It's unpleasant to watch something die.
For months, I've held back writing about healthcare "reform" - at least, that's what those crazy kids in DC call it, these days - as much as possible because I felt, in my gut, that the likelihood of actually getting a bill was debatable at best. Thus, a great deal of time, energy and writing being expended on discussing bill particulars (remember when we were all anxiously awaiting the word from the Senate Finance Committee? Fun!) which in the end mattered little or not at all.
In a flurry of late developments yesterday, my stance became, fairly obviously, smarter than I could have guessed: when Rahm Emanuel walked into Harry Reid's office (allegedly, if you like) and said "cut a deal", what basically happened is that healthcare reform died. What we're watching now - the roiling about finding a workable deal, the finger pointing and wails of unacceptability - are the death throes of reform. It's already dead... but not everyone knows how to recognize that.
I don't care who's to blame. To me, virtually everyone who weighed in on the creation of this bill - from the craven interests in the health care industries, to the politically motivated Democrats who pushed slogans over substance, to the "progressive activists" who fetishized a "public option" over other, necessary reforms - all deserve admonishment. Everyone failed here; and few, if any, contributed the kind of substance required to make real progress (though, all of that said, one will have to ask at some point how what happened in the past year constituted "leadership" by the White House).
Since 1994, there's been an unfair and dangerous retelling of the history of our last effort at major health reform: it's the familiar story of how Hillary Clinton, in secret, formed an Executive Committee to foist massive changes in healthcare, which was promptly rejected by the public and by Congress. Out of that failure came the lesson that drove many liberals and progressives in this year's reform attempt: just don't do it the way they did before.
Well... that worked out swell.
There are two key misunderstandings of the Clinton healthcare efforts that have to be sorted out: the first is that you can't have a "reform" absent a clear definition of the problem; and second, that you can't run a successful reform process out of the public eye, or with a process that favors political gains over sensible, necessary policies.
Until we understand both these lessons, we can't have reform in healthcare. It's that simple... and that complex.
From the beginning, this year's efforts to cobble together a health reform package were hamstrung by a clear failure, by the incoming Obama Administration and by knowledgable progressives, to make a meaningful case for reform to the public. The Obama team's failure is the more visibly obvious, and centers very much on the selection of longtime Washington insiders to shepherd a process that clearly, all along, was more focused on inside the Beltway dealing than making a public case and mustering public pressure on Congress for change. People like Tom Daschle, Rahm Emanuel, Peter Orszag and the like are political operatives with the know how and skills to drive a legisative process; they are poor spokespeople for gaining public support.
And you can argue that the Obama folks outsourced the public argument to progressive activists... but that outsourcing was uncoordinated, poorly thought through, and often incoherent. If Howard Dean has represented a "voice for reform" in healthcare, for instance, it's not clear he voices the Administration's goals; like many progressives - many of whom he inspired in 2003 with his early run for President (me included) - Dean advocates for a single payer solution without a lot of specifics (often the vague "Medicare for all" proposal that has little real substance, and many problems). More pointedly, Dean is lousy at laying out the case about our current healthcare systems: as a recently practicing physician, he tends to reflect his training, and rarely questions notions of hospital based care or physician-centric notions about how care is obtained in the US, instead focusing on questions of insurance and payment that are really, in many ways, ancillary to the central challenges of American healthcare.
With no one to lay out the problem, and no one to sell a thoughtful, sensible approach to crafting a solution, the White House threw the whole process into Congress, which was ill-prepared to craft such a far-reaching, complex piece of legislation; never minding the right-left divides which have torn apart the normal political work of crafting policy across party lines, Congressional power is especially centralized in both party's leadership roles, meaning that policy is often in the service of maintaining power, and good policy is sacrificed for political donations and votes.
The decision to leave everything to Congress, in turn, recreated the old dynamic from 1992-3: too much of the discussion that happened to make the bills that eventually were presented in committee were done, yet again, in secret, with little outside input or request for public comment. That meant that, even as bloggers were talking about "open" posting of billsto review, the problem was already cast in stone: major elements could not be altered in any significant way, once the bills were written, because they were constructed to muster needed support. That's why the "public option" debacle was so pained - the time to craft a successful government insurance option was before the bills were written, not after. By May and June, when "public option" demands began to surface, it was hard to imagine how such major proposals could be filtered into already esiting legislative constructs.
But by midyear, the bigger disaster was also rolling in: by not involving the public in defining the case for reform, many people interested in reform were surprised by the size, shape, and scope of the reforms under consideration. And progressives were surprised, repeatedly, by conservative moves to re-argue positions that had supposedly been "obvious" to all concerned... indeed, questions as basic as "why do we need reform at all?" The return of these questions led to a great deal of backpedaling, trying to get more people up to speed, while, at the same time, forces that were always likely to oppose efforts at reform, from conservative groups to subsets of dcotors, hospitals, and other providers, begain to raise objections. Just as they had 15 years before. In many cases... the exact same objections they'd had, all along.
By August, the Obama Administration's decision to set artficial deadlines - remember how this would all be settled by mid July? - seemed both cavalier and naive; rising frustration, both with specific elements of healthcare reform as well as larger questions of our economic downturn, made opposing healthacre reform all too easy. As well, the breakdown of comity between right and left meant that Democrats could not really expect any knd of support from Republicans at the late point of brining finished bills to the floor of both houses; it was clearly going to unify Republicans to oppose whatever bill was presented.
As I said when the House bill passed, at every step of this process, people have oversold the successes and overlooked major obstacles to finishing the process. Passing the House was never the question; the shape, size and form of reform out of the Senate was never clear, and, even now, remains mostly a muddle. If a compromise can be crafted to attract the needed 60 votes - which clearly involves either appeasing Joe Lieberman, ben Nelson or Olympia Snowe, if not all three - the result, as of today, looks like little in the way of real reform, and a great deal of crafting new problems to add on to our old ones (like expanding Medicaid when the current system is poorly managed and underfunded with no reform of the underlying structures). And again... that's presuming you will even get a bill to a vote.
The question of "what can we accept" - which currently distracts lefty bloggers appalled at Emanuel's orders to Reid - is a straw argument: it presumes, as many have all along, that what progressives, or any of us, want in this bill was ever the question. If it were, the process of crafting this legislation would have been vastly different... and the bill we'd be debating would be, too. Progressive bloggers can't kill this bill, even if they wanted to, or tried. What's killing this bill, as in 1994, is a broken political process, a failure to define a good process going in, and a refusal to understand the basic issues in healthcare which we actually face. If we want history to go differently next time... we need to better understand what just happened, what happened in 1993, and restart this discussion in a much different way and from a much different place. Until then, it's just squirmy watching healthcare reform die.
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