For Starr, the only way to make sense of America’s peculiar relationship to healthcare is to explore its history: this was not a foregone conclusion. Although Americans like to use “American self-reliance” to explain their resistance to public healthcare, Americans are also egalitarian. “How is it that we never hear the phrase ‘socialized education?’” he asked, drawing laughs from a full house at the Skirball Center, at an event sponsored by the California HealthCare Foundation.

The healthcare industry has gotten rich off privatized care, and those Americans who are protected by current policies (what Starr called “the best-organized groups in society”) feel that they deserve their healthcare for moral reasons. They don’t want to be taxed for other groups who haven’t “earned” their healthcare. This attitude is “partly responsible for the bitter, vituperative aspect” of our healthcare politics, said Starr.

To illustrate the history of America’s healthcare wars, Starr likened the conflict to a play in three acts, which continues today.

Act One begins in the post-World War I era, when the first proposals for a government healthcare program in the U.S.–to be instituted at the state level–were modeled on well-established European systems, and Germany’s in particular. Opponents called this “a plot by the Kaiser” and succeeded in defeating it across the country, including in New York, where Franklin Roosevelt was governor. He’d put healthcare reform on the back burner as a result. And once the Cold War began, government-run healthcare was equated with Soviet socialist policy thanks to a script that the American Medical Association and other groups had developed over time.

In Act Two, Lyndon B. Johnson passed the 1965 Social Security Act to establish Medicare in the hope that it would be the first step to a universal health insurance system. But the high cost of both programs (thanks to steep concessions) made them an obstacle rather than a boost. And though Richard Nixon and John F. Kennedy both had healthcare plans–Nixon’s in 1974 was in fact to the left of both Bill Clinton and Barack Obama’s plans–Watergate (and a scandal involving a stripper and Congressman Wilbur Mills, one of the architects of Johnson’s plan) ultimately meant failure.

Act Three, said Starr, is “the escape from the health policy trap”–perhaps. In the 1980s and early 1990s, healthcare costs were increasing more quickly than earnings. Americans could agree that the current healthcare system wasn’t working, but there was no consensus about a solution. Bill Clinton’s plan (on which Starr advised) “began with a lot of optimism, energy, and belief that something was going to happen” before devolving into divisions between Democrats and Republicans and within the Democratic party itself. When the Republicans who had offered cooperation withdrew their support to unite against Clinton, the plan was dead–and then 1994 saw Newt Gingrich take power in Congress. (“When I wrote the book, I thought was writing about a historical figure,” Starr quipped.)

Why did Obama succeed where Clinton failed? The answer lies in what Starr called “minimally invasive reform.” Healthcare reformists concluded that any legislation that could possibly pass would need to solve the most urgent problems of the uninsured and eventually control costs–but it couldn’t disturb people who were employed and had good insurance or conflict with the major interest groups.

Ironically, it was the right who led the way. In Massachusetts, Mitt Romney passed a plan (designed by the Heritage Foundation) that relied on a health insurance exchange with subsidies for private insurance and an individual mandate. In the Democratic primaries in 2007 and 2008, Hilary Clinton, John Edwards, and Barack Obama all put forth proposals following Romney’s framework.

By 2009 and 2010, the people leading the effort to get Obama’s legislation passed had the battles of 1993 and 1994 under their belts. “They had become both more cautious and more determined,” said Starr–as well as willing to make many more concessions. And the top leadership in Congress was determined, too, to pass the bill.

“It’s a miracle that they were able to get all 60 [Democrats] when they had 60, in order to pass it in December of 2009,” said Starr. Although he has criticisms of the bill, he was clear that its passage was above all “an achievement … given the long history that preceded it and all of the obstacles that stood in its way.” This is the most important legislation in decades for improving the lives of low-wage Americans, he said.

Starr didn’t hesitate to point out the bill’s problems: the four-year lag between passage and implementation in 2014; the individual mandate, which is the focus of legal challenges and political opposition; and the fact that “the bill is unloved by Democrats because it doesn’t live up to their expectations, and hated by Republicans.” If the bill fails, said Starr, our healthcare war will continue–and the search for remedy will resume under a cloud of uncertainty.

Watch full video here.
See more photos here.
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Read expert opinions on why America’s healthcare reform wars are so bitter here.

*Photos by Aaron Salcido.

The post The Not-So-Great War appeared first on Zócalo Public Square.

Most Americans agree that everyone needs doctors, hospitals, and access to the best medical care possible. Countries compete for the highest life expectancies and the lowest infant mortality rates. But in the U.S., when we start talking about how to get there, we stop agreeing–at all. Healthcare has become a political rallying point and a subject it might be unwise to bring up at the dinner table, but it’s not like this in other countries. How did a policy become a symbol for so much more in America today? In advance of Paul Starr’s visit to Zócalo to discuss our healthcare wars, we asked health policy experts what makes us a most peculiar nation when it comes to this issue.

Healthcare Realities Clash with Our Beliefs

Policy disputes about healthcare in the U.S. are about much more than healthcare. They’re really about our perceptions of ourselves as individuals and as a society. They are disputes about who we are, what we inherited from our history, and what kind of society we want to be.

The U.S. is divided between two groups. One group thinks the U.S. should become more like European countries, which have strong values of social solidarity and universal health systems. The other group is convinced the European model is the wrong way to go. Meanwhile, healthcare policy disputes force us to confront three deeply held beliefs:

1. The belief that the U.S. has the best healthcare system in the world. The Speaker of the House of Representatives, John Boehner, has insisted that the U.S. healthcare system is the best in the world. Experts in the U.S. and elsewhere know that is simply not true.

2. The belief that everyone in the U.S. who really needs medical care will receive that care, regardless of ability to pay. Many patients in the U.S. receive free or discounted care, but many other patients fall through the cracks.

3. The belief that Americans are “rugged individualists” who cannot be forced to do anything. Americans may indeed be more individualistic than other people, but they accept federal mandates like the payment of federal income taxes and Social Security taxes.

Debates about health policy and health reform force us to confront these deeply held beliefs. That’s never easy.

Dean M. Harris is a clinical associate professor in the Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill.

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It’s a Three-Ring Circus: Politics, Symbolism, and Defining Ourselves

When Harry Truman first proposed national health insurance, Senate minority leader Robert Taft (R-Ohio) promptly tagged it “the most socialistic measure that this Congress has ever had before it.” Shouting “Socialism!” in the middle of the Red Scare was a serious charge, and Democratic Committee Chair James Murray responded furiously. “You have so much gall and so much nerve,” Murray screamed at his colleague. “If you don’t shut up, I’ll have … you thrown out.”

Every time the issue comes up (and it has come up often: 1946, 1949, 1962, 1964-5, 1974, 1979, 1991-4, and 2009), the rhetoric runs long, loud, and hysterical. Why? Because big health reforms always plays out on three different levels–every one of them a killer.

First, the debates rest on honest philosophical differences. Liberals believe healthcare is a basic human right while conservatives insist it is a market commodity. There are not many policy areas where the disagreement is so stark. Healthcare has become a badge of shame for liberals (“We’re the only nation without national health insurance”) and a point of pride for conservatives (“We’re the only nation without national health insurance”).

Second, national health insurance proposals provoke intense images. Never mind the actual proposal on the table; opponents always see the triumph of socialism, the death of free enterprise, the iron rule of the bureaucrats, or the cruel murder of innocents. “If this program passes,” warned Ronald Reagan about Medicare in 1963, “one of these days we will tell our children and our children’s children what it was like in America when men were free.” Sarah Palin offered the most memorable image during the latest round of health reform. “The America I know and love is not one in which my parents or my baby with Down syndrome will have to stand in front of Obama’s ‘death panel’ so his bureaucrats can decide … whether they are worthy of healthcare. Such a system is downright evil.” Palin’s “death panels” went viral. Talking heads, bloggers, radio jocks, editorial writers, Congressmen, and citizens all repeated and dissected the phrase.

Those supporting healthcare reform are invariably stunned by the assault. They try to dismiss the exaggerated charges. No, Medicare was not the end of the land of the free. No, health reform did not include death panels or anything like them. But their efforts don’t matter much, because even if the attacks are exaggerated, they connect with real anxieties. What reformers must articulate in response are hopes and dreams that go as deep as people’s fears.

Third, healthcare systems are about life, death, comfort, dignity, and pain. Every healthcare system in the world tells us something important about the society that created it. Healthcare reform gets to the most fundamental question Americans can ask: Who are we as a nation? That’s why the debate touches all the hot-button issues, like abortion and immigration. The debate gets especially angry when images of our community degenerate into nasty pictures of “us” and “them.”

So keep those seatbelts fastened. There’s lots more health reform turbulence ahead. It’s a political circus with three rings: a great debate about the nature of healthcare policy, lots of anxieties about the state of the nation, and a conflict over the deepest question of all: who we are as a nation and a people. If all that were not enough, there’s one final thing to consider: healthcare is often decisive in the battle for control of Washington, D.C.

It may not be pretty. But it’s the way we’ve been doing health reform since Harry Truman first tried it in 1946.

James Morone is professor and chair of political science at Brown University and author of The Heart of Power: Health and Politics in the Oval Office (written with David Blumenthal) and Hellfire Nation: The Politics of Sin in American History.

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The Financial Stakes Are Higher Here

Because medical care involves the most basic issues of life and death, and because healthcare is a major segment of the economy in every wealthy nation, healthcare systems spawn endless debate and consternation all over the world. But health policy disputes in the U.S. tend to be the nastiest of all, for two reasons. First, the U.S. spends much more of its wealth on medical bills than any other country. We’re putting 17 percent of our GDP into health care; the other industrialized democracies spend about half as much. So there’s a lot of money at stake in our debate.

Beyond that, all the other industrialized democracies have already recognized the first principle of a healthcare system: they cover everybody. They consider it a moral imperative to do so. The United States has never committed to universal coverage. In 2011, we had 49.9 million people without health insurance.

Americans tend to do the right thing over time–the civil rights revolution is proof of that. Eventually, we will recognize that the world’s richest nation has a moral obligation to provide medical care for anyone who needs it. Until we do, our debates over health policy will continue to be angry and polarizing.

T. R. Reid is an author, lecturer, and documentary filmmaker. He is the author The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care (Penguin Press).

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It’s An Existential Debate

While people in Japan, Canada, and other nations enjoy gains in life expectancy every year, in the majority of U.S. counties, life expectancy is actually decreasing. Worse still, this reversal of fortunes is occurring in the context of the most significant health spending in the world.

According to Austin Frakt, a health economist at Boston University, there is no good explanation for the poorer outcomes and higher costs observed in the U.S. He writes: “Our population is younger than the average OECD country (source). Growth of U.S. health spending is much higher than that of other OECD countries even after controlling for population aging (source).”

In the presence of these evident shortcomings, you’d think that policy debates would be more technical, focused on any payment, pricing, or quality solution that promised to improve health and save costs. Instead, U.S. healthcare politics is anything but technical. Instead, the politics are party-driven, theatrical, and just plain nasty. Health reform was termed Obama’s “Waterloo” by Republican lawmakers in spite of its similarity to earlier Republican proposals. Don Berwick, a highly qualified technocrat, has been accused of an unpatriotic “affection” for the British model. The estimates of the non-partisan Congressional Budget Office are said to be “gamed.”

But while OECD countries aren’t different in terms of health behaviors and demographics, there are at least two reasons why their politics are less ugly.

First, there’s just less at stake. Financial and economic interests are just more limited. Most countries spend less than 9 percent of GDP on health. In the U.S., we spend almost double that amount. When the health sector is less important to the economy, there are fewer, less significant economic interests to lobby politicians and legislatures. Unlike the U.S., government is the main funder of care in most countries of the OECD. When government is the main purchaser, insurers and providers have less political leverage. Contrast this to the U.S., where multiple small-scale purchasing agents (employers, individuals) are dispersed, not easily organized, and lacking purchasing know-how and market information.

In most countries around the world, there is consensus on the role of government in healthcare. People expect their governments to help mitigate health and financial risks on their behalf. Political debates in these countries focus on why the government isn’t doing more or why the government is not obtaining sufficient value for money. They’re not focused on existential debates on whether risk sharing for the poor or sick should exist at all or whether people should be obliged to be insured.

Amanda Glassman is director of Global Health Policy, Center for Global Development.

*Photo courtesy of mediateletipos.

The post A Sickening Dispute appeared first on Zócalo Public Square.

The 2010 legislation calls for the establishment of insurance exchanges, subsidies to the poor and near poor to make insurance affordable, and a mandate requiring individuals to maintain a minimum level of health coverage. That approach was championed originally by the leading conservative think tank, the Heritage Foundation. It was the basis of legislation co-sponsored by 20 Senate Republicans in the early 1990s, and it was the framework of the reforms that Mitt Romney enacted when he was governor of Massachusetts. Romney isn’t the only Republican presidential candidate haunted by his record on the issue; his main rival, Newt Gingrich, also used to support an individual mandate, though he has now apologized for it.

Moreover, the framework of the 2010 Democratic reforms bears a striking resemblance to current Republican proposals to convert Medicare into a “premium support” system. Under those proposals, Medicare would remain compulsory; Americans would have no choice about paying taxes for the program during their working years. Then, when they became eligible for Medicare–whether at age 65, as under current law, or at age 67, as under the budget introduced by Rep. Paul Ryan and approved by House Republicans–they would receive a “premium support” (more generally called a voucher) to cover part of the cost of enrolling in a private insurance plan.

Democrats object to Ryan’s proposed elimination of the traditional, public Medicare program and his plan to tie the value of the voucher to the consumer price index, which has long grown more slowly than medical costs. These provisions would dramatically shift healthcare costs to the elderly. But the Republican plan for Medicare does resemble the 2010 Democratic legislation in its basic “architecture”: health insurance exchanges, affordability subsidies, and an individual mandate.

Medicare is not the only area where Republicans would like to introduce changes that resemble the 2010 healthcare law. GOP proposals for privatizing Social Security follow a similar pattern. Under those proposals, Social Security would remain a compulsory program; workers would have no choice about whether to pay into it. But they would be able to choose among a set of private-investment alternatives (and the value of the annuities they received would vary with the success of their investment choices). In other words, there would be an individual mandate for retirement savings, but the vehicles for these savings would become private.

So while conservatives now object to the individual health insurance mandate and other provisions of the 2010 law, it’s not clear that this is an objection on principle. The rule seems to be that a mandate for private insurance is acceptable when they propose it, but when Democrats do, it is an intolerable violation of individual liberty.

As so often happens in the United States, a debate about whether a policy is legitimate has become a debate about whether it is constitutional. This coming spring, the Supreme Court will hear arguments about the constitutionality of the individual mandate. If the law had been drafted differently, it could have provided a clear constitutional rationale under the taxing power of Congress–the same rationale that Social Security and Medicare have. For example, the law could have imposed a healthcare tax and then provided an off-setting credit to all those with private insurance; the net result would have been the same as the mandate. But Democrats shied away even from the use of the word “tax” and instead justified the mandate under their authority to regulate interstate commerce. That choice has left the law vulnerable to challenge.

But should thoughtful conservatives want to see the mandate overturned? After all, a decision against the mandate could have wider implications, undermining the legitimacy of other proposals conservatives favor.

That concern was raised in a fascinating opinion on the individual mandate by Judge Brett Kavanaugh, a conservative, Republican appointee to the District of Columbia Circuit Court of Appeals. The D.C. Circuit is one of the appellate courts that ruled in favor of the constitutionality of the mandate. Judge Laurence Silberman, appointed to the bench by Ronald Reagan, wrote the majority opinion, a striking affirmation of the mandate’s constitutionality.

But just as striking was the dissent by Judge Kavanaugh, a figure who bears watching.
Some observers have suggested that although we don’t yet know who will win the Republican presidential nomination, we do know the identity of the next Republican nominee for the Supreme Court–Brett Kavanaugh.

To the disappointment of some conservatives, however, Judge Kavanaugh did not vote to strike down the mandate. Nor did he vote to uphold it. He ruled instead that under the 1867 Anti-Injunction Act, no one has standing to contest the mandate until penalties are imposed under the law–that is, not until 2015. But by then, he noted, the law might be revised (or possibly repealed), so the courts would never have to resolve the issue at all.

Toward the end of his opinion, Kavanaugh introduced another reason–a “results-oriented” consideration–for judicial restraint on the mandate:

This case also counsels restraint because we may be on the leading edge of a shift in how the Federal Government goes about furnishing a social safety net for those who are old, poor, sick, or disabled and need help. The theory of the individual mandate in this law is that private entities will do better than government in providing certain social insurance and that mandates will work better than traditional regulatory taxes in prompting people to set aside money now to help pay for the assistance they might need later. Privatized social services combined with mandatory-purchase requirements of the kind employed in the individual mandate provision of the Affordable Care Act might become a blueprint used by the Federal Government over the next generation to partially privatize the social safety net and government assistance programs and move, at least to some degree, away from the tax-and-government-benefit model that is common now. Courts naturally should be very careful before interfering with the elected Branches’ determination to update how the National Government provides such assistance.

The only surprise about this point is that it took so long for a conservative to make it. The individual mandate is the child of conservative thought. Killing that child might be satisfying for immediate political reasons, but it would make no sense from the standpoint of conservatives’ long-term goals. In thinking about what the Supreme Court will do, conservatives might heed an old caution: watch what you wish for.

Paul Starr, a professor of sociology and public affairs at the Woodrow Wilson School at Princeton, is co-editor of The American Prospect magazine and author of Remedy and Reaction: The Peculiar American Struggle over Health Care Reform.

Buy Remedy and Reaction: Amazon, Skylight, Powell’s

*Photo courtesy of IowaPolitics.com.

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