The topic of health-care reform in the presidential campaign thus far has been notable for the brevity of the discussion about it—the sound bites that have created the impression that the sum of the debate facing the nation is whether or not to mandate coverage and whether 15 million people will go without coverage if Barack Obama is elected. There’s been strong oratory from both Obama and Clinton. As Clinton said in the Ohio debate last night, “health care reform and achieving universal health care is a passion of mine.” But in the end, impassioned rhetoric is no substitute for convincing voters why the U.S. health care system must change and how. Any president embarking on this journey again needs buy-in from the voters, and neither Clinton nor Obama has yet to close the deal.
Author Susan Jacoby, who is promoting her new book The Age of American Unreason, made that point in a recent op-ed in the Los Angeles Times. Jacoby noted how Abraham Lincoln and Franklin D. Roosevelt would never have succeeded as commanders-in-chief without first being teachers-in-chief. Lincoln, she said, explained to the public why slaves had to be freed, and Roosevelt began to prepare the country for war after Germany invaded of Poland even though most Americans wanted no more foreign entanglements. Bill Clinton, however, Jacoby explains, never educated the public back in 1993 about his health-reform plan or why Americans should support it. The Clintons failed to make the case, however complicated, for their employer-mandate, managed-competition model spawned in the heyday of HMOs. I recall how this became painfully clear to me one day in the subway when I overheard a woman sitting next to me complain that everything written about the Clinton plan was so boring that she had simply dismissed it. We journalists, too, had failed to explain what was at stake.
Here is what the candidates would say to educate consumers about the current struggle over health reform if they were being honest: we are trying to get universal coverage. We can’t do it like other countries because the insurance companies will clobber us just as they’ve done before, and besides, we take money from them. We could require all employers to provide insurance coverage, but we know that many of them, especially the smaller ones, won’t like that and will clobber us, too. So we have to make you buy your own coverage if you don’t get it from your boss or from a public program. There’s just one problem: insurance companies don’t like to cover sick people, and to make them do that we must require that everyone buy a policy, even if it is expensive. That means an individual mandate. If insurers have a good mix of healthy and sick people in their gigantic risk pool, they will still be able to sell lots of policies and make money. Voila! We will have found a way to give everyone a ticket to health care and keep our market-based system. But there is also the matter of expense. Insurance premiums keep climbing because we haven’t found a way to really control the underlying cost of medical care. That’s hard to do because Americans want the latest and greatest treatments, and health-care providers want to provide those treatments even if there’s no evidence that they’re effective. We will continue to work on this to build consensus for real cost control, but we need you, the consumer, to understand the tradeoffs.
There was nothing approaching such candor last night. In the sixteen-minute segment of the debate that dealt with health care, Clinton and Obama tossed out bits of explanation that, if glued together, might form the nucleus of the syllabus they need to get the public on board. Clinton, for instance, said that unless everyone is in the system, insurance companies will cherry-pick only the healthiest people to insure. She also brought up the hidden tax that everyone pays when people without coverage use hospital emergency rooms. For his part, Obama noted that insurance companies don’t mind that everyone has to purchase insurance, because more people will buy their products. All true, but much more needed to be said; instead, both candidates returned to their familiar quarrel over mandates. And that is what the press picked up. A McClatchy Newspapers story, for example, said that Clinton insisted that she alone would expand insurance to all the uninsured by mandating coverage while Obama countered that Clinton would force people to buy insurance even if they couldn’t afford it.
Clinton argued that FDR did not make Social Security voluntary and Lyndon Johnson did not make Medicare voluntary. Her reference to Medicare reminded me of how Medicare supporters neutralized strong opposition from the American Medical Association and worked to educate the public before the Medicare law was passed. They didn’t do it with sound bites but with hundreds of pieces of literature that gave precise details of how Medicare would work and why it was necessary. A representative of the National Council of Senior Citizens recalled, in One Nation Uninsured by Jill Quadagno, “There was no other bill in history where details were as widely disseminated.”
That’s a history lesson worth remembering.