The Inside/Outside Strategy On Health Care

I know that the Democratic platform, which will be ratified this week in Denver, is a worthless piece of paper, in many respects. But the movement that led to the language change in the platform - with Democrats asserting a guarantee of health care for everyone - is very much worth considering. Clearly, the movement progressives made it impossible for Democrats to ignore them on this issue:

If one thing came through in the platform hearings, it was that Democrats are united around a commitment that every American man, woman, and child be guaranteed affordable, comprehensive healthcare. In meeting after meeting, people expressed moral outrage with a health care crisis that leaves millions of Americans–including nine million children–without health insurance and millions more struggling to pay rising costs for poor quality care. Half of all personal bankruptcies in America are caused by medical bills. We spend more on health care than any other country, but we’re ranked 47th in life expectancy and 43rd in child mortality. Our nation faces epidemics of obesity and chronic diseases as well as new threats like pandemic flu and bioterrorism. Yet despite all of this, less than four cents of every health care dollar is spent on prevention and public health.

The American people understand that good health is the foundation of individual achievement and economic prosperity. Ensuring quality, affordable health care for every single American is essential to children’s education, workers’ productivity and businesses’ competitiveness. We believe that covering all is not just a moral imperative, but is necessary to making our health
system workable and affordable. Doing so would end cost-shifting from the uninsured, promote prevention and wellness, stop insurance discrimination, help eliminate health care disparities, and achieve savings through competition, choice, innovation, and higher quality care. While there are different approaches within the Democratic Party about how best to achieve the commitment of covering every American, with everyone in and no one left out, we stand united to achieve this fundamental objective through the legislative process.

As Paul Krugman noted a couple weeks ago, this was put front and center in the platform because the party listened to the desire for change. The middle class is overwhelmingly open to national health care, as they see that the current system is fundamentally broken.

Americans are struggling to pay medical bills and are accumulating medical debt at an increasing rate, according to a survey released today.

"A perfect storm of negative economic trends is battering working families across the United States," said the survey by the Commonwealth Fund, a private foundation that supports independent research on health care [...]

Two-thirds of the working-age population was uninsured, underinsured, reported a medical bill problem or did not get needed health care because of cost in 2007.

More than two in five adults in the 19-to-64 age group reported problems paying medical bills or had accumulated medical debt in 2007, up from one in three in 2005. Their difficulties included not being able to afford medical attention when needed, running up medical debts, dealing with collection agencies about unpaid bills, or having to change their lifestyle to repay medical debts.

It's clear that there's a movement toward revamping the health care system, and it's being achieved with an inside/outside strategy. On the inside, grassroots Dems with an assist from Rep. John Conyers got the health care guarantee in the platform. From the outside, Health Care for America Now has been putting extreme pressure on Congress through an avalanche of phone calls, getting 188 members on the record on whether they support the guarantee. They've also been blasting the insurance industry and their front groups by exposing them and their tactics to block change and reinforce the status quo. There's even been a new-wave resumption of the Harry and Louise ads, with the difference being that they now understand the need for fundamental reform.

There is no doubt that enacting a universal health care plan would be immensely popular. Here's Krugman:

I know that’s not what everyone says; some pundits claim that the United States has a uniquely individualistic culture, and that Americans won’t accept any system that makes health care a collective responsibility. Those who say this, however, seem to forget that we already have a program — you may have heard of it — called Medicare. It’s a program that collects money from every worker’s paycheck and uses it to pay the medical bills of everyone 65 and older. And it’s immensely popular.

There’s every reason to believe that a program that extends universal coverage to the nonelderly would soon become equally popular. Consider the case of Massachusetts, which passed a state-level plan for universal coverage two years ago.

The Massachusetts plan has come in for a lot of criticism. It includes individual mandates — that is, people are required to buy coverage, even if they’d prefer to take their chances. And its costs are running much higher than expected, mainly because it turns out that there were more people without insurance than anyone realized.

Yet recent polls show overwhelming support for the plan — support that has grown stronger since it went into effect, despite the new system’s teething troubles. Once a system of universal health coverage exists, it seems, people want to keep it.

Obviously, the biggest barrier to this is making sure John McCain isn't elected. He literally wouldn't insure more than 5% of the currently uninsured with his health care plan, and by charging health care benefits from employers as income, his plan would massively raise taxes on the middle class. But Barack Obama's plan, as currently constructed, wouldn't get us to universality either. And he hasn't been raising the issue in a progressive way on the campaign trail, either. He has talked in the past about supporting single payer, but that was in a different context, one he doesn't see as politically possible right now.

Obama can't argue that he's a centrist on health care with no plans for increased government involvement because he likes to say things like “if I were designing a system from scratch, I would probably go ahead with a single-payer system." Other campaigns notice him saying those things, and they send the quote to reporters. On the other hand, he can't extract the maximum political advantage from his universal health care plan because he doesn't have a universal health care plan [...]

His plan manages to occupy an uncomfortable middle space where it's neither liberal enough to really fit into the sharp liberal argument nor centrist enough to protect him from attacks of being a traditional liberal. And that's not a point of abstract logic: In the primary, he got slammed for not being liberal enough, and now he's getting slammed for being too liberal. it's almost no surprise that Obama doesn't really seem interested in making health care a defining issue. It's not really worked for him thus far.

So how do we tease out Obama and make sure he leads on health care? Jon Cohn's piece is a nice one, and suggests some tea leaves to read about Obama's priorities.

Does Obama grasp this? There are good reasons to think he does--starting with the fact that the platform language was strong even before the activists introduced their amendments. The original platform, whose principal author was veteran Obama advisor Karen Kornbluh, specified that everybody should have health coverage on a par with what members of Congress have. That's no small matter, since members of Congress get relatively generous coverage. It's the right thing to do: without a promise of sufficient benefits, universal coverage is meaningless. But following through on this promise would require passing a bigger, more expensive reform. If Obama wanted to downplay his commitment to health care, he wouldn't have made this vow so explicit.

The same goes for another potentially controversial element of his health care proposal: Making sure everybody has the option of enrolling in a public insurance plan that looks something like Medicare. A viable public plan would help keep private insurance plans honest, by setting a benchmark for affordability, benefits levels, and responsiveness. And if a public plan proved to be more efficient than private alternatives, it might eventually lure most Americans as enrollees, effectively becoming a single-payer plan by acclamation. That's why liberals love the idea--and conservatives hate it. If Obama were going to back away from some of his primary-race promises on health care, that's another place where he might do so. But the public plan, like the promise of generous benefit levels, was always in the platform--again, even before the amendments in Pittsburgh.

Most striking of all, perhaps, is the sheer amount of attention--and apparent priority--health care gets in the platform. Health care is the first policy issue the document takes up in depth. No other platform in recent memory dealt with health care so prominently--or in such detail. Even in 1992, the last year in which a Democratic nominee seriously proposed universal coverage, the platform relegated health care to lesser status: It appeared ninth in a long list of measures to improve economic security. Priorities like deficit reduction, public investment, and agriculture all came before it.

The goal for activists is to continue with an inside/outside strategy, one that keeps the current broken system in the minds of the public to overcome their fear of the unknown, pressures Obama and Congress to act, and build support everywhere. I do think it's possible, more than at any time since 1992.