Friday, August 21, 2009

Perspectives on the Health Care Debate

[I must again inform new visitors, brought here by an email circulating under my name that compares President Obama to Adolf Hitler, that I did not write that completely fraudulent email. For comments on it see the post, "A Great Fear," below. For more information on it see
Not since 1935, the year of the Wagner Act and of Social Security, or 1964 and the great Civil Rights Act, has the Congress faced such a critical choice as it does now. The passage or failure of effective health care reform will determine the direction that the country takes for a long time. One can understand the debate from several related perspectives, both constitutional and geographic.

Ten or twenty years ago I read an interesting article in the New Republic arguing that the Senate had turned into the fatal flaw in our constitutional system, because it gave too much power to tiny states, many of which had little involvement in the great problems of modern life. Because those states were white and lacked industry, they were largely Republican, and their Senators played key roles in blocking liberal legislation and demoralizing Democrats around the country, the article argued. I thought the argument was interesting, and it certainly occurred to me in 2000 that the Senate--and the 100 electoral votes it represents--was the only thing that had made the lamentable presidential election of that year even close. George Bush beat Al Gore not only because he managed to escape with Florida's electoral votes, but because he carried 29 states to Gore's 22 (counting DC), giving him 14 more electoral votes unrelated to population. Take away those 102 electoral votes and Gore would have won. I am not sure but I suspect that is the only election in which this has occurred.

Now, however, this problem is re-emerging. The House, apportioned by population, seems ready to pass health care reform and the Democratic leadership is committed to a public option. In the Senate key positions are held by two Democrats from very small (in population) states, Max Baucus of Montana and Keith Conrad of North Dakota. Conrad in particular is trying to stop the public option and claims the votes for it are not in the Senate. When one thinks about this, especially in contrast to the two earlier great crises in American life in the 1860s and the 1930s, some interesting differences occur.

Differences between small and large states were far less significant in the mid-19th century, largely because the United States was still overwhelmingly agricultural. The main difference, of course, was between slave and free states. The smaller free states of the west opposed slavery for some of the same reasons as the larger states of the North: they wanted to preserve their own land for free labor and small farmers. (Ironically, the strength of the Democratic Party in the North was largely in urban immigrant populations, who disliked the Yankee elites and particularly despised black people.) Similarly, in the 1930s the depression had devastated farmers everywhere, enabling Roosevelt to put together a truly national coalition because he saved people all over the country from foreclosure and starvation. The paradox today is that those who need help the most--the citizens of the red states, including the smaller ones in the upper midwest and the mountain states, but especially in the South--have become most distrustful of the government and of the educated elites. The problem the President faces is to convince those people that broader, reformed health insurance will improve their lives, and it is not clear, in the current climate, that he can do so.

A second, unrelated problem may be equally serious. The New Deal, the New Frontier and the Great Society grew in tandem with the American labor movement, which provided much of the lobbying support and the votes for their programs. Over the last 40 years, as I have noted many times, unions in the private sector have suffered a spectacular decline. That is why, in my opinion, the right seems to be out-organizing the left during the health care controversy, successfully packing town meetings and turning them into bear-baitings similar to the confrontations I saw as a student more than 40 years ago between university Administrators and the SDS. (I'll be posting on that soon.)

There seem to me to be three sides to the health care debate right now. One is the insurance industry, determined once again to avoid real reform and to protect its profits, and its equally powerful allies in the drug industry. They are of course heavy contributors to all sorts of key legislators (including Max Baucus), and they are probably helping orchestrate the town hall protests (see below.) They are allied, as the President recognized on Thursday, with the Republican Party, which wants to replay the scenario of 1993-4 when its determined opposition sank the Clinton health care plan and paved the way for victory in the 1994 Congressional elections. And the strength of that party is among the roughly 30% of the population which evidently cannot reconcile itself to the election of Barack Obama and will therefore believe the most absurd accusations about him and the health care program--the ones who are providing the troops for the town hall meetings. Most of them are relatively elderly, although there are exceptions, like the young woman who asked Barney Frank why he continued to support Obama's "Nazi plan" the other day. (Frank's reply should be seen on youtube.) On the other side are younger, more educated Americans who want to see the new President bring intelligence, analysis, and sanity into various aspects of national policy. They have not found a way to make their voices heard yet.

We do not have a smoking gun regarding the health care industry's campaign, but one did emerge this week regarding another key issue, the cap and trade bill. The American Petroleum Institute has circulated a memo to all its members describing its strategy against the bill. It deserves to be quoted in full.

Dear API Member Company CEO/Executive,
As I have outlined in the past few editions of the weekly
“Executive Update,” API is coordinating a series of “Energy
Citizen” rallies in about 20 states across the country
during the last two weeks of Congress’s August recess. Most
of these will be held at noontime, though some may be at
different times in order to piggyback on other events.
Thanks to the leadership of API’s Executive Committee, I am
pleased to report that we have strong support for this
first-ever effort moving ahead. Now we are asking all API
members to get involved.
The objective of these rallies is to put a human face on the
impacts of unsound energy policy and to aim a loud message
at those states’ U.S. Senators to avoid the mistakes
embodied in the House climate bill and the Obama
Administration’s tax increases on our industry. Senate
Majority Leader Senator Harry Reid reportedly has pushed
back consideration of climate legislation to late September
to allow Senators time to get their constituents’ views
during the August recess. It’s important that our views be
At the rallies, we will focus our message on two points: the
adverse impacts of unsound energy policy (e.g., Waxman-
Markey-like legislation, tax increases, and access
limitations) on jobs and on consumers’ energy costs. And we
will call on the Senate to oppose unsound energy policy and
“get it right.”
Recent opinion research that Harris Interactive conducted
for API demonstrates that our messages on Waxman-Markey-like
legislation work extremely well and are very persuasive with
the general public and policy influentials. After hearing
that Waxman-Markey-like legislation could increase the costs
of gasoline to around $4 and lead to significant job losses,
these audiences changed their opinions on the bill
significantly. Opposition to the bill within the policy
influentials cohort grew 23 points, from 40% to 63%; with a
19 point increase in those who now “strongly” oppose the
legislation. The data clearly demonstrate the softness of
support of the current approach and very strong opposition
when people are educated about the potential job losses and
energy cost increases. Our expectation is to translate
peoples’ real concerns for job losses and increased energy
costs to all unsound proposals (e.g., Waxman-Markey-like
legislation, tax increases, and access limitations).
We have identified 11 states with a significant industry
presence and 10 other states where we have assets on the
ground. We also have attracted allies from a broad range of
interests: the Chamber of Commerce and NAM , the trucking
industry, the agricultural sector, small business, and many
others, including a significant number of consumer groups,
which have pledged to have their membership join in the
events in states where they have a strong presence. We also
are collaborating closely with the allied oil and natural
gas industry associations on these events.
While such efforts are never easy and the risk of failure is
always present, we must move aggressively in preparation for
the post-Labor Day debate on energy, climate and taxes.
The measure of success for these events will be the
diversity of the participants expressing the same message,
as well as turnouts of several hundred attendees. In the 11
states with an industry core, our member company local
leadership—including your facility manager’s commitment to
provide significant attendance—is essential to achieving the
participation level that Senators cannot ignore. In
addition, please include all vendors, suppliers,
contractors, retirees and others who have an interest in our
To be clear, API will provide the up-front resources to
ensure logistical issues do not become a problem. This
includes contracting with a highly experienced events
management company that has produced successful rallies for
presidential campaigns, corporations and interest groups. It
also includes coordination with the other interests who
share our views on the issues, providing a field coordinator
in each state, conducting a comprehensive communications and
advocacy activation plan for each state, and serving as
central manager for all events.
We are asking all API members to assist in these August
activities. The size of the company does not matter, and
every participant adds to the strength of our collective
voice. We need two actions from each participating company.
Please provide us with the name of one central coordinator
for your company’s involvement in the rallies. (We will look
to this person as your representative to assist the overall
effort.) If you will let me know ASAP, we can be in touch
quickly and provide that person with additional details
about the project.
Please indicate to your company leadership your strong
support for employee participation in the rallies.
(Unfortunately, we are already experiencing some delay from
your regional people since they are not yet aware that
headquarters supports the effort.) I believe that expression
of support to your company leadership is a fundamental
predicate to organizing quickly and achieving success in
this endeavor.
The list of tentative venues is attached. Please treat this
information as sensitive and ask those in your company to do
so as well, as some of these places may be subject to
change, and we don’t want critics to know our game plan. You
can assume with confidence that the advocates for Waxman-
Markey-like legislation and the critics of oil and gas are
going to be very active, particularly during the August
Once the list of venues and exact rally dates are
determined, we will contact your company’s coordinator to
distribute the information internally and to coordinate
transportation to the venues, if required, for your
employees. In the meantime, your company’s coordinator could
assist us by telling us in which of the venues listed below
your company has facilities or employees who can
I look forward to working with you to make the August rally
project and the other advocacy steps we are undertaking to
deliver the policy outcomes we support with measurable
results. Don’t hesitate to call me with questions.
All the best,
Jack N. Gerard
President & CEO
Tentative Venues
Houston TX
Perry GA
Detroit MI
Roswell NM
Greensboro NC
Farmington NM
Ohio (venue being finalized)
Greeley CO
Nashville TN
Indiana (venue being finalized)
Bismarck ND
Tampa FL
Sioux Falls SD
Greenville SC
Anchorage AK
Joliet IL
Charleston WV
Fairfax VA
Philadelphia PA
Lincoln NE
Missouri TBD
Arkansas TBD

What strikes me about this is the complete lack of interest in the details of the Administration's proposal--just repeated references to "Waxman-Markey like legislation," which is by definition bad. Greenpeace, which discovered the memo, pointed out that the $4 gasoline estimate comes from a study by the Heritage Foundation, which receives much of its funding from oil companies as well. The insurance industry has presumably sent out similar instructions. Because most educated, professional Americans of liberal views are not organized and because unions have become so weak, they--like myself, for instance--aren't getting any comparable instructions. That's a problem. Roosevelt's reforms faced the same mixture of determined and hysterical opposition, much of it from older Americans as well. He however rode into office on a much bigger wave of discontent, and even increased his majorities in Congress after the first two years of the New Deal. He made the United States the first truly advanced industrial nation in economic and social policy. The question now is whether we will fall out of the ranks of those nations.


Lee said...

Very interesting post. I do think that you may have overlooked another segment of American society in this debate-- those of us who believe that the health care system is indeed flawed, but are extremely skeptical about government involvement doing anything to improve the situation. (Please let me know if you did address this segment, I admit that with a toddler running around the house, I may have missed it!)

That being said, please do not read anything negative in my tone (as the internet is famously bad at conveying facts, much less "tone"!) The health care problem in this country is something that concerns me deeply, especially considering that my family and I do not currently have health insurance.

I am interested in your opinion, as a much more experienced historian than I, where the 10th Amendment would fit into a national health care plan? I specialized in the 19th Century in my history courses, so I'm ashamed to admit I don't know much about how this may have come into play with the New Deal/Social Security debates. (And perhaps those debates would be more appropriate for comparison with today's events as opposed to McCulloch vs. MD and how Abraham Lincoln may or may not have overextended his role)


I don’t see any blame of the Obama Administration in all of this critique. While it is quite valid to point out the relative weakness of unions, it is also a telling remark that “Because most educated, professional Americans of liberal views are not organized and because unions have become so weak, they--like myself, for instance--aren't getting any comparable instructions.”
Obama has quite rightly been distracted by the Great Recession, however, his organizational abilities belie a great spokesperson who doesn’t have a clue what to do once he gets what he wants – i.e. the White House. As mentioned this AM less than 20% of appointment posts have even been submitted for confirmation to Congress. Other aspects of this failure: the complete neglect of his electoral mobilization “grass roots” machine until only a few weeks ago. Remember that last spring Obama said he was ready to take on the insurance and drug industries in the healthcare fight, yet he his staff had done nothing to mobilize the base, and Obama instead was inviting the foxes into the henhouse to make deals which it appears he has, or is in process of making.
The accusation has been repeatedly made on the Left that Obama gave up “single payer” legislation before anyone had even argued about it. He has done nothing to revise existing programs, like the Medicare Drug Program to include negotiating lower prices, he has done nothing to guide the legislative process except to publicly state that he is willing to accept just about any healthcare bill with or without a serious competitor for the private insurance monopolists.
Here is the nut of it. While the structure of the Senate was purposefully built into the system to do exactly what is described in your essay – whether as a concession to the Southern states, or as a philosophical counter to pure majority rule – Lyndon Johnnson managed to twist enough arms, nor did he give away the store before the talking had even started.
Franklin Roosevelt also used what today would be called bald class warfare to get passage of many of his programs.
And Obama? He stumbles along just as one imagines Robert Redford would have done in the sequel to movie The Candidate. Remember? At the end of the movie, now that he has been elected, he says, “So what do we do now?”

cat.mailander said...

'Not organized?!?' obama ran the MOST organized campaign in the history of this country! Wow, I can't believe you actually wrote that! I really don't have anything else to say about what you wrote, because after the 'not organized' comment, I realized that you are too far gone. Except I will say that obama not only struck a deal with BigPharma, but he is negotiating with the 'big bad' insurance companies now, and they have agree that they don't mind being vilified by the administration, as long as they are in bed with the White House.

JOENYC said...

Your characterization of anyone who disagrees with the Obama plan as either a) an undeducated dolt or b) an opportunistic Republican candidate should alert your readers to your incredible bias.

There are many of us who oppose the Obama plan because it can't work as designed. You simply can't take the existing number of doctors, add 20% more patients and not expect that there will be rationing of medical services.

Claude said...

Ok Mr. Educated and elite northerner from the Oh so elite blue states....

First you INSULT those of us that live in the Red states (I could just read the patronizing tone in your words), then continue on to say that unions have lost power?! That Obama didnt not have an organized campaign? That is laughable. ACORN (one of the most marxists groups in America that should be on the same "Watch List" as any white supremicist group) made sure of that.

Name for me ONE...ONE... USG run program that always runs with a surplus or even breaks even ....

I dont like the escalating costs of medical care in this country either... but why dont we look at REAL solutions instead of just another social entitlement program.

Conserv Radical said...

The US certainly needs a health care system (vs. the current hodgepodge) that covers every citizen.
The there are two fundamental parts of this debate:
1. What kind of system should be designed?
2. How to pay for it?
The first thing is to develop a real health care system and then address how to pay for it. (It is my opinion is the US already pays enough to fund a good system, we just need to reallocate the wasted money).
-There is also no basis for unlimited tax exemption on health care insurance

Suggest that everyone be in the same pool (i.e., no exclusions) and then simplify the private insurance company 'system' by limiting the number of companies, by competition, and have a total of 10-12 companies administer the program. (This should look similar to the current federal program for civil service employees).
-This should preserve the private industry -but streamlined for efficiency.

One issue that must be addressed is that many Doctors currently refuse to accept Medicare patients- This must be corrected in the new system.

Bob said...

You all forget one thing. Healthcare,a high paying job, homeownership, a car, are not rights guaranteed by the constitution. Our founders are rolling in their graves. RIP America, You were once a great nation.

Conserv Radical said...

No, I did not forget anything. Just posted my opinion that the USA first needs a real healthcare system (not the current ad-hoc approach) and then - the hard part- we need to determine how to pay for it. I really believe that there is enough wasted money (e.g., unwarranted overhead costs, etc.) to cover everyone. This would avoid people going to the emergency room at high prices that the rest of already have to cover. If we had a real system, then the actual costs would be lower. Then the debate could shift to payment options. It is difficult to have any dialog with the current hard positions on both (all) sides.

Bob said...

Less interstate Govt rules prohibiting competition and tort reform would go a long way toward solving the problem of the app 11 million chronically uninsured. The rest could be handled by numerous avenues, including local clinics staffed by a PA and carefully means tested. Many other good ideas out there but neither I nor anyone else have any right to take ill gotten money taken from taxpayers to pay for someone elses healthcare. It is each persons responsibility to take care of themself. WE have strayed too far from what made this country successful and great.