Where Have All the Health Reform Goals Gone?

What will Obama articulate tonight?

When Barack Obama was running for president, he said he wanted to make sure every child had health insurance. That was a fundamental difference between him and chief Democratic rival Hillary Clinton, who preferred to make sure that everyone had coverage—a throwback to the days when she and Bill pushed universal insurance. Neither candidate, though, envisioned truly universal health care as a matter of right; they just wanted to make sure that private insurers would cover more people. But somehow, in the public’s mind, universal coverage became equated with universal health care—largely because the press did a bad job explaining the distinction—and the part about kids got lost. After the election, expectations ran high.

By the time Obama sent his budget message to Congress in February, the health care goal/ principle relating to insurance had morphed into an “aim for universality.” The message called for a “plan to put the United States on a clear path to cover all Americans.” Kids might be a stepping stone on the path, but what about everyone else? Whatever the goals were, they got tangled in the weeds of the public plan option, and the public focused on the right-wing cries of a government takeover of health care.

Then came the president’s press conference on July 23, when he let slip that, at its core, reform was about insurance reform, making sure companies treated policyholders more humanely—a snoozer of an issue if there ever was one. In late August, speaking to a group of clergymen, he stated yet another goal: health reform as “a core ethical and moral obligation.”

The public could be forgiven if they were confused about reform. And when the pols and special interests tossed in their focus-group tested messages, the slogans got mixed up with the goals. Was health reform about a “uniquely American solution,” as Sen. Max Baucus and his patrons in the insurance industry were saying? Was it about “affordable, quality health care,” as Celinda Lake advised Democrats to say, or was it about the dreaded government takeover of health care that Frank Luntz counseled Republicans to hammer home?

The lack of clear goals and ways to achieve them is at the root of Obama’s public relations problem. The public spotted the shift and the inconsistency, and that has been apparent in the town hall meetings that CJR has been holding with ordinary people. Many have just tuned out. A twenty-two-year old journalism student at the University of Missouri told me “the debate is clouding out my ability to understand it…. The more they argue and the more things change,” she said, “the more I don’t want to read any more about it. I’ve stopped paying attention.”

So far, the discourse of health reform has been what it has always been—making insurance companies behave better, expanding Medicaid to include more poor people at the margins, leaving the profits of the largely capitalist health care industry intact—- a point that I made in “Groundhog Day,” published in the July/August issue of CJR. The U.S. is stuck in the old ways of thinking about health care, and the shifting goals and distracting slogans have obscured the talk of new possibilities.

If the public plan was a stab at new thinking, the president and its advocates have done a poor job of bringing the public around to agreement. It hasn’t even been clear that its supposed advocates want a public plan. Here again the public caught the drift of the administration’s shifting sands. Telling Americans they could keep the insurance they had and saying that most people are satisfied with their coverage—that is, until they get sick—has done nothing to build toward the Eureka Moment needed for real reform. Ultimately, real reform must mean that Americans have to see other possibilities, and strong leadership will be needed to make that happen. It makes me think what’s needed is something like Lyndon Johnson changing the paradigm on civil rights. Will Obama do that tonight?

As academics know, in order for a social movement to succeed, the discourse—the terms of the debate—-must change. That has not yet happened with health care. Up to now, we’ve been asking the same questions: how much it will cost; who will be covered; what’s the subsidy level for people who need help paying premiums; can I keep what I have? The country is trapped in the logic of the prevailing system. Will Obama articulate goals that will confront health care problems in a new way?

That remains to be seen, but this morning the crawl at the bottom of my TV screen flashed that White House press secretary Robert Gibbs said Obama would give more specifics tonight, and would remain flexible. Specifics are fine. We on Campaign Desk have been urging those for months, but flexibility? Does that mean caving into the special interests that funded his presidential campaign? And how does that square with strong decisive leadership for which Americans apparently hunger? To me, this doesn’t sound like a change in the discourse that will lead to the Eureka Moment. Still, we in the media should keep our ears perked tonight and in the coming weeks for any signs of the kind of shift the country needs.

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Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR's healthcare desk, which is part of our United States Project on the coverage of politics and policy. She also blogs for Health News Review. Follow her on Twitter @Trudy_Lieberman.