The pundits are busy filing their reports on how President Obama blew it on health care reform. And while the health care fight is far from over--I remain convinced the Democrats will pass a bill, maybe even a good one--the pundits have a point. Obama surely has made mistakes, among them focusing so heavily on how reform would reduce the cost of medicine. Had he spent more time reminding voters that reform would provide them with the security they now lack--security from financial ruin and medical catastrophe, the type private insurance too rarely provides--he probably would have been better off.
But I’m not so sure this was obvious a few months ago, when Obama kicked off his campaign for health reform. On the contrary, I seem to remember quite a few writers and television commentators gushing over Obama and his advisors' aggressive approach to the cost problem. Remember, these were the days when Washington feted Budget Director Peter Orszag as a celebrity and turned “bend the curve” into a bumper sticker. And while you can--and should--write some of that off to typical Beltway mood swings, there were, at the time, plenty of reasons to think that Obama’s approach made sense.
First and foremost, it made sense substantively. Like a lot of longtime universal health care advocates, I’ve long focused on the need to give people economic security. Although improving the quality and reducing the cost of medical care seemed like worthy endeavors, those imperatives struck me as secondary. Very secondary.
But the evidence of unnecessary, even harmful medical care--compiled most famously by researchers at Dartmouth College and conveyed in books like Shannon Brownlee’s Overtreated--has simply become overwhelming. And the argument that health care is a threat to our long-term fiscal health--as advanced, most memorably, by Orszag before he joined the administration--has become impossible to ignore.
As a society, we can theoretically spend as much as we want on our health. Twenty percent of GDP, thirty percent, there’s no law of economics forbidding that. But the money spent on medicine is money not spent elsewhere--it’s government dollars that didn’t go into schools or public housing; it’s employer dollars that didn’t go into wages or other benefits. And don’t forget that, as health care gets increasingly expensive, it becomes harder for people to buy insurance--thus exacerbating the economic security problem.
Of course, the right policy isn’t always the easiest policy to sell. This is where political judgment comes in. Just because Obama was determined to make cost cutting a serious priority doesn’t mean that he had to sell it that way. But here, again, it’s easier to make the right call in hindsight. Americans still remain skeptical of government. And, particularly among political independents, government spending remains a proxy for waste. Making a big deal about how reform might curb health care spending--and, thus, ease the long-term burden on the federal budget--seemed like a perfectly plausible way to reach these voters.
No less important than the predispositions of voters was the predisposition of senators. For better or worse--and I would certainly argue worse--the makeup of the Senate means that small, relatively conservative states are represented. Throw in the filibuster, which can stall debate indefinitely until 60 senators vote to break it, and it becomes almost impossible for Democrats to pass legislation without convincing at least a few of their centrist members to go along. These centrists have turned balancing the budget into a fetish (although, it’s worth noting, they frequently make exceptions when it comes to helping out local constituencies or campaign financiers). Again, showing seriousness on cost control seemed like the best way to keep these senators in line.
The trouble for Obama is that, in getting serious about cost, he gave critics lots of fat, juicy targets. Obama proposed to tie payments to quality; Betsy McCaughey said he would be giving doctors money for pulling the plug on grandma. Obama proposed to put a board of experts, using clinical evidence, to set Medicare payment rates; Sarah Palin interpreted that as creating a “death panel” that would declare the sick and disabled unworthy of treatment. The great irony is that by trying earnestly to craft a plan that could control costs, as well as expand coverage, Obama has provoked a political backlash that will make cost control harder in the future. He’s tried to tackle health care like a grown-up and, at the moment, he’s suffering for it politically.
Should he have seen this coming? Should his advisors? Maybe. But plenty of other people missed the signals. And, speaking as one of them, I can easily see why.
Jonathan Cohn is a senior editor of The New Republic. This column is a collaboration between TNR and Kaiser Health News. KHN is an editorially independent news service and is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization, which is not affiliated with Kaiser Permanente.
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COMMENTS (8)
You write, "But I’m not so sure this was obvious a few months ago, when Obama kicked off his campaign for health reform.". I don't recall a kick off! There was an early admission it would be addressed in Year One and then President Obama waited as each committee leaked or made a formal announcement of their progress.
The White House only became aggressive to defend or defuse. By choosing not to lead or direct, there was no "obvious" kick off (roll out, "Hey folks, this is what we have!"). Yes, this is a consequence or risk of allowing a few committees to slowly grind out a program and we're still witnessing how it's easier for the opposition to attack bits and pieces because ever ... view full comment
You write, "But I’m not so sure this was obvious a few months ago, when Obama kicked off his campaign for health reform.". I don't recall a kick off! There was an early admission it would be addressed in Year One and then President Obama waited as each committee leaked or made a formal announcement of their progress.
The White House only became aggressive to defend or defuse. By choosing not to lead or direct, there was no "obvious" kick off (roll out, "Hey folks, this is what we have!"). Yes, this is a consequence or risk of allowing a few committees to slowly grind out a program and we're still witnessing how it's easier for the opposition to attack bits and pieces because everything is fair game until it's final. Obama is still defending a plan that is not his.
I still believe we'll see a bill but I also believe the country will only champion a version that is presented by President Obama. Perhaps he saw this as a necessary strategy: Let Congress run out of steam and at least he'll have enough Democrats begging to pull them from the brink and make a case (then they'll be quiet). But it will probably require a national address and probably a stand-up in front of the full session.
It does remind me of the primary when he allowed the Hillary crowd and any undecided Supers to flail until the end. Then, over a few days he announced the train was leaving and only a few decided to not to hop on. Over the Summer and Autumn, he had everyone on-board.
So what should Obama have done differently? I don't see it here. And it's both too early and too late for such an article, anyway.
So what should Obama have done differently? I don't see it here. And it's both too early and too late for such an article, anyway.
"He’s tried to tackle health care like a grown-up and, at the moment, he’s suffering for it politically." Jonathan, I enjoy your work, but this statement suggests blindness on your part. There were many things Obama could have done had he wanted to act like a "grown-up." He could have demanded taxation of employer provided health benefits, or exemption of all health insurance costs - leveling the playing field with respect to taxes; created a federally chartered private insurance option, which be available across state lines, requiring charterholders to provide insurance that is portable and non-cancellable, with adjusted community rating, and including a medicare-like high risk pool, ... view full comment
"He’s tried to tackle health care like a grown-up and, at the moment, he’s suffering for it politically." Jonathan, I enjoy your work, but this statement suggests blindness on your part. There were many things Obama could have done had he wanted to act like a "grown-up." He could have demanded taxation of employer provided health benefits, or exemption of all health insurance costs - leveling the playing field with respect to taxes; created a federally chartered private insurance option, which be available across state lines, requiring charterholders to provide insurance that is portable and non-cancellable, with adjusted community rating, and including a medicare-like high risk pool, private or public. Granted, these were probably closer to McCain's talking points, but it would appear that they are more in line with the preferences of the public, though not those of you and Klein, Hacker, et. al. I trust your integrity, and that of other likeminded thinkers, but think you have badly misunderstood the intense public opposition to the proposals you prefer. This probably stems from your (and Obama's) ultimate desire to see a single payor system. Most Americans are rightfully suspicious of congressional action which does not have broad support. You are right to be alarmed that what may ultimately come out of congress will contain the worst possible combination of changes to the existing system, with all sorts of unintended consequences. We've seen this movie before, it is the democratic process in action, and typical of the sausage congress produces. Perhaps you'll think it worthwhile, in order to move the chains. But I see it as an enormous, unnecessarily complicated risk to solve a relatively simple problem. Best of luck, though.
Mickey Kaus certainly saw this problem coming in advance, not just in hindsight.
Mickey Kaus certainly saw this problem coming in advance, not just in hindsight.
Obama's biggest mistake is being too abstract, focusing on both cost and (as in the campaign) the uninsured.
He should have focused, and still should, on the central points that unite the interests of the majority of insured Americans and the uninsured:
-portability
-non discrimination in prior disease
-universal coverage
This is politics 101. That is insurance reform. It appeals to self-interest. (Is there anyone who could object?). Everything else, whether the right and left likes it or not, is secondary. This is just not the time for big programs and spending. People are exhausted.
I'm shocked Obama got so off-message. The same happened in the campaign. Obama has great behind ... view full comment
Obama's biggest mistake is being too abstract, focusing on both cost and (as in the campaign) the uninsured.
He should have focused, and still should, on the central points that unite the interests of the majority of insured Americans and the uninsured:
-portability
-non discrimination in prior disease
-universal coverage
This is politics 101. That is insurance reform. It appeals to self-interest. (Is there anyone who could object?). Everything else, whether the right and left likes it or not, is secondary. This is just not the time for big programs and spending. People are exhausted.
I'm shocked Obama got so off-message. The same happened in the campaign. Obama has great behind-the-scene players. But his strategic communications is the pits. The team abhors the 24-hour news cycle. It falls behind the latest charge/counter charge. If, as they've been quoted, they were 'suprised by the negativity', then the whole team should be fired. This is the big time. He needs verbal sharpshooters.
I responded to voter inquiries at Chicago headquarters during the campaign. The communications staff should take WH calls two afternoons a week. This would give them a needed 'feel' for how things are going, the raw, first response that every politician needs to hear. You'll also hear people grounded in their community who can come up with better messages than most of us.
jc:
Is there anything Obama could have done differently to avoid the current health care mess?
george:
Sure.
1]
He might have asked his staff to assemble clips from his campaign stops...clips where he spoke of the need for quality health care for all Americans
2]
He might have noted a correlation between his promises and the rip-roaring enthusiasm the crowds fed back to him
3]
He might have noted the correlation between his campaign promises and the polls showing that most American citizens trusted the Democrats over the Republicans by far on health care
In last week's issue of Newsweek, Sharon Begley [one of the most insightful opinion makers around] wrote and article about ObamaCare.
Begley:
Anyone ... view full comment
jc:
Is there anything Obama could have done differently to avoid the current health care mess?
george:
Sure.
1]
He might have asked his staff to assemble clips from his campaign stops...clips where he spoke of the need for quality health care for all Americans
2]
He might have noted a correlation between his promises and the rip-roaring enthusiasm the crowds fed back to him
3]
He might have noted the correlation between his campaign promises and the polls showing that most American citizens trusted the Democrats over the Republicans by far on health care
In last week's issue of Newsweek, Sharon Begley [one of the most insightful opinion makers around] wrote and article about ObamaCare.
Begley:
Anyone who believed that the battle over health-care reform would be waged on facts, logic, reason, and concern for the less fortunate—46 million uninsured—probably also scoffed at Lyndon Johnson's daisy ad. As politicians and strategists (at least the successful ones) have finally learned, appeals to emotion leave appeals to logic in the dust. And no emotion moves people more powerfully than fear. To explain the remarkable traction that death panels and other lies have gotten this summer, however, you need to probe deeper than the emotions-trump-reason truism.
george:
And when you probe deeper you begin to grasp how appeals to emotion are not at all the same thing as appeals to base or lowest common denominator presentiments. It simply means you draw the obvious connection between what we think and how what we think makes us feel. That's why I have come to call Obama "the cool cat brainiac" in the White House. Everything seems to be a problem to be resolved much as an engineer would try to resolve a problem in building a bridge.
Health care reform is not a bridge.
Begley:
The power of "death panels" as a phrase and a scare tactic also works because Americans are deeply uncomfortable with death. We don't like to think about it or talk about it, says bioethicist Tom Murray, president of the Hastings Center. Only 29 percent of us have a living will. As a result of that discomfort, reminding people of death sends them off the deep end, into the part of the neuronal pool where reason cowers behind existential terror. And we're particularly vulnerable to scaremongering in the atmosphere of dread created by the economic meltdown. When people are already scared about losing their jobs and their homes and paying for health care, it doesn't take a lot to make them afraid of one more thing.
George:
Why can't Obama seem to broach this effectively? Why? Because cool cat brainiacs almost never go there. And they don't because emotional and psychological reactions are hard to reconcile with the engineering feats they easily accomplish with words.
Begley:
It is a truism of political campaigns that you can't beat somebody with nobody, or something with nothing. It is equally true in propaganda wars. Opponents of Obama's health-care reform have un-leashed all the bogeymen and pushed all the emotional buttons. "All the horror stories are being told by the Republican side," says Nunberg. The Democrats have struggled to make an emotional connection with the public, even though it is possible to do that without lying. [Drew] Westen [author of The Political Brain] suggests the Democrats "should say that, since health insurance is tied to employment, 'the current system takes away your freedom to quit your job.' " Berkeley linguist George Lakoff thinks the White House could win hearts and minds by emphasizing that in the current system, "insurance companies deny you care." And the administration could score extra points by describing people who have been bankrupted or killed by that denial. There is no shortage of examples, from Blue Shield denying high-tech cancer surgery that oncologists said was patients' only hope, to Cigna nixing a liver transplant that was a 17-year-old's only chance of survival. She died. (Wall Street rewards insurers for denying claims; a company with a claims-paid rate of, say, 80 percent is viewed as better run than one with a rate of 85 percent.) "If you told the story of how greedy insurers deny coverage to sick people, you could whip up emotions in favor of reform," says Westen.
Not surprisingly, proponents of health-care reform are somewhere between furious and incredulous that the White House has been so ineffectual at countering the lies. "The White House's philosophy seems to be, don't counterpunch till you're on the ropes," says Westen. "Even now, the president refuses to call out anyone by name who is trying to undo his signature issue."
george:
I have brought up Weston's book a number of times myself because it is a brilliant deconstruction of the Gore and Kerry campaigns. These two gents were like stick men with bulging brains. They simply did not connect with "ordinary Americans" and allowed the ingenius Republican smear machine to pulverize them over and again. In some importnt respects, Obama fits right in here. He is president in my view only because the economy was buried so deep in the toilet all the roto rooters in the world couldn't help McCain yank it back out.
Obama seems genuinely passionaite about "solving" things. But that's not the same thing as connecting with citizens who are invested emotionally in having the problems solved.
george walton
[d/a]
It is truly amazing how your analysis of the ongoing health debate in Washington is not just incorrect, but literally upside down. First of all, the Administration nor any of the Congressional bills (none of which can really be analyzed because none of the four Committees of Jurisdiction has posted an official amended bill) really had any cost containment. Anyone who knows even the basics of CBO scoring methodologies knew that CBO would never score IT, comparative effectiveness, and preventive care as containing health care costs. Orzaig was doing his best at CBO to try to change these rules when he headed this organization, but thankfully the career professionals at CBO and other honest ... view full comment
It is truly amazing how your analysis of the ongoing health debate in Washington is not just incorrect, but literally upside down. First of all, the Administration nor any of the Congressional bills (none of which can really be analyzed because none of the four Committees of Jurisdiction has posted an official amended bill) really had any cost containment. Anyone who knows even the basics of CBO scoring methodologies knew that CBO would never score IT, comparative effectiveness, and preventive care as containing health care costs. Orzaig was doing his best at CBO to try to change these rules when he headed this organization, but thankfully the career professionals at CBO and other honest policy economists put a stop to this once he left the organization to join the Administration. CBO just has stated the obvious--the congressional bills were straight out entitlement expansions of at least one trillion (and probably significantly) more over ten years. One CBO letter to the ranking member of ways and means stated that in the out years the entitlement was growing at 8 percent while offsets were growing at only 5 percent. I assume even you can do the math.
Additionally, the white house has far from distinguished itself in this debate. First, a bunch of closed door deals with various groups which are so now confused that no one can even explain them. However, these deals have been repudiated by Democratic Committee chairmen and Leadership in no uncertain terms. Plus the "demonization" of the insurance industry has been a calculated, focus group/poll driven stratedgy which has been totally dishonest. The industry throughout has tried to have a constructive seat at the table while defining its business model.
If reform fails again this year, the lesson is that one party partisanship drafting 1000 page bills behind close doors cannot produce lasting change in an area that is as important and personal as health care. Congress cannot force this type of change through reconciliation without permanently damaging the entire legislative process for many years. Hopefully, everyone will step back and start over in a REAL BIPARTISAN process in the future.
law:
[neither] the [Obama] Administration nor any of the Congressional bills (none of which can really be analyzed because none of the four Committees of Jurisdiction has posted an official amended bill) really had any cost containment. Anyone who knows even the basics of CBO scoring methodologies knew that CBO would never score IT, comparative effectiveness, and preventive care as containing health care costs.
george:
Law may not back the Obama administration's approach to health care reform but the two of them would certainly wonk each other senseless debating it.
Now, I am not suggesting that analysis like this is the wrong way to go. After all, the reason legislation of this magnitude [and ... view full comment
law:
[neither] the [Obama] Administration nor any of the Congressional bills (none of which can really be analyzed because none of the four Committees of Jurisdiction has posted an official amended bill) really had any cost containment. Anyone who knows even the basics of CBO scoring methodologies knew that CBO would never score IT, comparative effectiveness, and preventive care as containing health care costs.
george:
Law may not back the Obama administration's approach to health care reform but the two of them would certainly wonk each other senseless debating it.
Now, I am not suggesting that analysis like this is the wrong way to go. After all, the reason legislation of this magnitude [and importance] can run to hundreds and hundreds of pages is that the sheer magnitude of the thousands upon thousands of variables that must be weighed and then intertwined is something only someone who actually goes down into the pit and starts constructing, deconstructing and reconstructing all the actual nuts and bolts of something this complex can even begin to appreciate. Government, insurance, prescriptions, health care professionals, K Street, Wall Street etc. etc. etc; they must somehow all come together in confronting 330,000,000 men women and children who have health care needs that revolve around an unending plethora of medical afflictions that play themselves out in a virtual infinity of circumstantial contexts.
I had a friend once who worked for a company that imported commodities from China. She was the transportation manager and she showed me the "rules and regulations" that come down from on high at the U.S. Customs Service. You think: Why do we need all this of mumbo jumbo legalese? Then you start in on a section that deals with, say, importing and exporting foodstuffs. That's when you begin to grasp just how many fucking transaction permutations there are between what people grow over there and what people consume over here. The variables are virtually endless. But each different combination has to be considered because if it is not what they make over there might possibly kill those of us who consume it over here.
You simply cannot get around the implications of chaos theory here. Laws and legal scaffolding are enormously complex because human motivation, intention and behavior is enormously complex.
But: Law and Obama seem intent on simplifying it all the more by generally eshewing emotional and psychological reactions in this debate. Yet we can't ignore the innate manner in which human thoughts and feelings forge unimaginably tortuous, labyrinthian reactions to virtually everything.
Instead, it comes down more to how effective or ineffective we are in discussing these emotional facets. Especially how effective or ineffective we are in exposing those who will mold and maniputlate emotions like anxiety, fear and dread into million dollar mansions and yatchs
And above all else that means exposing all those who try to convince us that health care reform can be reduced down to a 30 second soundbyte or a 60 second commercial.
Law:
...the "demonization" of the insurance industry has been a calculated, focus group/poll driven stratedgy which has been totally
dishonest. The industry throughout has tried to have a constructive seat at the table while defining its business model.
george:
I'm no expert on the health care insurance industry. But I do know that for every point of view like this one there are equal and opposite points of views out there from others.
For me the bottom line seems clear enough: If you are someone who earns a living by sucking up as much cash as you can selling health care insurance or providing health care options, it behooves you to expend the least amount cash as you must when the claims come in. No other modern industrial nation treats its citizens' health care as though it more just one more commodity in the marketplce. And for every "horror story" we hear about government run health care there are just as many that come from the way things are run now. There is no "cure" for it.
That is what counts here: Not how much should be spent to treat each condition in each particular circumstantial context. That will ALWAYS be inexpressably and inextricably complex---whether the government rations the health care or the "private sector" does.
Instead, it revolves around the "political philosophy" subscribed to by those who believe health care is a basic right all citizens must be afforded; or by those who believe it is not. We side against all those nations comprising what we call the "civilized world" in this debate.
And for those of the latter persuasion, please: Don't pretend that most of those who want the status quo to stick around are driven by "the principle of the thing" rather than by the Benjamins.
george walton
[d/a]