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.

In the second 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.

By David Coates

Healthy as an Economy

Why do we need fast food? We largely need fast food because we don’t have the time and energy to prepare food ourselves. That may be partly because of the need so many of us now seem to have acquired to watch American Idol,  and Monday night football, but it is mainly because we are all working such long hours for such poor pay. As Americans we work on average close to 2000 hours a year: that is, we now work at least 160 hours more than was common in the US at the end of the Vietnam War, and amazingly 400+ more hours than is currently the norm in Northern Europe. We do that in part because pay/hour has not risen for most working Americans (with the exception of a slight increase in the late 1990s) since the 1970s. In one generation we have transformed ourselves into a long-hours, low-wage economy with all the stresses on family life and personal health that such a mixture of work and pay entails. We have become two-income dependent for the maintenance of a modern life-style, and in the process we have lost more than time. We have lost skills – cooking skills. We have lost family meals, cooked and eaten at home. We have lost leisure. We have lost quality time together away from work. We have freed women from the drudgery of unpaid housework and loveless marriages only at the cost of doubling the female work load and pushing us all into a low quality food economy. We need a different economy as well as a different diet.

Making America Healthy

December 4, 2009

The Senate will continue to debate health care reform through the weekend. But according to David Coates, political science professor at Wake Forest University and an expert on the health care reform legislation, 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. In the first of a three-part series, he shares his insights into how to make America healthy.

Healthy as Individuals

By David Coates

France comes top of all the league tables of world health not just because of the clever way it organizes its health care system. It comes top because of the French diet – wine, freshly made bread, olive oil, and significantly lower intakes of industrially-produced food: all a fortunate by-product of the under-developed state of the French agrarian and retail sector. The French are not obese. Walking is not a loss art in France as it visibly is in parts of North America. As Americans we are becoming fat, at an ever earlier age and at a growing rate.  In June 2009 the Centers for Disease Control and Prevention reported that the direct medical costs of obesity now total $147 billion a year, 9% of all American medical costs. (You can add to that $116 billion to treat diabetes and billions more to treat the cardiovascular and cancer conditions linked to the Western diet.[i] ) American fast food not only feeds us fast. It also kills us fast. The American car not only drives us to the far horizon. It also brings us to our own final horizon faster than it should. There are serious life-style issues in play behind the health debate. There are serious issues about agribusiness and the dangers of industrial food production. There are serious moral hazard issues for all of us to face. We need to ask ourselves basic questions that so far we have ducked, to our very serious cost. Are we breeding a generation of ever greedier eaters; or are we the victims of a food industry determined to supersize their profits by supersizing us? Possibly the answer is a little of both, since corporate America creates markets as well as responds to them. Either way, we certainly need to get back to smaller portions – and to get back to healthy eating as a matter of urgency.


[i] There are some real gems out there for sale. The KFC Double Down sandwich at 1200 calories, or Starbuck’s Mocha Coconut Frappuccino Blended Coffee with Whipped Cream at 550 calories, or the KFC Famous Bowl at 720 calories, or Hardie’s Monster Thickburger at 1420 calories and 107 grams of fat (in just one sandwich), supplemented if you wish, by a dish of cheeseburger fries (each fry a mere 75 calories!). Source: Brad Reed, ‘The Fast Food Industry’s 7 Most Heinous Concoctions, Alternet August 27 2009