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.

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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

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

By David Coates

As health care reform legislation moves to the Senate floor for debate later this month, the stakes are high for President Obama and the nation. Health care reform is Obama’s Waterloo. He has to win this one. A loss on the health care front would lead to losses on future key legislation as well. If Obama loses health care, he will lose immigration.

In order to pass health care reform, the two sides must consider the following key points.

“The Perfect Must Not Drive Out the Good” – While the current legislation is far from perfect, it does pave the way for important changes in the U.S. health care system that could ease the anxiety level among Americans. We want to get to the point where health care is not something Americans worry about. Even though there is a widespread belief that we have the finest health care system in the world, we also have a higher level of anxiety than any other country about the cost and availability of the heath care that makes us so proud.

“Weakness on the Cost Side Must Not Prevent Reform on Access” – Much of the opposition to reform is focused on the costs involved, but there is a critical need to broaden access to health care in the U.S. now. The current reforms would only be Round 1, with Round 2 to follow as the cost implications play themselves out. Paradoxically, the public option, which Republicans oppose, is the very provision that would drive down costs by providing competition for private insurance companies.

“Health Care Reform Would Stimulate the Economy” – The U.S. health care system accounts for 1/6 of the economy and employs 14 million people. New players on the demand side would provide an economic stimulus, whereas the status quo will lead to escalating costs and stagnation.

Informed discussion on these and other issues is the key to overcoming the current divide.

Health care is arguably the most important political issue touching the daily lives of each of us, yet deep ideological differences scar the political landscape. The final settlement will be a compromise satisfying neither extreme, but definitely privileging access over costs with proposals designed to widen and deepen access to health care.

David Coates is a political science professor at Wake Forest University and a frequent speaker on health care reform. For interviews with him, contact Carol Cirulli Lanham at 972-818-0895.

By David Coates

As the debate over health care reform moves to the Senate floor, there is a consensus on what President Obama refers to as at least 80 percent of what is needed: no denial of coverage because of pre-existing medical condition, help to the low paid and the small business sector to buy basic health care for themselves and their employees, and a resulting mandate on both individuals and companies to participate in the health care system (to “pay or to play”).

But two major stumbling blocks remain unresolved: the issue of the public option, and the issue of costs

The Public Option The voluntary offer on cost cutting that the White House won in May was made by insurance companies determined to block the public option; and that opposition could not be talked away, no matter how hard the White House pressed the case Progressively, the issue of the public option divided the leadership of the Democratic Party in Congress – as a vital element in all the bills passed by the House, and a conspicuous absentee from the bill designed by Max Baucus in the Senate. His finance committee twice voted down in September amendments to include such a public provision – conservative Democrats (including Baucus himself) joining with minority Republicans to produce that result. Opponents of a public option regularly presented it as the precursor of a single-payer system, one that would inevitably shrink employer-provided coverage and force health insurance companies out of the market. Advocates of a public option dismissed that as hysteria: a cover to avoid what a public option would do, which is stop insurance companies overcharging for services and denying coverage to the genuinely sick. Into that impasse then flowed a series of different alternatives, not least the idea of a “trigger” – a public option only to be created if the insurance companies failed to deliver extensive coverage that met other criteria – a trigger that liberal Democrats believed was being offered by people determined never to trigger it. Add to that the notion of non-profit-based co-operative insurance exchanges to compete with private insurance providers, or the idea that individual states could chose/not chose to have a public option; but still the danger was obvious. Without either competition or tight regulation, the insurance companies stood to gain massively from any federally-funded expansion of the numbers of those insured; and as the President told the AMA in June, what he “refused to do was simply to create a healthcare system where insurance companies have more customers on Uncle Sam’s dime but still fail to meet their responsibilities”. (The Financial Times, June 16 2009)

Health Costs The Obama position throughout 2009 has been that any reform had to be “deficit neutral” over a ten year period – meaning that any upfront costs had to be fully paid by cost reductions or revenue generation elsewhere. The administration’s first budget proposed $300 billion less to Medicare and Medicaid, through cuts in subsidies to private plans participating in Medicare and by cuts in payments to drug companies and hospitals. Later proposals from the president raised that number to $600 billion. Proposed cuts of this kind mobilized resistance. The administration continued to seek good models from within the existing system – the Mayo Clinic became an early Obama favorite, Green Bay Wisconsin became another – and there was much talk of how dramatically health costs varied by state ($9564 in New York in 2006, but only $5311 in Hawaii – The New York Times, June 9 2009), with all the promise that held of cost-saving through the sharing of best practice.

  • But there was no avoiding the thorny issue of tax rises: could some of the extra cost be offset by taxes on the very rich (the House bill added $1500 to the taxes paid by those earning over $500,000 a year), or by taxes on things that make people ill (soft drinks were a popular liberal target by mid-summer) or by taxes on generous health care packages (the gold-plated Cadillac packages also favored as a tax target by some on the Left). Neither would sit easily with the Obama campaign promise not to raise taxation of people earning less than $250,000 dollars a year!
  • Nor could legislators easily escape the dilemma of making insurance affordable. The CBO’s regular estimates of the cost of each bill as it emerged continued to make the choice clear: coverage or costs. The wider the coverage, the larger the price-tag, on each bill in turn; yet without subsidies, people on low income could never afford the coverage they will be mandated to buy. But scaling the subsidy has the classic welfare trap problem: that as you phase out the subsidy as income rises, the effective income tax rate can reach 100%.
  • Beneath this tax discussion is the thorny issue of rationing. Conservatives like to claim that Obama and the reformers are introducing rationing, but the status quo rations anyway: allowing those with generous coverage to get what those without cannot. But the reforms are bound to change the rationing system: raising issues of whether, by widening access, the reformers will lower either the speed of delivery, or the quality, of medical coverage for the rest. the Centers for Medicare and Medicaid Services (the non-partisan watchdog institutions similar to the CBO) warned on November 14 that the Medicare cuts contained in the House bill “are likely to prove so costly to hospitals and nursing homes that they could stop taking Medicare altogether”. The CBO estimate that Medicare spending per beneficiary would have to grow at half the rate it has over the last 20 years to meet the measure’s saving targets. Politicians are unlikely to live with that – grey power being what it is – but increasing Medicare payments will erode much of the claimed savings.