can impose climate change regulation by fiat through the Environmental Protection Agency rather than through Congress; he just got a jobs package through with Republican votes; he can expose how easy it is merely to oppose in difficult times and wait for the public to see the deep divisions and utopian anti-government extremism on the current right. This is how FDR navigated the shoals of the constitution.

Obama, as I keep reminding people, sees the long term; he sees around future corners before most do; and America is a resilient place, even though its problems are rightly seen as especially grave right now. This is a time for neither despair nor glib optimism. It is a time to watch a politician manoeuvre, from day to day and month to month, which our instant media seem incapable of seeing or understanding.

Well, I guess we'll see.

--Jeff Weintraub