The health care discussion of the past year has been remarkable for the narrow range of ideas and opinions that have floated down to the man on the street. Looking back, it appears that journalists have sought out the same organizations and sources to build and shape their stories, offering up what has become the conventional wisdom for reform. To bring more voices into the conversation, our new series, Excluded Voices, will intermittently feature health care experts people who haven’t been on the media’s A-list of sources. We want to offer journalists more options for their stories and encourage a deeper discussion. To that end, we’ve asked the experts featured in each post to respond to questions from Campaign Desk readers. The entire series is archived here.
In mid-October, the Philadelphia Inquirer ran an op-ed by Yale professors Theodore Marmor and Jerry Mashaw. The headline, “Health-care plans familiar; Obama and McCain fall into old traps when it comes to financing,” intrigued me—and so did the commentary. “American health policy debates have for some time been dominated by technical fixes, faddish nostrums and gimmicks. The news cycle of commentary about reform ideas is both brief and superficial,” they wrote. I know Marmor, who has also written a classic text on the politics of Medicare, and asked him to elaborate on the points he made in the op-ed—points not being made elsewhere.
Trudy Lieberman: Would you say that your op-ed is bringing a different voice to the debate?
Theodore Marmor: We have a distinctive social insurance voice that has been underrepresented in American public discourse. Social insurance programs in the U.S. are widely popular in a superficial way. You have popularity without understanding. If you were having this conversation in Berlin or Paris, people would easily know what we’re talking about. They wouldn’t use the word “entitlement” as a budget term but a as a social and cultural understanding of the obligation to pay and the obligation to receive when eligible
TL: How has this year’s discussion of health care and possibly next year’s been a rerun of 1993-94, when the Clintons came in with grandiose plans for reform?
TM: Of course, it’s not identical, but the parallels are stunning. The Democrats are all embracing a variant of what we called “pay or play” plans that require employers to provide insurance or pay into a fund to support people buying on their own. The Republicans are all pro-market enthusiasts with more or less commitment to tax credits that permit some expansion of access to care. The variant on this year’s offering is a public plan (promoted by Barack Obama and Hillary Clinton) that over time through competition its advocates hope will become the dominant plan.
TL: What has been missing in this year’s debate?
TM: It’s very different from the debate that occurred from 1989 to 1993, when there was a lot of talk about what we could learn about health care in other industrial democracies. This year’s discussion of that has been anemic.
TL: Why is the debate no better than last time?
TM: A set of analysts have had a mistaken understanding of why the Clinton plan failed. Apparently there is polling data showing that the loss of choice of peoples’ insurance plan explains the loss of support for the Clinton proposals. Pollster interpretation has generated Washington-based wisdom that Americans got scared of losing their employer-provided health insurance, and that’s why they turned away from the Clinton plan. People did fear a big change that they didn’t understand, but that has been reinvented to mean that they are devoted to their employer’s health plan. It’s like equating it to that old saw that a bird in the hand is worth two in the bush except that the bush is fraying at the edges and is disappearing for many. It’s literally idiotic to suggest that the choice of insurance plan rather than the choice of provider is paramount in peoples’ minds. During the campaign, choice of plan became the most important issue as evidenced by Obama’s slogan that if you like your insurance, you can keep it.
TL: Will a public plan work as advocates envision it will?
TM: If it were possible to get enough political agreement to get an attractive public plan to dominate, it would really be possible to get something more straightforward. Supporters have a naïve but earnest hope that a “Medicare-like” public plan will be a stepping stone to a dominant public program for most Americans. Those who oppose it will fight like hell to make sure that the stepping stone does not become that attractive.
TL: What are the elements that will make or break a public plan?