international analysis and commentary

When change takes time: the US health care debate

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The Obama administration’s struggles in enacting health care reform leave many abroad puzzled:  Why is it so difficult for America to do what virtually every other developed country did long ago?  The answer lies less with patients than with patience.

Health care advocates have long argued that the subject is so complex, and involves so many inter-related moving parts, that the whole system must be changed all at once.  But that perhaps is why it has been changed not at all for decades.  This administration in particular believes that all things – health care, energy, economic productivity, foreign debt, the future of mankind – are inter-related and all must be addressed.  That may be true, but the real question is the less heroic, tactical one:  Must it all be addressed at once?

There’s no denying that reforming America’s costly-yet-ineffective health care system is important, both economically and morally.  But more so than battling the recession?  The Obama administration’s quick pivot from that issue to the health care push, though much less bloody, might someday be compared tactically to the Bush administration’s taking its eyes off Afghanistan in order to invade Iraq.  More immediately, next year there will be large numbers of disappointed voters – already convinced that the stimulus bill has done nothing to reverse the recession and has saddled us with massive debts – who currently believe incorrectly that at least health care reform will lower insurance premiums right away (the reality: 2013, in the best-case scenario).  Many Democratic consultants expect the party to suffer a bloodbath in the 2010 midterms approaching if not eclipsing the 1994 “Hillarycare”-induced debacle that crippled the Clinton presidency. 

Given all that, you might think health care reform must be a deeply-held value for President Obama if he is willing to pay so dearly for it.  But you’d have to look very hard for evidence:  He let Hillary Clinton take the lead on the issue in the Democratic presidential primaries last year, and his White House initially decided to leave drafting the legislation entirely to Congress, happy simply to sign anything sent their way.  All this hardly indicates a passion for health care reform.  Yet Obama, like Bill Clinton before him, has staked his presidency on it.  One has to ask if there isn’t a better way. 

Lyndon Baines Johnson, not exactly a man devoid of grandiose ambitions, built perhaps the most imposing edifice of domestic accomplishments of any president save Franklin Roosevelt – but, like FDR, he built it brick by brick, not just in landmark legislation that would put him in the history books in one fell swoop.  Johnson took pride in his huge collection of pens from innovative legislation he had signed into law. 

Whether because of LBJ’s own imposing example of legislative accomplishment, because no former legislator as skilled as Johnson has since occupied the Oval Office, or perhaps because the political environment has so changed, presidents today rarely build brick-by-brick. They instead aspire to build Rome in a day. In fact, the Obama team talked openly upon taking office of a president really having only one year to make a difference before the inevitable erosion sets in. Whatever the explanation, presidents since Johnson – especially Democrats – have resorted to very un-Johnson-like legislative strategies, attempting to build their monuments early and in one (or a small number) of well-defined, large-scale initiatives. 

Presidents Carter and Clinton both proposed sweeping reforms in health care that turned out largely to be the undoing of their presidencies.  Carter’s first choice for a monument, however, was large-scale energy policy reform, at which he also famously failed.  Republicans have been more successful with their grand gestures – Reagan’s dismantling of virtually all that came before him, and the younger Bush’s sweeping rewrite of the nation’s tax laws – but one could argue that these succeeded because it is easier to tear down than to build up.  Perhaps the most dramatic attempt by a Republican to build a domestic monument to equal FDR’s or LBJ’s was Richard Nixon’s proposal to transform most domestic social programs into a guaranteed minimum income for all Americans.  This, too, failed (like Carter’s initiatives, done in by liberals who found them not monumental enough).  On the other hand, the only period of true Democratic success since Johnson was the second Clinton administration, which produced a large number of successful initiatives after the loss of Congress forced a tactical, if grudging, small-steps approach.

Yet, these lessons go unlearned.  At a minimum, Democrats would have been well-advised for over a decade now to focus first on cost-control before coverage:  It’s true that part of the system’s cost lies in the inefficient way in which we provide health care to the poor, but fixing the other parts would more immediately benefit the vast majority of voters and build broader support for reform.  In fact, taking the LBJ approach and breaking things down even further would provide a host of strategic advantages.

There are clearly components of health care reform that could have been sent to Congress in a long stream of individual bills:  allowing Americans aged 55-64 to buy into Medicare; improving veterans’ health care; requiring insurers to let young adults up to age 25 stay on their family’s coverage; capping interest rates on medical-related debt; limiting the administration costs of insurance plans and simplifying the paperwork.  The list could go on and on.   These and many other reforms could be — in fact, are more likely – achieved on their own, isolating the interests of individuals who might object to each instead of assembling them into a grand coalition of the unwilling, as large edifice-complex reforms do.   Of course, proceeding by such small tactical steps provides no grand moment when a president can claim to have made history.  There is, instead, the slow steady march to greatness recognized only in retrospect.  The reality that history unfolds over time is apparently not of much interest at the present.