THE TREATMENT DECEMBER 28, 2009
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If you're logging in for the first time in a few days and catching up on health care reform, you've probably read a few articles about how the issue will play in the 2010 midterm elections, assuming Congress passes a bill sometime early in the new year.
Some people think the issue will help the Democrats, because it's a huge, historic accomplishment that will (eventually) address economic insecurity. Others think it will hurt the Democrats, since it's a big government program and won't do anything to boost jobs in the next few months. Also, polls suggest that health care reform is not particularly popular right now, although that could simply reflect predictable (and fleeting) ambivalence about the legislation process.
I really don't know who is right. But I do have some ideas about how health care reform will play out in the long term. And for that I have to thank Bill Kristol, of all people.
In a blog item posted back on December 16, Kristol wrote an item for the Weekly Standard blasting the Senate Democrats' bill and urging Republicans to hang tough in opposition:
Republicans should say: No, No, a thousand times No.
And if the legislation passes, the GOP should immediately begin trying to repeal key parts of it. The moment it passes, Mitch McConnell might introduce free-standing legislation repealing the Medicare cuts. Republicans could highlight their opposition to Big Pharma and Big Insurance by trying to force votes--in 2010--on drug re-importation and more insurance competition, measures that could go into effect right away so as to be of immediate benefit to the American people. And of course they should promise to relieve the American people of the prospect of living under the Democrats' health bureaucracy regime by promising repeal of the whole thing in 2011.
Republicans invoked the same refrain during the final days of the Senate debate. And, at a time when voters were pretty clearly disenchanted with the legislative process, I'm sure it didn't help the Democrats in the polls. But did it help the Republicans? Will it help them in the future?
I can't imagine how.
Voters don't tend to associate Republicans with populist crusades against the drug and insurance industries. And for good reason. In debates over the balance between business and government, whether its the economy generally or health care specifically, Republicans have always been the one standing up for the corporations.
Back in 2003, for example, it was the Republicans who insisted upon creating a Medicare prescription drug benefit that channeled coverage exclusively through private insurers, padded insurance company profits with unjustified subsidies, and blocked efforts to let the government bargain directly over prices. The Democratic alternative would have provided prescription coverage directly through the government--which, by the way, would have meant less money for the drug makers and insurers, but cheaper drugs for seniors.
It's true that President Obama and the Democrats cut deals with the drug industry in order to pass a reform bill this year. And while they didn't reach such an agreement with the insurers, as far as we know, the final bill is friendlier to the insurance industry than many of us would like.
But it's not as if Democrats were, by and large, excited about these compromises. Most of the party's leaders saw them, rightly or wrongly, as an evil necessary for getting a bill through Congress.
And it's not as if the Republicans were proposing to come down even harder on the health care industry. You didn't hear Mitch McConnell demanding that the government bypass private insurers. You didn't hear John Boehner clamoring for direct government negotiation over drug prices. Instead, you heard them proposing to minimize government intervention in the business of medical care and calling to deregulate the insurance industry, which is what Kristol means when he says "more insurance competition." In case you were wondering, this is precisely the sort of change the insurance industry would love.
The future should make this distinction even more clear. Republicans are vowing to repeal health care reform if they get into power--and, I suppose, it's possible they'll succeed. But it seems far more likely that, once enacted, health care reform is here to stay. However unpopular this bill is today, the underlying concept--that government ought to make health insurance a right--remains popular. To repeal health care reform, Republicans would have to convince voters they're better off without laws prohibiting insurers from discriminating against the sick--and without subsidies that would help middle class people, as well as the poor, pay for their premiums. I just don't see that happening.
Instead, the coming fights over health care are likely to be over how to improve whatever measure Obama signs into law--which will mean, among other things, arguing over whether to regulate insurance practices even more aggressively, whether to use government bargaining power with the drug industry, and, yes, whether to start some kind of public plan.
In these debates, Democrats won't be the ones championing the interests of the health care industry. The Republicans will. It's hard to imagine the voters won't notice.
P.S. Speaking of the 2003 Medicare fight, Charles Babington of the Associated Press had the good sense to ask some Republican senators opposing this year's reform on budgetary grounds why they voted for the Medicare drug benefit, which had no offsetting revenue or taxes whatsoever. The answers are, um, interesting.
Update: Austin Frakt identifies a more likely line of attack for future Republicans.
Read Jonathan Chait's dissection of Kristol here.
Follow Jonathan Cohn on Twitter: @jcohntnr
23 comments
Republicans vowing to repeal Medicare cuts! The world is a strange place. But someone's got to rail against these pinko giveaways to private corporations.
- frippo
December 28, 2009 at 2:37pm
This just shows how the Republicans have been outfoxed on this issue by Obama and the Senate Democratic leadership, and why they Democrats knew that they needed to get health care reform finished and (hopefully) signed into law early next year. Before a bill is passed, all sorts of arguments can be used to derail it, and many of the arguments will carry traction with the public and voters in the deluge of information that surrounds the passage of a major bill. Once the bill is signed, and at least some popular policies are enacted immediately, then the attempt to repeal the bill has to deal with the repeal of the popular policies as well. You won't convince any persuadable voter in 2010 or 2012 that a the newly-legislated health reform would mean death panels or jail time for failure to buy insurance, because the reform would have been law and none of those things would have happened to anyone by then. That's why killing the bill was so important to Kristol, and why running on a repeal platform will be exceedingly difficult for Republicans in 2010 and 2012. Another thing for the Jane Hamshers and Louise Slaughters of the world to think about, if they ever bother to think before they act.
- wildboy
December 28, 2009 at 3:01pm
I say if Republicans want to repeal the medicare cuts, then Democrats should join them provided the Republicans show how they will pay for the cuts without increasing the deficit.
- blackton
December 28, 2009 at 3:38pm
I dount this kind of tactic will work. It'll probably backfire. All the Democrats have to do is sit back and wait till Bill Kristol and his ilk start talking repeal and then reply by stating the obvious: the attempt to repeal health care legislation is the first step to repealing other government programs such as social security. I am sure the baby boom generation about to retire will love to hear that. Kristol isn't politically very bright, people with fixed ideologies seldom are.
- jacksondyer
December 28, 2009 at 7:57pm
By 2012 everyone should have felt a non-trivial bump on premiums, and many in the middle class that were forced to buy insurance might be smarting. I'd think at the 2012 debates, it should be fairly easy to remind everyone that the president that said he'd raise taxes "by not one dime" indeed decided to raise them on the middle class by 50,000 dimes. And then a republican challenger can remind the audience just how friendly this administration has been with bankers, and how bankers are making more than ever. And perhaps he could ask just exactly how many laws have been put in place to ensure there isn't another meltdown? Hmmm: Obama equals huge tax increases on the middle class while the bankers make out like bandits. Seems like it could be made to stick.
- SeattleEngineer
December 29, 2009 at 2:19am
Health care as a right will remain popular until people have to start paying for it. Then we'll see. In 2010, "It's Better than Nothing" does not inspire confidence as a slogan.
- butchie b
December 29, 2009 at 10:45am
"And then a republican challenger can remind the audience just how friendly this administration has been with bankers, and how bankers are making more than ever. And perhaps he could ask just exactly how many laws have been put in place to ensure there isn't another meltdown?" So a Republican challenger is supposed to convince the audience that he/she is the anti-Wall Street, pro-regulation candidate? Hmmm: Seems like a snowball's chance in hell.
- Fishpeddler
December 29, 2009 at 11:11am
"So a Republican challenger is supposed to convince the audience that he/she is the anti-Wall Street, pro-regulation candidate?" Hello? Wall street has voted democrat over the years. Overwhelmingly. Dems have wall street and the trial lawyers, republicans have big oil. And ti was the republicans that tried to put legislation in place on fannie/freddie. And because fannie and freddie are filled with democrats, and because dems in congress were addicted to cheap housing, the regulation didn't happen. It's not a stretch to sell at all.
- SeattleEngineer
December 29, 2009 at 11:48am
"By 2012 everyone should have felt a non-trivial bump on premiums, and many in the middle class that were forced to buy insurance might be smarting." That may be true, but then the Republican candidate will have to explain how the GOP's failure to produce a plan would have avoided rises in premiums, premiums that had been exploding on the Republicans' watch. Maybe the public will buy the lies, but the candidate will have no choice but to lie in making his or her case. Meanwhile, Obama can point to the real merits of the bill: expansion of coverage to 30 million people, the end of losing coverage due to pre-existing conditions, no capping of insurance expenditures in a given year, and federal subsidies for those rising premiums. Unless matters change, he'll be much more vulnerable regarding jobs, which is why he needs to focus on that issue during the coming 2 years.
- propositionjoe
December 29, 2009 at 11:49am
The idea that health care is a `right' is the fatal flaw that will bankrupt the country or, more likely, result in lower and lower quality of health care at higher and higher prices. There really, really, really is no free lunch.
- rvogel
December 29, 2009 at 1:40pm
Actually, joe, the GOP candidate won't have to explain squat, because the issue will be what did the incumbent do? If premiums go up, every Dem incumbent will have to explain why. The real merits of the bill, whatever they turn out to be, will not have revealed themselves by 2012, but higher taxes will have. Oh, yeah, jobs too, and an Iranian nuke to boot. Should be fun. rvogel, you will find no market for your ideas here, if all you have to offer is common sense.
- butchie b
December 29, 2009 at 1:58pm
Remember all of the great Democratic electoral gains in 1966, the year after they enacted Medicare and Medicaid? How about that permanent Republican majority, cemented by the 2003 Medicare Prescription Drug Bill that was strong-armed by Tom Delay et al? If you don't, that's because health care expansion has never been the major short-term contributing cause to electoral shifts one way or another in this country -- it's always been jobs, the economy and, depending on the time, foreign policy. Which is mostly what it will be in 2010 and 2012. On the other hand, the attempt to scale back health care entitlements, such as those by Reagan in 1981 and by Newt Gingrich's Congress in 1995-96, do tend lead to electoral defeat for their proponents -- which is why Republicans have been so eager to kill health care reform in its crib, before it actually gets signed into law. Bill Kristol may be dumb, but he isn't stupid. Oh, and one other thing to rvogel in particular -- if you want to lecture the bleeding hearts about how health care isn't a "right", you need to do that in The Nation or The American Prospect and not TNR. Most of the writers and commentators here don't hang their hats on some vague notion of individual rights and how health care is the fulfillment of some sort of Rawlsian fantasy. They hang their hats on how health care costs are gobbling up almost 1/3 of our annual spending, are responsible for the large majority of our budget deficits and skew the everyday economic decisionmaking of tens of millions of Americans (and most of their employers) in myriad unproductive ways. And all this without a particulary healthy, fit or satisfied public to show for it. If this kind of massive resource mis-allocation was primarily for the benefit of poor people or unionized manufacturing workers, you and your ilk would see it as the epitome of evil in the world. But because it benefits insurance companies, drug makers and hospitals, you humbug us about a free lunch. It's not about a free lunch, it's about a lunch which is not filling or tasty but whose cost always keeps rising.
- wildboy
December 29, 2009 at 2:48pm
"That may be true, but then the Republican candidate will have to explain how the GOP's failure to produce a plan would have avoided rises in premiums, premiums that had been exploding on the Republicans' watch." Failure to produce a plan? As if it would have mattered? Did you read the republican plan? The free market is the best controller of prices. Ask yourself why boob jobs and lasik cost less today than a decade ago. Why is that? When everything else has nearly tripled in price over the last 10 years, lasik and boob jobs have dropped by half or more. How can that be? Hint: Neither are covered by insurance or medicare/medicaid. Answer: Competition and a Free Market. What will piss off the public is to learn that health care costs will STILL rise uncontrollably. They WILL see waiting times go up. They WILL see denials still occur. Remember, Medicare denies coverage for procedures at a rate greater than private insurance. The likely way to correct all this would be to provide everyone a catastrophic care policy courtesy the US government (with a $10,000 deductible, which would cost less than $80/month/person for a family) and then share the costs with employer for each service rendered under a certain amount. This was pretty much the Whole Foods plan, which has demonstrated tremendous cost controls. Do not underestimate how pissed consumers will be to pay Euro-style taxes on this. If you follow my postings here, I've said all along that charging euro-style taxes on the middle class will be the only way this is funded. And here we are, contrary to what all the others argue would NOT happen. Hah. The largest tax increase on the middle class EVER is in this bill.
- SeattleEngineer
December 29, 2009 at 4:08pm
PS. If "read my lips: No new taxes" sunk Bush 41, why do you believe that "If you make less than $200,000, your taxes will not go up. Not by one dime", followed by the largest 3 year tax increase on the $55K to $200K earners in the history of this country will not be the undoing if this president?
- SeattleEngineer
December 29, 2009 at 4:13pm
seattle, please. Obama won't be running against himself but a real live living Republican, and at the rate they are immolating themselves that nitwit Palin might be all that is left, in which case Obama will likely carry all 50 states. Who are the likely nominees? Huckabee now has his own Willie Horton. Romney will still be a plastic Morman (still, in my mind, the best of that bunch by far) and fundies simply won't vote for a Morman. Pawlenty is invisible. Jindal is too exotic for Republicans (VP maybe) and Palin is insane, Jeb Bush is undone by his own last name. As of now Obama will win in a walk, and since it is highly likely the economy will be on a strong upswing in 2012 the question will be how big he crushes the Republicans.
- blackton
December 29, 2009 at 5:02pm
Seattle, did you ever notice who works at Whole Foods? The workforce is overwhelmingly young and healthy, so catastrophic coverage is pretty much all they need. Companies like Whole Foods and Starbucks can afford health coverage for all their employees because their employees are unlikely to ever need actual medical procedures for as long as they work there. What do you propose to do for the vast majority of other businesses in this country, who need to get by with people in their 50s and 60s who have diabetes, heart disease and high cholestorol? Those are the people (plus, of course, the elderly) whose health care needs drive insurance prices ever-upward. We don't have the option of putting sick people on an ice floe here in the Lower 48, so your recommendation for a Whole Foods-like policy is pretty much useless.
- wildboy
December 29, 2009 at 5:16pm
wildboy, very, very few people need more than $10,000 annually, year in and year out. That's true even among our medicare recipients. Check on-line yourself. A 50 year old mom and dad with teens can get monthly policy with $10K deductible for about $200/month. That's why catastrophic care policies are so cheap. The government should just "give" that to us. Then nobody loses their house due to cancer or a bad car wreck. But it does require people to save for things like babies, and shop around for sore throats. If people were shopping for the first few thousand of insurance, then costs, like with boob jobs and lasik, would have fallen substantially.
- SeattleEngineer
December 29, 2009 at 5:57pm
I can see how in having us all included in a tax supported, single, not-for-profit system to finance insurance, health care could be seen as a right. But mandating ourselves to purchase health insurance in the most expensive system for financing health care that the world has seen? What the Senate just passed does not make health care a right.
- bsemple
December 30, 2009 at 2:19am
blackie, I'm not sure "the fundies" won't vote for Romney. It will depend on how much they can't stand BHO in 2012. He better hope the economy is on an upswing, because otherwise he's going to have real problems, and I don't see much chance of foreign policy triumphs by then.
- butchie b
December 30, 2009 at 10:44am
butchie, I mean they won't vote for Mitt in the primaries, I have no idea what they will do if Mitt won the nomination, how much they will turn out, donate, etc. or is it likely they will turn to a third party tea bag candidate, Dick Armey and his dick army perhaps?
- blackton
December 30, 2009 at 11:19am
Ah, thanks, blackie. BTW, Happy New Year to you and all my online friends hereabouts.
- butchie b
December 30, 2009 at 1:30pm
blackton, you are right there's nobody exciting in the queue for the right. But 2012 is a ways away. Obama has dramatically lowered the bar in terms of just how much experience is needed, which means the mouth of the funnel got a whole lot wider. If the supply-siders are right, then president Obama MUST reduce taxes on top earners to get this economy going again. He's already made a first nudge towards small businesses, which are a lot of the top earners. It's funny because 2012 could have him trying to explain to people why he cut taxes on the wealthy and let all the benefits ride for wallstreeters, and also having to explain why the taxes on the middle class jumped more than any other time in history. Ahhh, the irony.
- SeattleEngineer
December 30, 2009 at 4:15pm
It would be foolish for any Republican to pin hopes on gaining seats in 2010 on the platform of opposition to the Senate and House health care bills as they sit now. Polling on whether a majority approve or disapprove of the bills as they are currently constructed doesn't remotely tell why they don't like what's proposed and unless a group trying to capitalize politically knows the "why" or "why not", the risk of damaging it's chances for gains rises drastically. Just because the snapshot at the time indicates that Americans are disappointed with the near-end result of "reform" doesn't mean that Americans don't want real reform in the big picture. While Democrats certainly could have done way better in my opinion and no doubt in the views of many, many others as well, it's also a pretty good bet that the Republicans couldn't have done any worse in advancing their chances in the coming mid-terms by blatantly trying to derail any chances of meaningful reform that many Americans were hoping for. Just because a full-blown campaign of fear and misinformation running 24/7 did the trick for the GOP in '93-'94 doesn't automatically guarantee a repeat. As someone firmly left-of-center, I wouldn't mind if the GOP went all-in on the "repeal-the-whole-thing" sales pitch. By not ever even bothering to offer anything resembling a serious proposal of their own on health care while Americans watched for months on end, they have already cemented the impression among many skeptical voters that they weren't serious about meaningful progress in any case. On the other hand, it's not like they have any original ideas of their own that can be considered a success for working people. So stoking fear and continuing outrageous claims is probably all Republicans have at this point.
- fultimr
December 30, 2009 at 10:31pm