• Did Obama fail to justify why universal coverage is necessary?

    Theodore Marmor thinks Obama missed a step, writing in the Journal of Health Politics, Policy, and Law,

    But what makes the Obama reform package a just one? Or a morally compelling legislative effort — and to what end? The expression “affordable health care for every American” was bandied about, but it was not and still is not clearly defined. Instead, it was repeatedly invoked as a means to go beyond the various personal horror stories told and retold throughout the long debate. In fact, there was little talk about why affordable health care for all is a good idea, much less an important or democratic one. […]

    Having neglected a clear account of why universal health insurance was justified, the administration now must offer that account postenactment. They will need to rally a public in response to the certain efforts of their Republican opponents to, first, attempt repeal and then, when unable to do that, to weaken the ACA as it faces an extended implementation schedule that stretches beyond Obama’s first term, let alone the Congress of 2010.

    I’m puzzled by this, but I recognize that one reason for that may be that I’m too close to health reform and health care. I know too well the importance of affordable care and the purpose of universal coverage. As such, even vague hints or terse references to the arguments call them to my mind in full.

    Maybe the vast majority of the populace, being far less plugged in to the health care policy debate, missed the crucial arguments. Did Obama and the Democrats fail to justify health reform? What do you think? If so, what should they have done differently? How much do you think it would have mattered and why?

    • Yes, Obama did fail — as some observers were writing even two years ago:


      But then, no political advocate of universal coverage has ever clearly explained the practical rationale for it — maybe because most don’t actually understand the rationale themselves. They usually invoke normative arguments about fairness and misfortune, which, as the linked commentary above notes, are “moving but not explanatory.” And by not explaining why the market cannot solve the problem of the uninsured, you leave the floor open to right-wing flim-flam about how the market will fix matters — arguments most people are not equipped to see through. Indeed, these arguments have a certain surface plausibility to a culture steeped in pro-market, anti-government sentiment.

      • @ Chris

        This is an extremely astute statement. Leading democratic proponents of universal healthcare have totally played in the GOP’s hand due to their inability to grasp the economic rationale for universal healthcare. They’re just hanging the “bleeding heart” stereotype out there and its getting appropriated to great effect.

      • I neglected to address Austin’s question, What should Obama have done differently? In short, he should have come at conservatives from the right. There are two powerful arguments that he failed to make, one for the reform as passed and the other for the single-payer idea that was never on the table but should have been (Obama is on record as favoring it).

        The first argument has to do with the individual mandate, which conservatives have treated as some sort of Bolshevik assault on individual liberty. But the argument for the mandate is essentially a conservative one – namely that people who can pay their way should. It’s usually the Right that accuses the Left of coddling free-riders, so conservatives would be helpless to answer this essentially conservative argument without looking incoherent (not that incoherence is a liability on the right).

        The second argument, if single-payer had ever been up for discussion (which it wasn’t, despite a single-payer bill in the House that has several dozen sponsors), is that removing the burden of healthcare from American companies would make them more competitive. There’s no particular reason the corporate sector should have to carry this enormous load. Healthcare became an employment benefit largely by historical accident in the 1940s, when employers facing severe labor shortages but constrained by wartime wage controls began offering health insurance to attract workers. In the early postwar years, health coverage was fairly cheap, so it became a standard component of many benefit packages. By the 1980s, however – thanks to cost-raising factors ranging from therapeutic advances to the inflationary bias inherent in labor-intensive industries like healthcare (see “Baumol’s Law”) – the burden had become a significant one.

        There is no regulation that the Chamber of Commerce won’t object to on grounds that it will compromise U.S. competitiveness. It would have been interesting to see Obama forcing conservatives to confront an essentially pro-business argument for single-payer. Alas …

    • I agree with Chris. I followed the whole process closely from outside (Canada), and even factoring out noise about death panels, I would not say it was clear, and the rush to pass it hardly helped.

      When I talk to Americans who have defined ideological positions but are not wonks, I consistently hear both lefties and righties refer to PPACA as “government health care”, which as we know here is essentially incorrect. On the other hand, most people have such a very limited understanding of the health care system (and rightly so, I would add), that we should not be surprised that the first messaging about an Obama health care law is the one that stuck–“government health care”.

      My own impression is that, comparing the 2009 rhetoric with what has ultimately come to pass, a semi-plausible case was made for something that did not happen.

    • One of the problem in this health reform debate is that “reform” may mean different thing in different people.
      To Obama and the leading Democrats, the main purpose of reform is to cover those 30-40 million uninsured. They promise the health care cost will come down, but nothing concrete has been shown.
      But to many ordinary Americans, the priority is lower cost. They want reform to bring them lower premium and lower drug cost. They do not see how universal care can help them reach that goal.

    • Remember that at present, something like 80-85% of all Americans are insured at any point in time. Many folks who are uninsured at any point in the year aren’t uninsured for very long periods. Policy folks know that employer sponsored coverage is eroding among small employers and low-margin employers, and that employers alone aren’t sufficient to restrain growth in health care spending. However, I’m not sure that the public knows that. Most people think it’s someone else’s problem. Most people are wrong, and Obama hasn’t convinced them otherwise, imo. Most people don’t think that the ACA will lower health care costs, and Obama hasn’t convinced them otherwise, imo. So yes, he and the Democrats need to do a better job of selling the law. And people like Rep. Allison Schwartz (D-PA) need to stop sabotaging the law’s cost control efforts.

    • The most unpopular aspect of the new law might be the individual mandate. The most popular is probably the ban on refusing insurance to people with pre-existing conditions. The administration occasionally linked them, but. as another poster mentioned,didn’t explain the link and emphasize the need to prevent freeloading often enough.

      It is also true that the President did not make the case for the medical benefits of universal coverage nearly as well as he could have.. Convening a national conference on that issue and using the power of the presidency to draw attention to it or simply asking the House and Senate to hold prime time hearings might have helped.

      The failure to make the strongest possible case that universal coverage will prevent death and disability on a large scale over the next decade..probably stemmed from a decision to respond to the fears about government spending and the growing deficit by emphasizing the cost control aspect of health reform. The President should have given the highest scientifically defensible estimate every time he spoke about health reform but I never hear him to do that, one time.

    • It seemed to me that Michael Moore’s “Sicko” primed the pump for health care reform and Obama’s election provided an opportunity not to be missed – according to RE – but as noted above, we didn’t have the needed social debate.

      At the time I was reading George Lakoff’s “The Political Mind” and it became abundantly clear that the politicians had given no thought to preparing people’s minds to accept the ‘reform’ agenda that was being constructed.

      As emphacised by Mr. Lakoff, “Cognitive policy is a framing campaign that preceeds specific material policies. It introduces the deep frames, the moral frames, that come first….All material policies are based, explcitly or implicitly, on prior morally-based frames. The first justification of any policy, often unconscious and implicit, is its moral correctlness…It operates in a circle: framing precedes policy.” (p. 170)

      In hindsight, Obama might better have used the time spent on health care reform to tackle the economy. The current deficit debate would have been an appropriate time to discuss health care reform.

    • The entire political structure has failed to make people understand why universal coverage is important – to them personally, their families, their employers, their government, their pocketbook.

      Nothing made that clearer than this survey, during the height of the debate:

      When people don’t know what things cost, they don’t know how to value them. Insurance – public or private – insulates people from the knowledge of the true cost of medical care, and even whether that care works especially well.

      Those who have decent employer-based insurance have no idea what the real cost is of either that coverage or of the care they receive. When they don’t understand the risks of incurring high medical bills, they don’t comprehend the value of insurance.

      People think insurance is “other people’s money” (OPM) but it’s their money. It’s either tax money or subverted wages.

      Universal coverage – with either single-payer or combination public/private system – is fair, humane and can be economical in conjunction with actions targeting cost, safety and quality of care. But when people – and doctors – remain insulated from costs, they will keep treating “insurance” money like OPM, instead of their own money. That mindset will trump any legislation that can be devised and passed. THAT’s where we need real leadership and reform.