It's Supposed to Be Difficult, But...
Friday morning, Andrew Sullivan voiced a point that certainly has occurred to me over the past few months:

Watching how this government can do nothing to reform healthcare, nothing to end the wars and occupations that drain the coffers, nothing to tackle entitlements even as the country teeters toward complete insolvency, nothing to reform a broken immigration system ... even after a president is elected with a clear mandate and a Congressional majority in both Houses: well, we know why America is fucked, don't we?

He was responding specifically to a reader's complaint about the climate change bill that the House narrowly passed later on Friday, which has been attacked from the left as insufficient for the magnitude of the challenge, and from the right for adding a cost burden to taxpayers in a time of recession. Its prospects for passing the Senate seem somewhere between slim and none, particularly given the president's likely reluctance to push anyone hard on its behalf. But I was thinking of health care, a higher priority for the Obama administration but an issue perhaps even more resistant to meaningful solutions. (I mean this as distinct from political action. My guess is that Congress actually will pass something--Democrats up for election next year will need it, as will the President when the economy doesn't revive on cue--but it won't be that helpful as far as expanding coverage or controlling costs.)

In an important piece differentiating between health care reform that limits costs and reform that actually improves health outcomes, Ezra Klein offers a key insight into just why this issue, but not only this issue, is so resistant to progress. He points out that the congressional committees with the most responsibility for getting health care legislation through are Energy and Commerce in the House and Finance in the Senate--because it's about the money, not the outcomes. A second point is that "health" as a concept reaches into the realms of other committees that have no obvious role in the current debate; this is really where we see how hard it is to create meaningful change.

The country's health-care debate is like a driver who has grown so obsessed with the workings of his car that he's largely forgotten where he was driving. We built a health-care system because we care about our health. But the means have become the end, and it is now the system, and not our health, that obsesses us. And that obsession may be preventing us from doing things that would actually make us healthier.
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[T]he spending conversation has consumed the health conversation. It is not hard to understand why. "Somebody makes money taking care of a person once they're diabetic," says Shannon Brownlee, author of the book Overtreated. "They don't make money making sure all elementary schools have a playground and neighborhoods have sidewalks." They don't make money preventing the diabetes in the first place. In 2007, we spent $2.2 trillion on health care. A mere 3 percent of that went to measures meant to improve public health. Similarly, Obama's health-care plan in the campaign was estimated to cost $65 billion a year (which was an absurdly low estimate). The plan included a provision that would "promote public health," but it had neither specifics nor a price tag. "The irony is that we use health as a rhetorical trope a lot in the health-reform debate," says Harold Pollack, a professor of public health at the University of Chicago. "There's a big payoff to pointing to health as a beneficial outcome from health reform. There's not a big political payoff to advocating for enacting specific measures that would improve health."

Indeed, lots of interest groups stand to lose money if society becomes more concerned about health. As Brownlee notes, "Our agricultural policy is actually counterproductive for health. We subsidize everything that gives you diabetes and nothing that keeps you healthy. Every grain you can think of is subsidized, particularly corn, but are carrots subsidized? No. Is the advertising of carrots subsidized? No." But if you want to change that, you've added the agricultural industry and politicians from corn states to your list of opponents. "As you expand this question you gain more enemies who prefer the status quo than you gain friends," says Sen. Sheldon Whitehouse, a Democrat from Rhode Island.
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It's not easy for the political system to combine health promotion with health-system reform. Nutrition is inarguably a major determinant of health. But the Senate Finance Committee, which has jurisdiction over health-care reform, has little power over farm subsidies. Those go through the Agriculture, Nutrition and Forestry Committee. Crime reduction is similarly important -- children don't play outside if their community is unsafe. But public safety is handled by the Judiciary Committee. Pollution is also a huge issue, as one might expect. But that's the Committee on Environment and Public Works. "One thing I've learned here," sighs one senior administration official, "is that the structure of the committees inhibits you from considering multifaceted, complicated legislation."

Emphasis mine. Probably most public policy debates could be framed as "focused special interest good versus diffuse public good." This makes it easy for progressive activists to demonize insurance companies, agribusiness, "polluters," weapons manufacturers, and other deep-pocketed malefactors. (Those on the Right do this too, with a different cast of villains; trial lawyers are probably the most common and reviled, IMO with at least a little justification for the sand they throw into a wide variety of societal gears.) But focusing the public is a nearly impossible task, even with "a clear mandate and a Congressional majority." And it's not always the obvious bad guys who are in the way: to take the example Klein uses, it's not implausible that cutting corn subsidies today could lead to enormous health savings ten or twenty years, as unhealthy foods become more expensive to the point where lower-income families shift consumption away from them. But to Sen. Whitehouse's point, if you take on Big Corn, your math (especially in the Senate) gets that much harder--probably past the point at which you can pass anything.

There's a reason, beyond their own self-sabotaging tendencies, that Democrats have tried and failed to get this done for more than 60 years. It's our system itself. Every time is different, and maybe the ways in which this moment is different--larger and more ideologically coherent majorities, numbers that tell us without question that the status quo will crush us in terms of budget strains, a business community that has moved from full-throated opposition to ambivalence--will prove meaningful enough to get something done. But I'm not particularly optimistic that whatever is done ultimately will be all that helpful.