Saturday, March 6, 2010

What Is Good Enough? Following the Education Strike, Quoting Ted Marmor

Writing from Santa Cruz, CA, a day after the massive one-day statewide strikes and day of action against the draconian budget cuts to public education in California - uniting teachers and school employee associations with parents and students, tartgeting cuts at every level (kindergarten - high school, community college, university) in our massively dysfunctional state. Something we haven't seen in health reform since the community-based struggles of the early 1970s. I found these excerpts from Ted Marmor's article of 2007 interesting:

Universal Health Insurance 2007: Can We Learn From the Past?
By Theodore Marmor

Americans are not well served by their current medical care arrangements. Compared to our major trading partners and competitors, we are less likely to be insured for the cost of care, and the care that we receive is almost certain to be more costly. Although U.S. medicine has produced many “miracles,” we are not the undisputed leader in medical innovation, only in the costliness and ubiquity of high-technology medicine. Most Americans “covered” by some form of health insurance still worry about its continuation should we or a close family member become seriously ill. Some of us are locked into employment we would gladly leave but for the potential catastrophic loss of existing insurance coverage.

While most commentators decry our peculiar ability to combine insecurity with high cost, the substantial reform of American medicine at the national level has been enormously difficult to achieve, and comprehensive reform has been impossible.

There is now once again a remarkable consensus that American medical care, particularly its financing and insurance coverage, needs a major overhaul.

The bad news for reformers then and now is this: for a variety of ideological and institutional reasons, American politics makes it very difficult to coalesce around a solution that reasonably satisfies the requirements for a stable and workable system of financing and delivering modern medical care. Agreement on the seriousness of the nation’s medical ills will not necessarily generate the legislative support required for a substantively adequate and administratively workable program. That is as true in 2007 as it was in 1948, 1971, 1993, and 2000.

Before an administration and a Congress can meet the challenges of workable reform, they have to resolve—or at least cope with—some of the nastiest ideological and budgetary conflicts in American politics. As did their predecessors, they face the seemingly intractable problems of substance, symbol, and support.

The fight over Medicare illustrates the rarely achieved conditions sufficient for successful (if partial) reform. Before 1965, the conservative coalition was formidable. The Democratic landslide of 1964 swept away the key conservative bases of institutional power: dilatory tactics by the Rules Committee, control of other key committees, and a Congress as a whole less liberal than John F. Kennedy or Lyndon B. Johnson. The massive electoral shift of 1964 held a lesson for future reformers: a fully sufficient condition for reform was a two-to-one Democratic majority in the House of Representatives, a margin large enough to contain within it a (smaller) majority on Medicare.

By 1970, the debate had shifted back from Medicare to national health insurance once again. Though it is difficult for many to remember, the striking feature of the 1970–1974 years was the intense competition among proponents of different forms of universal health insurance. There was the catastrophic proposal advocated by Senators Russell Long and Abraham Ribicoff. There was the Kennedy-Corman bill that closely followed Canada’s national program as of 1971. And there was the Nixon administration’s plan for mandated health insurance for employed Americans known then as the Comprehensive Health Insurance Plan, or CHIP.

Reform failed because shifting coalitions defeated every attempt at compromise—cycling negative majorities, we might say in political science jargon. The majority that agreed on the need for reform consisted of factions committed to different proposals. The more modest proposals—such as the Long-Ribicoff catastrophic bill—seemed too limited to those who wanted to translate the negative consensus into universal, broad coverage. The proposal for employer-mandated insurance—similar in financing to what Bill Clinton later proposed—seemed too indirect, incomplete, and incapable of cost control to those favoring more straightforward forms of national health insurance. And even Ted Kennedy, who moved from his more ambitious version of national health insurance to a compromise plan that he and the powerful Wilbur Mills could both accept, was incapable of organizing a coalition of liberal and conservative Democrats.

What worked once may not, in changed circumstances, work again. What failed may succeed. But some constants in American politics are relevant.

First, compulsory health insurance—whatever the details—is an ideologically controversial matter that involves enormous symbolic, financial, and professional stakes.

Second, the limits of political feasibility are far less distinct than Beltway commentators seem to recognize.

Third, the role of language and emotive symbols in this policy world cannot be overestimated.

But the central lesson of the past—of both defeats and victories like Medicare—is cautionary in a different sense. It is wise to wait if what is acceptable is not workable. It is foolish to hesitate if what is workable can be made acceptable. If the central elements of a workable plan are acceptable, the pace of implementation can be staggered. But, American political history in this area shows that the opportunities for substantial reform are few and far between, precious enough to make squandering close to a sin.

No comments:

Post a Comment