Healthcare for the Ages

March 23, 2010

David Coates is a political science professor at Wake Forest University and author of the new book, “Answering Back: Liberal Responses to Conservative Arguments.”  Here he shares his perspective on the passage of the healthcare reform bill. If you are a journalist who would like to interview Coates, email Carol Cirulli Lanham at carol@sternersedeno.com or call 972-818-0895.

By David Coates

Sunday was a good day. The House vote for health care reform was a good vote. It started us on a journey towards universal health care. It threw up a road block against some of the most egregious practices of the insurance industry. It established the principle that when you’re healthy you pay in so that when you’re sick you can take out; and that if you don’t earn enough to make that paying easy, tax dollars provided by the better paid should be used to ease that burden. Good principles – the healthy looking after the sick, the affluent helping out the near poor – a kinder and more compassionate social settlement than the one in place the day before: the one in which if you couldn’t afford to buy health care, you didn’t get it; the one in which if you became very sick, you ran a real risk of losing the very health cover you needed.

 So yes, a good day – one that will be long remembered – a good day, but sadly not a perfect one.

 The Senate bill was significantly weaker in its reforming zeal than the House bill, and it remains an open question how much of that weakness will be corrected through reconciliation. The answer is likely to be less rather than more.

  • We are likely to remain stuck with 50 state-level exchanges, not the one national one that the House bill initially contained.
  • We are likely not to find in those state exchanges any public option worthy of the name, so that the exchanges will be a site for competition only between private insurers, private insurers whose coffers will be overflowing with tax payer dollars paid over to them through the subsidies given to their low paid customers.
  •  We will have to live with the Hyde amendment enshrined into law, and extra hurdles created within the exchanges for women wishing to obtain health insurance that will give them the right to choose.
  • And even if it is a better week in the Senate than I fear, we will still remain wedded to a health care system based on profit-taking private insurance companies, one in which the main drivers of rising costs remain uncontrolled.

 So Sunday was both an ending and a beginning. It was an ending. It marked the moment when the US health care system was at last reset to give access to affordable health care to virtually all Americans. But it also was also a beginning. It set the stage for the next struggle: on how to keep that health care genuinely affordable, by addressing the inflationary forces still at work deep inside the system.

David Coates is a political science professor at Wake Forest University and author of the new book, “Answering Back: Liberal Responses to Conservative Arguments.”  Here he shares his perspective on the healthcare reform efforts. If you are a journalist who would like to interview Coates, email Carol Cirulli Lanham at carol@sternersedeno.com or call 972-818-0895.

By David Coates

This is crunch time for health care reform. The Democrats cannot afford another stalled attempt at reform. Nor can they afford another long, dragged out process of negotiation.

It is now or never for major health care reform.

The reform will not be perfect. The President does not have the Congressional numbers for perfect.

But he does have the numbers to shift the goal posts decisively in a progressive direction.

Shifting goal posts is good. If he can get us to a new system, taking us back to the old one will be politically impossible.

 The new system is significantly better that what we have now: ensuring:

  •  No pre-existing conditions
  • A health care exchange for the uninsured
  • Federal funds to help the uninsured buy basic coverage

 What is missing will need to be added later:

  •  A genuine public option and/or tight limits on what insurance companies can charge
  • Real cost reductions, linked to changes in the whole fee-for-service system
  • Even a single-payer system if insurance companies continue to misbehave

 This is the start of major health care reform, not the end. Better start with something than with nothing.

 The strategy is credible – pass the Senate bill in the House, and reform the joint bill by use of reconciliation

 But success, even on modest change, is still not guaranteed. Watch those blue-dog democrats!  Watch the Stupak amendment crowd.

 Let’s hope liberals in the House don’t let the perfect drive out the good. Snatching defeat from the jaws of victory is not sensible politics, this close to the mid-terms.

David Coates is a political science professor at Wake Forest University and author of the forthcoming book, “Answering Back: Liberal Responses to Conservative Arguments.”  In the second of a two-part post, he shares his perspective on the healthcare reform efforts. To interview Coates, email Carol Cirulli Lanham at carol@sternersedeno.com or call 972-818-0895.

If reconciliation was easy and problem free, this would be a no brainer. If the version of the public option contained in the Senate bill was a powerful one, its loss would make the bill significantly weaker.

Sadly neither of those propositions is true. Reconciliation as a process is fraught with danger for progressives. Parliamentary rules could gut the reconciled bill of even more than has already been lost, and very likely would. The public option now cut from the Senate bill would have covered at most 3 million Americans, and been no significant competitor to the private insurance industry. Indeed its premiums may have had to be higher.

The House bill is not perfect either. Remember, it (unlike the Senate bill) contains the Stupak amendment, and even so passed with a majority of just 5 votes. A majority of five votes is no great shakes! It is not only in the Senate that the progressive instincts of the modern Democratic Party are held in check by the party’s conservative wing.

So why threaten to withdraw support from the Senate bill?

If this is a ploy designed to play chicken – to see who blinks first – it won’t work. After all, to play chicken you have to face each other. You have to be going in opposite directions. Withdrawing support from the bill would put progressives on the same side as the conservatives, going in the same direction: creating a majority to do exactly what the Republicans have wanted all along. No health care reform. Losing 1-6 would be a huge Republican victory, and open the road to a mid-term disaster for progressive candidates that would close completely the possibility of real legislative progress on any major issue in Obama’s first term. Shades of 1994: there is more at stake here than health care reform alone

Letting the perfect drive out the good is never a good strategy for progressive politics. Progressive objectives in a political system as dysfunctional as ours are won inch by inch, negotiated clause by negotiated clause. Health care reform is a process, not a moment – it is a series of stages won one at a time.  On health care now, as on immigration reform later, progressives will need to win what they can when they can, then dig in and fight on.

This is no time to fold. It is time to play out the hand we have, take what winnings we can, and then re-deal the cards. There will be another day and another play.

David Coates, political science professor at Wake Forest University and author of the forthcoming book, “Answering Back: Liberal Responses to Conservative Arguments,” shares his perspective on the current state of the healthcare reform bill. To interview Coates, email Carol Cirulli Lanham at carol@sternersedeno.com or call 972-818-0895.

David Coates

It is crunch time for progressives and health care reform. Have we reached the moment, as Howard Dean now says we have,[1] that so much has been drained out of the Senate bill in attempts to appease conservative Democrats that what is left is not worth supporting?

Do we abandon the bill and either start over, or use the reconciliation process to force through the House’s more progressive alternative? The numbers aren’t there in the Senate for a bill containing either the public option or Medicare expansion. The numbers are said not to be there in the House for a bill that excludes them. We seem defeated by the numbers.

But are we? Let’s do some other numbers. Let’s count what we have and what we might lose.

In the current Senate bill we have:

l. An extension of coverage to an additional 31 million Americans, with sliding-scale subsidies for those making up to 400 percent of the poverty level.

2. The largest extension ever of Medicaid to low-income families, making it available to families with incomes up to 133 percent of the poverty level.

3. Tighter regulation of the health insurance industry, to proscribe some of its more egregious practices – not least exclusion because of existing pre-conditions.

4. State-run insurance exchanges in which those without employer-provided coverage can find affordable health care.

5. New rules to allow young adults to remain on their parents’ health care plan until age 27.

6. New federal dollars for wellness and prevention programs.

What we apparently don’t have is:

7.   A public option in those exchanges, to compete with private insurers.

8.   The extension of the right to purchase Medicare coverage to Americans aged 55-64.

9.   Taxation on the super-rich to finance the reforms.

10. The abolition of annual and lifetime benefit caps, and other key consumer protections.

The question is this. Are 1-6 to be jeopardized because 7-10 are missing? Would that be good politics?

The answer depends on two things. It depends on how valuable the version of 7 and 8 in the Senate bill is likely to be? And it depends on how securely 1-6 (and a potential 7a – the House version of the public option) can be guaranteed by turning away from this bill to run the House bill through the budget reconciliation procedure.

Answering those questions has less to do with health care than with politics – pure, naked politics. At crunch times like these, politics is like poker. You have to decide whether to hold or to fold.

Next blog entry: Holding or Folding.


[1] Howard Dean, “Health-care bill won’t bring real reform”, The Washington Post, December 17 2009

Wake Forest University offered a course this semester called “Health Care Reform:  A Sociological View of America’s ‘Non-System.’”   From preventive health to cost containment, the class has explored the fragmented landscape of health care reform from the sociological perspective.  Students who took the class are now blogging on why they are concerned about healthcare reform.

By Erin Kelly

It is just another sign of Wake Forest’s commitment to mold critically-thinking students inside as well as outside the classroom that we are able to take a class that directly addresses and critiques political reform currently taking place in America. By learning about health care reform through a sociological perspective we are learning how to analyze political theory through different view points and question the pros and cons of President Obama’s reform plan. We will be responsible for our own health care coverage very soon and Wake Forest is giving us the opportunity to decipher the complicated health care system armed with a breadth of knowledge.

Wake Forest University offered a course this semester called “Health Care Reform:  A Sociological View of America’s ‘Non-System.’”   From preventive health to cost containment, the class has explored the fragmented landscape of health care reform from the sociological perspective.  Students who took the class are now blogging on why they are concerned about healthcare reform.

By Dan Jandreau

Healthcare reform is very important for college students. Soon after graduation at the young age of 25, young adults are no longer covered by their parents’ insurance plans. If their parents do not have an insurance plan, they are possibly entering the market to buy medical insurance. After paying for college, graduates want comprehensive care at a fair price. They also do not want to be burdened with debts in the future because of ill-advised reforms made today. The U.S. is currently the closest it has been to healthcare reform. The bills on the floor are being debated by Republicans and Democrats who have vastly different views on how to reduce costs while extending coverage to more Americans. I personally feel that there are cheaper, free-market solutions to the healthcare “crisis,” but seeing as the government sponsored public option has large support in Congress, it will be interesting to see how it turns out.

Wake Forest University offered a course this semester called “Health Care Reform:  A Sociological View of America’s ‘Non-System.’”   From preventive health to cost containment, the class has explored the fragmented landscape of health care reform from the sociological perspective.  Beginning today, students who took the class will be blogging on why they are concerned about healthcare reform.

By Molly Hintz

For me, understanding and learning about health care reform is crucial now because as a college student I’m preparing myself to enter the real world. In a few short years I will no longer be under the coverage of my parent’s insurance which means what’s happening now will affect me sooner than I’d like to believe. Being active in the health care reform debate now can only benefit us; without voicing our opinions we will be living under a reformed system decided upon by the pharmaceutical industry and other big business groups who fund our politicians. As a pre-med student not only is my health insurance being debated but also my future job description and role in society.

After senior Senate Democrats reached a “broad agreement” on Tuesday night to drop the public option in favor of a compromise plan, David Coates, political science professor at Wake Forest University and author of the forthcoming book, “Answering Back: Liberal Responses to Conservative Arguments,” offered the following commentary. To interview Coates, email Carol Cirulli Lanham at carol@sternersedeno.com or call 972-818-0895.

For most liberals fighting for health  care reform, the idea of the ‘public option’ was never to put the government in the driving seat of health care provision. That claim was a piece of conservative hyperbole. The use of the public option as the thin end of a wedge that would ultimately take us to a single-payer system, was long recognized by many liberals as a non-starter, given the weight of conservatives within the Democratic coalition in Washington.

Instead, the role of the public option was to strengthen the forces of competition in the health insurance market, to make private insurance companies offer more generous and more reliable health care coverage without increasing the cost of premiums.  Conservatives pushed the public option back for precisely that reason – that it would hurt the profits of the insurance companies – by squeezing them between consumers with wider choices and a government plan with real teeth.

By steadily denuding the public option of those teeth – restricting access to the public option only to those without health insurance, and obliging the public option to negotiate its prices with health care providers in exactly the same manner as private insurers, conservatives have already seriously undermined the capacity of the public option to bring private insurers into line.

That is why dropping it in favor of tighter direct regulation of the private insurance companies through the Office of Personnel Management may indeed be the better imperfect solution.

It all depends (a) on the detail of the regulations that the OPM will set; (b) the nature of the threshold set before a government scheme can be introduced; and (c) the staying power of the OPM. If that office falls into Republican hands, the regulations can go  backwards, as all sorts of regulations did during the Bush years.

The devil here will literally be in the details. Chances are Lieberman and co. will try now to gut them of content. If the conservatives prevail, and the final bill creates a structure of regulation without potency, the fight will then be on again, to give the regulations real force.

The shell of a tighter regulatory structure may be all that can be salvaged this time round. That would be better that than nothing – giving us a framework to defend and a set of regulations to thicken. Health reform in this generation is clearly going to be a process rather than a moment!

Rebecca Matteo, a lecturer in sociology at Wake Forest University, teachers the first-year seminar “Health Care Reform:  A Sociological View of America’s ‘Non-System.’”   From preventive health to cost containment, the class explores the fragmented landscape of health care reform from the sociological perspective.  Here Matteo shares her views on the most important issues in health care reform today.

By Rebecca Matteo

As I tell my students, I think one of the biggest “issues” in health care reform currently, is the lack of understanding we, as a country, have about the “health care system” itself. I am excited to hear my students talk about conversations they have with family and friends outside of class related to health care reform. Their eyes are open … and they feel confident to have an opinion that they can both articulate and defend. What I believe is that our system is not truly a “system.” We currently lack centralization, regulation, communication, and organization in the way health care is provided, which is not to say that a socialized system is necessary. But, there are so many gaps in our current fragmented medical complex that the “where to begin” question is overwhelming. I am reminded of this at the start of the semester, when I realize that there are never enough weeks in the semester to consider every relevant topic.

In terms of health care reform in general, I believe that our “non-system” is in need of major change. Compromise is inherent in sweeping policy, but I do agree with the specific focus of removing pre-existing condition clauses from insurance plans, and greater coverage of Americans in general, without losing options (or choice) in coverage. Furthermore, continuity of care is something I personally believe will improve our system, but this requires access and availability of both insurance and general practitioners (potentially facilitated through electronic medical records). In an era marked with the proliferation of chronic disease management and increasingly expensive, yet beneficial, health technology, there must be an effort to support preventive health, both through individual and system-level changes, rather than continued “reactive” and “defensive” medicine, which ultimately lead to wasted time and money.

Within the long history of attempts to provide major reform to the health care system in the United States, I feel that President Obama has forced conversation to an unprecedented level. Creating a dialogue and making decisions transparent are critical ways to help alleviate fears of government control that are pervasive in our society. Sadly, as medicine developed into “big business,” market ideals became entangled with the altruism of the profession. We all suffer for that trend – as the collective interests of health care are now intertwined in a web of fear about life-threatening chronic illness, medical bills, losing insurance, malpractice – on and on. What we do know, is that Americans are very diverse in both their opinions about what is best for the health care system and their own individual health care needs. Whether reform is based upon cost containment, health outcomes assessments, or the satisfaction of patients and health care workers, what we need most is a level of security and consistency for health care providers and their patients.

In the last of a three-part series, David Coates,  discusses why we will not fully resolve our health care crisis until we choose to start living healthily again as individuals, as an economy, and as a society. Coates holds the Worrell Chair in Anglo-American Studies at Wake Forest University. The argument developed here can be followed up in his Answering Back: Liberal Responses to Conservative Arguments, New York: Continuum Books, December 2009

Healthy as a Society

By David Coates

This is not to glorify the 1950s, a time that for many Americans was scarred by misogyny, racism and hidden female despair to which there must be no return. But it is to remind ourselves that in 1970 the ratio of CEO pay to average pay in the top Fortune 500 companies was 70:1. It now normally oscillates somewhere between 250 and 300 to one. We have watched a reasonably equal society separate itself off into an excessively rich minority and a financially challenged bottom third. Poverty and ill-health go together. A more equal society is a healthier society. There are routes to health, we need to remember, which run through social change and economic justice rather than through a resetting of the health care system, vital as that resetting is.

It is surely time to call on America to wake up and smell the coffee. The last years of the Roman Empire were marked by “bread and circuses”. We don’t do bread and circuses here in the United States. We do fast food and the NFL instead. The parallels are terrifyingly close.

Follow

Get every new post delivered to your Inbox.