Wayne O’Leary

Health-Care Conundrum

Guaranteed universal health care, the dream whose roots extend far back in Democratic party history—Al Smith, Franklin Roosevelt, and Harry Truman all favored it—may at last be reaching fruition. The Obama administration is on record in support of enabling legislation, and majority-party bills incorporating comprehensive coverage, from John Conyers on the left to Max Baucus on the right, are in the hopper or being formulated. The main question going forward will be what form the ultimate product will take, whether a single-payer proposal for a government-run system, a subsidized individual or employer mandate for private insurance, or something in between.

In 1934, FDR, who predicted the adoption of federal health insurance “sooner or later,” laid out its parameters in the following words: “I am confident we can devise a system which will enhance and not hinder the remarkable progress which has been made in the practice of medicine and surgery in the United States.” With that observation, he opened a Pandora’s box, the contents of which Democrats have been wrestling with ever since.

National health insurance, which the New Dealers had hoped to incorporate in the Social Security Act of 1935, did not survive the cut imposed by practical politics; the opposition it engendered among organized physicians and insurance companies caused the Roosevelt administration to postpone it in order to guarantee passage of the less controversial and higher-priority provisions for retirement pensions and unemployment insurance. In the late 1940s, Democrats tried again, but the inclusion of a national health-care component in Truman’s Fair Deal program died in its crib, when a GOP Congress turned thumbs down. Only in 1965 was partial national health insurance enacted, with the passage of the single-payer Medicare program for seniors. A generation later, the Clinton administration attempted, and failed, to institute full universality under the rubric of “managed competition,” a public-private mishmash using the government as marketplace referee rather than provider or insurer.

Now, the Obama administration and congressional Democrats will take another stab at the gold ring. One of the unresolved issues that doomed the Clinton plan, the old question of “universal” versus “national” health insurance (whether comprehensive coverage will be through private insurance companies or through the government) is back on the table, and lines have been drawn. Except for the Republicans, who want either no plan at all or one based on tax rebates, the baseline argument boils down to two opposing positions: the single-payer or something like the Romney individual-mandate scheme in Massachusetts.

To oversimplify, the single-payer, favored by most House progressives and, until recently, by Sen. Ted Kennedy (D-Mass.), can be characterized by the slogan “Medicare for All.” The alternative approach, advanced by Senate Finance Committee Chairman Max Baucus of Montana, a certified “ConservaDem,” would keep health reform on a relentlessly market-driven track by reinforcing the existing employer-based system and encouraging the subsidized purchase of private plans by the uninsured.

President Obama, as is his wont, is straddling the issue by calling for a single-payer option within a universal health-care model, giving those seeking coverage the choice to buy either a private or a public, Medicare-like plan. Lately, he has been joined by Ted Kennedy, who, no doubt hoping to see some kind of reform introduced while he can still influence the outcome, has dropped his insistence on an out-and-out single-payer plan and acceded to Obama’s “public provision”—single-payer as just one of multiple coverage options.

Simultaneously, Kennedy is negotiating with Baucus to achieve some sort of compromise bill satisfactory to both, a worrisome development because there’s not much left to compromise. Whether the president himself will remain steadfast for a competitive public option during the legislative give and take is another problematic unknown. His spokesperson, Secretary of Health and Human Services Kathleen Sebelius, has been waffling on the issue, so we’ll see. House Speaker Nancy Pelosi, for her part, is so far holding firm on public provision.

The main action, however, will be in the Senate, where the issue will ultimately be decided. As the Democratic rank and file wait to see if their expressed preference for public health insurance will be once more shunted aside, we are treated to the arrival of a new party member, Pennsylvania’s Arlen Specter, welcomed aboard by a White House that, oddly enough, sees him as an additional key vote for health reform and the guarantor of a filibuster-free Senate.

In reality, the corrupt bargain that jammed Specter down the throats of Pennsylvania’s Democrats—he’s been virtually guaranteed the party’s 2010 Senate nomination, along with campaign funds and presidential backing—gained the administration next to nothing and may have derailed worthwhile health legislation in the process. Turncoat Specter, who freely advertises his disinclination to be a “loyal Democrat,” is on record against any public option (the official Obama position) in the upcoming medical-reform bill; he’s essentially a new recruit for the insurer-friendly ConservaDem faction, moving Senate Democrats incrementally to the right on the health issue.

The bottom line in the internal Democratic debate is that the public-option provision, should it survive the opposition of Specter and others, opens the door to revolutionary changes in American health care. (Critics on the Republican right, such as former Bush speechwriter Michael Gerson, commenting in the Washington Post, correctly view it as “slow-motion Medicare for all” because of its undeniable economic appeal, a frightening prospect in their eyes.) Conversely, any reform without a public provision will be next to worthless—merely a new subsidy for the heath-insurance industry. It’s not clear if the White House, with its predisposition to please all health-care “stakeholders” (Big Pharma, the Americal Medical Association, the insurance companies, et al.) appreciates its historic opportunity. Is public provision the president’s legislative line in the sand, or just a bargaining chip?

More to the point, can he be persuaded, through an overwhelming show of public opinion, to go the whole hog and endorse a clean, unambiguous single-payer bill in its entirety? The answer may determine whether marketplace medicine in America is immediately put out of its misery, or whether it lingers in an induced coma for several years more, expiring fitfully by stages amidst messy recriminations. Either way, unless the Specter factor somehow changes the dynamic, the die appears to be cast.

Wayne O’Leary is a writer in Orono, Maine.

From The Progressive Populist, July 1-15, 2009

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