If one had to bet, one would bet that the Democrats are likely, in the end, to "get something." Public option? Probably not. Universal coverage? Definitely not. "Bending the curve" on costs? Definitely not. But that's OK, because "muddling through" is always a good option in a democratic society. The joke floating around town is that if a piece of paper bearing only the words, "Health Care Reform Act of 2009" floated onto Barack Obama's desk, he would happily sign it and take credit for it--mission accomplished.
But the question is, Why has it been so hard for the Democrats? After all, there's a Democratic president who campaigned on healthcare reform, and who won the biggest landslide for a Democrat in more than four decades. And the Democrats have huge majorities in both houses of Congress.
So why the difficulty? I can think of five reasons, which are full of implications for this bill as it struggles to come to life in the years ahead.
The first reason is the simplest: Obama shot his fiscal wad on Wall Street bailouts, and auto takeovers, and stimulus packages. As Obama said of the national fiscal situation on May 22, "Well, we are out of money now." And as I wrote in June for US News, When confronted with a choice between healthcare for the poor and the near-poor on the one hand, and the continued overstuffing of the overclass on the other hand, Obama made a decisive choice: He chose the overclass. He put rich people first.
It's a first-class-first process ably described by the economist Mancur Olson, and any number of economists way to Olson's left--the rich belly up to the food table ahead of everyone else, eat everything they can till they are done, and then the middle class and the poor are left to fight over the crumbs.
The second reason for the difficulty is the public perception that the current plan is a welfare plan in disguise. The common jibe among Republicans is that Obamacare will degrade coverage for 250 million or so Americans so that Obamacare can function as a voter-registration plan for 30 or 40 million Americans. Benjamin Barber-type “Strong Democracy” is popular enough, if you are inspiring the broad middle to take greater control of their own lives, in an Andrew Jacksonian sense, but if the thrust of contemporary liberalism proves to be just a veil ill-concealing yet another welfare program, well, the middle class is unlikely to like it. As the late Daniel Patrick Moynihan long lamented, in recent decades, the national Democrats have seemed mostly incapable of thinking of a plan for helping the middle working class, as opposed to the poor or some other avant-garde group. (Or the rich, see reason #1 above.)
The third reason is the manifest failure of government to prove its competence. A century ago, Max Weber could write, with a straight face, that the reason for the rise of bureaucracy was its "technical superiority." Times have changed. Today's federal government is not exactly bureaucratic, of course. Policymaking has been substantially outsourced to judges, lawyers, and outside activists--and contractors seem to be doing a lot of the in-house work. But by any name, or in any form, the business of the federal government does not smell sweet to most Americans. When today's liberals say that "health care management" is the answer, with them, of course, doing the managing, some Americans think "death panels," and plenty more are skeptical that any kind of government management can work.
The fourth reason is the breakdown in the mutuality that is needed for a welfarist, communitarian ethos to flourish in a nation. That breakdown was incapsulated in "The Heckle Heard 'Round The World," that is, Rep. Joe Wilson's "You Lie!" catcall against President Obama when Obama said, in his September 9 speech to Congress, "There are also those who claim that our reform effort will insure illegal immigrants. This, too, is false — the reforms I’m proposing would not apply to those who are here illegally." Whereupon Wilson erupted.
The point here is not to defend Wilson or his manners. Instead, the point is that the Democrats, trying to manage their rainbow coalition, feel electorally vulnerable on the question of whether or not their healthcare plan will cover illegals--and with good reason. Everyone knows that they want to cover illegals, as a matter of social justice, and everyone who thinks about public health realizes that some provision needs to be made so that nobody is walking around coughing up tuberculosis on the streets. Like any other contagious disease, TB is completely agnostic about legal vs. illegal.
The broader issue crunching down on the Democrats is welfare-state liberalism vs. multiculturalism. As Harvard's Robert Putnamhas noted, along with many others, the communitarian ethos that upholds the welfare state is based substantially on ethnic trust and national commonality, and those bonds of affection and unity have a way of breaking down amidst multiculturalism. Welfare states thrive in homogenous countries, they are smaller and less expansive in heterogenous countries--and as for really heterogenous countries, well, they have a way of becoming ex-countries, viz. the USSR, Yugoslavia, Czechoslovakia, and so on.
The fifth reason for the Democrat's difficulty is the basic flaw in the intellectual model: "health insurance reform" is not the goal of most Americans. What the American people really want is cures. You don't go to the doctor because you can, because the government has given you some card entitling you to low-tech care. Nor do you go to the doctor to show off the intellectual ingenuity of your health savings account. Instead, you go to the doctor to get better. Ask yourself: Where in the Obama pitch is there any discussion of actually curing anything? (One doesn't hear much "cure talk" among Republicans, either, but they, being the minority, aren't the issue right now. In the next Congress, or the one after that, they might regain the majority; we can revisit them then.)
The story of 2009 is the apotheosis of the left-liberal idea--inflected by "Club of Rome"-ish environmentalism and residual enthusiasm for barefoot doctors--that we have enough health, or maybe even too much health. So don't worry about the creation of health; in fact, the creation of new medicines needs to be restrained, in the name of "cost control. The main imperative is the redistribution of health, not the creation of health.
Here at Serious Medicine Strategy we think that redistributionist ethos is bad politics and even worse for medicine, but the Democrats now have their moment.