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Conservative arguments against health care reform tend to be monochrome: too many pages, too costly, too much government interference in our lives. But while the right supplies nearly all opposition to the health care bill, it does not have a monopoly. There is also an emerging opposition from liberals and the left. Thus far, it remains small, but its arguments are more diverse and more interesting—though ultimately, I think, mistaken. Among left-liberal opponents, I count three factions.
The unemployment-is-more-important faction. One short month ago, health care reform had no more ardent advocate than Robert Reich—former labor secretary, current Berkeley professor, and longtime policy entrepreneur. On Oct. 12 Reich wrote on his blog:
Now's the time for Congress and the White House to say to the insurance industry: You want to play hardball? Okay. We'll play it, too. … We're going to make sure Americans have the freedom to choose a public insurance option that's cheaper and better, and you're going to have to work hard to keep them your customers.
Reich fought ferociously for the public option, which remains in play; in a June 24 Wall Street Journal column, he urged President Obama to "come out swinging for it." But other issues in health care reform have engaged him, too. On Oct. 18, he wrote that Obama ought to abandon a deal confining Big Pharma's contribution to health care reform to $80 billion in exchange for the pharmaceutical manufacturers' support, likening it to the hush money David Letterman refused to pay a blackmailer. A consistent theme in Reich's commentary was his worry that Congress and the White House might be insufficiently bold, but that only added to the urgency of his message: We must do this.
Then, on Nov. 1, Reich posted a blog entry under the headline, "Health Reform Is Critically Important, but Getting Americans Back to Work Is More So." Huh?
Obama, Reich wrote, "seems to have made all the right moves to enact something he can credibly label health-care reform." Reich continued: "I sincerely hope America gets genuine health reform and I hope it's stronger than what's emerging in the Senate." But Reich then went on to fault Obama for making health care reform his top domestic priority "when the economy is still so fragile and unemployment moving toward double digits." He continued:
While health care reform, if done right, can help American families stay afloat in the economy, the current bills won't offer most Americans any appreciable decline in the cost of their health insurance nor clear improvement in the efficiency or quality of the health care they receive, and those who will benefit won't see the benefits until 2014 at the earliest.
What's more, Reich argued, the Obama administration's reluctance to take on Big Pharma, the American Medical Association, and the insurance lobby, will probably
make the resulting reform far more costly than it would be otherwise. These extra costs will be borne by those Americans who will be required to buy insurance but won't qualify for federal assistance, along with Medicare beneficiaries who will be paying more and receiving less. These people may not know they're indirectly paying the costs of buying off these industries, but they'll know they're getting shafted (Republicans will be sure to make them aware, even though the GOP has a much longer record of shafting the middle class for the benefit of big business).
Reich stops short of saying Obama should immediately drop health reform and fund a jobs program instead. Indeed, Reich says the "realist" in him recognizes that even if Obama were to "pivot off a health-care victory" with legislation aimed at reducing unemployment, that would still come too late to make much difference in next year's congressional midterm elections. The inescapable conclusion is that it's already too late: Obama should have bypassed health reform months ago and assembled a jobs bill instead. Never mind that Reich himself has, for months, been urging swifter, bolder action on health care reform.
I initially dismissed this analysis because Reich is only one man—and one with a uniquely short attention span. But the unemployment-is-more-important movement has since acquired a second adherent in Bob Herbert of the New York Times. In a Nov. 9 column, "A Word, Mr. President," Herbert writes that although health care reform is important, it is not nearly as important as putting Americans back to work or ending the war in Afghanistan. Like Reich, Herbert now thinks Obama should have put off health care reform to focus more of his attention on these other problems. "We have spent the better part of a year locked in a tedious and unenlightening debate over health care," Herbert complains, "while the jobless rate has steadily surged. It's now at 10.2 percent. Families struggling with job losses, home foreclosures and personal bankruptcies are falling out of the middle class like fruit through the bottom of a rotten basket."
I believe as strongly as anyone—even the two Bobs—that the government should be working to reduce unemployment as quickly as possible, through direct public employment if necessary. (See "Wrong Harry," in which Charles Peters and I called on the Obama administration to emulate Harry Hopkins' Civil Works Administration, which in 1934 created 4 million government jobs in two months.) But the idea that health care reform represents some petty distraction from what truly ails America is just screwy. In February, when Obama first turned his attention to health care reform, sagging employment meant that 14,000 Americans were losing the health coverage every day. Today the comparable figure is probably more like 5,000, since the economy is shedding jobs about one-third as quickly as it was nine months ago. That doesn't mean lack of health insurance has become a less urgent problem. In February, unemployment stood at 7 percent; now, as Herbert noted, it's above 10 percent. And as Herbert's New York Times colleague Paul Krugman noted in January,
helping families purchase health insurance as part of a universal coverage plan would be at least as effective a way of boosting the economy as the tax breaks that make up roughly a third of the stimulus plan—and it would have the added benefit of directly helping families get through the crisis, ending one of the major sources of Americans' current anxiety.
Most of health care reform doesn't kick in until 2013 (Reich is off by one year), but some important parts take effect sooner. Under both the House and Senate finance committee timelines, for instance, the prohibition against insurance companies excluding applicants with pre-existing conditions starts phasing in next year. In the House bill, so does a ban on insurers' lifetime payout caps and a requirement that insurers spend at least 85 percent of the money they collect in premiums on medical benefits.
Over the long term, the unemployment rate will come down with or without government intervention. But failing government action, the percentage of uninsured people will probably, after a small post-recession drop, resume this past decade's upward climb. That's a pretty good argument for making health care reform a priority.
The this-is-a-gift-to-insurers faction. A troubling aspect of health care reform that I've noted before ("The Paradox of Health Reform") is that it may end up rescuing employer-based health insurance, an inefficient and inegalitarian system of delivering health care that is already in the process of dying off. Shoveling half a trillion dollars to private insurers over 10 years does seem a strange way to reward them for their spotty record helping sick people get the medical care they need.
Rep. Dennis Kucinich, D-Ohio, was thinking along these same lines when he voted against the health care bill on the House floor Nov. 7. "We have been led to believe," Kucinich said in a prepared statement afterward, "that we must make our health care choices only within the current structure of a predatory, for-profit insurance system which makes money not providing health care." The health reform bill, Kucinich continued, "incentivizes the perpetuation—indeed, the strengthening, of the for-profit health insurance industry, the very source of the problem." Better, Kucinich says, to hold out for a "not-for-profit, single-payer health care system."
Similarly, Marcia Angell, a former editor of the New England Journal of Medicine (and wife of Arnold Relman, another former editor of the New England Journal, whose views on health reform I've written about) concludes, in a Nov. 8 column for the Huffington Post ("Is the House Health Care Bill Better Than Nothing?") that the health care bill "simply throws more money into a dysfunctional and unsustainable system, with only a few improvements at the edges, and … augments the central role of the investor-owned insurance industry." Angell proposes that instead we gradually drop the eligibility cutoff for Medicare, "decade by decade, until everyone is covered."
Both Kucinich and Angell argue that the public option, which conservatives have labeled (with some justification) as a potential bridge to single-payer, has been watered down to the point of ineffectiveness—a point the Congressional Budget Office largely concedes. But if conservative health reform critics like the Washington Post's Fred Hiatt can doubt "whether Congress will truly cut hundreds of billions of dollars from Medicare programs in coming years, as the House bill assumes," then it seems to me that liberal health reform advocates can doubt whether Congress will long allow a public option to drain the treasury when the simple corrective of aligning its hospital and doctor fees with Medicare lies within reach. (Psst! Don't tell Sen. Kent Conrad!)
"We don't pass perfect laws in the U.S.," notes the New Republic's Jonathan Cohn in a blog post about Angell's column. "We pass imperfect ones and then do our very best to improve them over time." The eventual result might or might not be single-payer, but even it were merely that a government insurance program, made available to ever-greater numbers of people, really did keep private insurers honest, as Obama predicts, then perhaps Kucinich and Angell might reconsider their views. In the meantime, I tend to agree with Kucinich's fellow single-payer advocate, John Conyers, D-Mich., who swallowed hard and voted for health care reform "because the cost of inaction is too high."
Much of this logic, I'll concede, may not apply if the public option disappears from the bill altogether.
The abortion-rights-are-more-important faction. Forty-one House members are pledging not to support any health reform bill emerging from House-Senate conference that contains the anti- abortion language that Bart Stupak, D-Mich., inserted into the bill prior to its passage. We don't know who these 41 members are, but the ringleader, Rep. Diana DeGette, D-Colo., voted for final passage Nov. 7 (after voting against the amendment itself). So did Rep. Jan Schakowsky, D-Ill., who co-authored an op-ed with DeGette threatening not to support a conference bill containing the Stupak language. * So I think probably it's an empty threat. Indeed, Nate Silver reports on his blog that 17 of the House's 20 most pro-choice Democrats voted for the Stupak amendment itself.
I don't mean to belittle the rottenness of the Stupak amendment, which I've elaborated on here, here, and here. It's a genuine affront that anti-abortion groups might prove able to leverage language borrowed from the 1976 Hyde amendment to prohibit effectively coverage for abortion in private-health insurance policies offered to previously uninsured people through the newly established exchange (or exchanges, since the Senate finance committee bill has one for each state). It's also exasperating to consider that the Stupak amendment would complicate any effort to repeal the Hyde amendment, a plausible medium-term goal in a Democratic Congress.
But the Stupak amendment is not a good enough reason to sink the most ambitious piece of social legislation in decades. DeGette and Schakowsky showed in their votes Saturday that they don't think it is, and neither do I.
E-mail Timothy Noah at firstname.lastname@example.org.
Correction, Nov. 11, 2009: This article originally misspelled Rep. Jan Schakowsky's last name. ( Return to the corrected sentence.)