It sounds like one way or another, we'll know the fate of health care within the next week or so. The Democrats certainly seem to be confident, a welcome change from their usual embrace of fecklessness and despair. But enough possible mines still lay in the road--the Congressional Budget Office score, a new round of polling or two--that I'm far from certain the legislation will pass.
I've written a great deal about what I think is riding on the outcome here: not just a long forward step toward universal coverage and getting costs under control, but a signal that our fractured and fractious political system can address and make progress on big challenges. It's deeply unfortunate, and I think entirely unprecedented, that this measure will pass (if it passes) on a partisan basis... but less unfortunate, and no more unprecedented, than the Republicans' total subordination of policy outcomes to political considerations.
As it happens, the Republicans do have a vision for changes in health care policy. It's just that, as Jonathan Chait describes, their core objective for reform sharply diverges from what the Democrats want to accomplish:
What separates the two parties is not how far to go, but in which direction to go. The divide is simple. Democrats propose to shift resources from the rich and the healthy to the poor and the sick. Republicans want to do just the opposite. Republican health care plans reflect the party’s increasingly widespread belief that good health, like other forms of prosperity, is a matter of personal responsibility. Democratic plans to help the sick at the expense of the healthy therefore amount to socialism.
The Democrats’ health care plan aims to create pools for people outside of the employer market, joining healthier individuals together with the sick, so that the former effectively subsidize the latter. The common element of all the Republican plans is to do the opposite-to separate the healthy from the sick.
Republicans have long championed Health Savings Accounts, which give individuals who buy insurance a tax deduction for money they set aside for a high-deductible plan. Since tax deductions are worth more to people in higher tax brackets, and since high-deductible plans appeal more to those with lower medical expenses, the plans attract the rich and healthy, leaving the poor and sick behind.
The thrust of the GOP ideas currently on offer is to reduce health insurance regulation. Republicans would create financial incentives that, according to the Congressional Budget Office (CBO), would encourage states to cut regulation; they would also let businesses and individuals buy insurance from other states. (Health insurance is regulated by state governments.) As a result, health insurance regulation would sink to the level of whichever state offered the laxest regulations. If it worked like the credit card industry, governors would be competing to undercut each other’s regulations in order to lure insurers to their states.
Republicans boast that the CBO says their plan would reduce insurance premiums. This is true. The CBO predicted this would happen because the GOP plan would reduce premiums for healthy people, bringing more of them into the insurance pool, and raise premiums for sicker people, driving more of them out.
Why would Republicans favor a result like this? The better question might be, why wouldn’t they? The modern Republican domestic agenda is, above all, an attack on redistribution, a crusade to free society’s winners from shouldering the burdens of its losers.
This short but devastating article took me back about twenty-five years, to when I first started thinking about political issues in a systemic way. Simply put, when I was 12 or 13 I realized that the conservative movement in the age of Reagan seemed to embrace concentration of wealth and protection of privilege as their desired end, with the means of twisting "values" principles to support those goals. The liberals--muddled, ineffectual and contradictory as they were and are--at least occasionally seemed to embrace the notion that society is best advanced by actions to equalize opportunity. The formulation of WITT ("We're in this together") vs. YOYO ("You're on your own") is a bit flip but nonetheless apt. (For an even more breathtaking example of Republican devotion to comforting the comfortable, check out this Center on Budget and Policy Priorities assessment of Rep. Paul Ryan's budget roadmap. Long story short, it creates the greatest upward redistribution of wealth in history--million-dollar tax cuts for the very richest with higher taxes for just about everyone else--while wrecking Social Security, Medicare and Medicaid... and failing to eliminate the debt, despite Ryan's statements to the contrary. )
I've always thought that this was the story Obama was meant to tell: that as a nation we can come closer together, to our broadly shared benefit, or drift farther apart, to the great advantage of a few but the collective detriment of all. Indeed, he's told it better than anybody, at the 2004 Democratic convention and again in his 2005 commencement address at Knox College. The president's political team is obviously skilled; perhaps they tested this message in the context of health care, found that it didn't play, and bent their efforts toward trying to make this a case for self-interest ("without this reform, you're at the mercy of the insurance companies"). But this has to be in there somewhere, not least because the rest of Obama's agenda, from education to immigration to taxes to entitlements, will rise or fall on the same lines. Only the identities of the privileged/protected few--including some pretty powerful Democratic constituencies--will change. It might not be too much to assert that his presidency will succeed or fail on how effectively he can make this case. And if his presidency itself is as consequential as I believe it to be, we all have a great deal at stake.