And the hold-ups on this bill haven't been a travesty of democracy. The polls I've seen suggest that less than 40% of Americans support the changes being made (http://marathonpundit.
I think a lot of the problems the bill had, and the sacrifices made, have to be laid at Obama's feet. Frankly, he did a poor job of shepherding this thing through. He promised to lead, to make changes, blah blah blah, but then handed his biggest cause to the "business as usual" party chiefs. Incidentally, this was exactly the complaint many people raised about him before the election: that despite his outstanding rhetoric, he'd never really stood up to the party chiefs. If he'd taken the reins and pushed this thing through 9 months ago on his terms, we'd probably have the public option. Instead, everyone got their turn at the trough - no surprise, then, that so few voters support the final outcome. The Republicans were dicks, but it's not like he made much effort to get them on board ... even for their good ideas, like tort reform (trial lawyers write big checks to Dems, business as usual) or other cost-cutting efforts.
So now he's got a second chance at making something of his presidency. Hopefully he'll continue actually leading, rather than reverting to the "give pretty speeches to give the party chiefs air cover for business as usual" approach. Voters like his ideas, but he has to be willing to stand up to the special interests ... and it's apparently easier to make a speech saying you will, than actually to do it.
As for the bill ... socializing some of the risk of health problems is a good thing. It's good for all the liberal ideal reasons, but it also makes it easier for workers to switch jobs, for people to make decisions about their futures without "will I have health care" hanging about their necks. The costs worry me. Even the most optimistic seem to be delivering the "this won't be super-expensive" line ... that is, no one seems to think this is going to reduce the costs. But even if health care stays on its current cost trajectory, it's still far too expensive in the long term.
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Yes exactly, this bill is more about universal coverage than socialized medicine or cost control. But of course this still falls short of universal coverage. Universal coverage is Cuba or the UK, where I can walk into a clinic and get treated without showing any papers. I can elect to not have insurance and just pay a small yearly fee to Uncle Sam. And I think the paperwork to get uninsured people into the system will be substantial, which can be intimidating to rural, recent immigrant, or non-English speaking citizens. So will we punish those individuals if they are unwilling/unable to get coverage? And even if those people are covered, there's no guarantee that they will have reasonable access to care providers (imagine people on remote Indian reservations or in poor urban areas with overwhelmed, poor-quality public clinics). It's not very useful to give free gas to someone who doesn't own a car.
I don't think that universal coverage and socialized medicine should be relegated to a "liberal aspiration". Americans have the right to life, liberty, and the pursuit of happiness (or was it property?). Basic education and security (police, fire, etc.) are included in that, so why not health care? We are guaranteed healthcare in prison and the military, but not out on the streets? We are the only developed nation where healthcare bankruptcy exists - how obscene is that? With our progressive tax, the rich subsidize the poor, elderly, and disabled. So the rich and healthy should subsidize the sick as well. No society can survive unless the populace is healthy and productive. Especially in this era of obesity and possible pandemics and bioweapons terrorism, accessible healthcare is a national security concern. So it's not about the evil big government trying to control how much medicine you get and when you die. Government needs to be involved in healthcare for the best interests of the nation, even if the people don't realize it.
According to the CBO, this bill will reduce the deficit by $140B or so over a decade, by restructuring Medicare reimbursements. I am not sure how that affects the quality of coverage for seniors. I think that the bill authors also anticipate cost savings by making preventative medicine more affordable/accessible to uninsured people, thereby preempting more costly serious procedures later. Electronic medical records will save a little, but only pocket change compared to the bill's price tag. And no one is sure if the health insurance exchange/marketplace will function properly and lower prices. It's nice to close the Medicare drug "doughnut hole" immediately, but that only affects a small minority of seniors. It's also good that uninsured young adults can be covered by their parents' plans until age 26, but young people consume less healthcare anyway.
In France (their health system was ranked highest by the WHO in 2000), they have several private insurance companies, but all of them charge the same rates, can't turn anyone away, and don't have lifetime maximum benefits. As far as I know, they are nonprofit and heavily regulated too. Then every so often, they get together with the government and medical providers to modify costs and coverage based on social needs. Germany is similar, but also with the option to buy more private supplemental insurance on your own. So you have guaranteed coverage and the freedom to get more. Patients get care, medical providers get reimbursed by the insurance companies, and the government reimburses them. I guess it's like Medicare for everyone, but with an efficient private sector middleman that hopefully doesn't game the system for profit. Their systems are going broke too, but at least their people enjoyed decades of better care with less worry and cost.
To me, employer-provided insurance and for-profit medicine make no sense, and have led to our horrible problems. That's why the public option was so crucial, so hopefully even employed people can choose between their employer's plan or a plan through the gov't. The gov't should low-ball coverage and put the heat on insurers. Other industries do it all the time to jolt the competition (think Walmart vs. mom-and-pop stores), so the insurers should stop their bitching. The current bill mostly helps the uninsured and individually-covered, which is 15% and 5% of non-seniors, respectively. What about the 60% of non-senior Americans on group coverage? If we decline employer coverage and switch to the gov't plan, we could possibly save our employers millions. The public option is the first step towards single-payer, and phasing out of the insurance companies, which is probably why they fought it so hard. The more people that switch to the public plan, the harder it will be for bad private insurers to stay in business. When the public plan gets enough customers, they will have great bargaining power to get cheaper drugs/services (as the VA system already does). Or on the flipside, private insurers can get leaner and deliver better service to customers that surpasses what the gov't can provide, which will lead to retiring of the public option, which is fine too. Better service for the money is the end goal, and I don't care how we get there.
I think Obama made a reasonable effort to include the GOP. He extended his hand but they didn't take it. "Tort reform" was a non-starter, because they didn't offer a concrete plan and knew the Dems probably couldn't get it approved within their ranks. It's like Israel making disarmament a precondition for peace talks with Hamas. If they agree, there's not much else to talk about! But they say it because they fully know Hamas won't agree to it. So they appear diplomatic but have no intention to open dialogue. GOP want to get re-elected too, so they won't be caught cutting deals and making compromises on ObamaCare. To be frank, the GOP didn't offer anything helpful to add to the legislation.
As you said, Obama has a precious second chance now, but won't get a third. He still won't stand up to the party bosses though, because he owes a lot of them for getting him elected, and now owes them on healthcare. He is no LBJ who built up decades of Washington favors/leverage, and can force his will on others (be it good or bad). He was a junior legislator and has a history of conflict aversion. Supposedly his chief of staff and other enforcers should help corral Congressmen and get stuff done, but I'm not sure how many bridges they have left intact. The GOP are outraged, and maybe they can only count on Lindsay Graham to support climate change legislation.
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I'm not so sure I agree about the party bosses argument. To whom he owes his election is an interesting question, but I think, related to passage of health care, is that he disengaged too much from the process early on. He thought that if Congress did most of the detail work, they'd be more likely to own it and then want to pass it. Instead (and perhaps predictably) Congress stalled and stalled without much direction, especially on the attempt to corral a few Republican votes. If Max Baucus (who was probably doing so at the urging of the President's strategists) hadn't dragged out the Senate Finance Committee work on the bill for 5 months in an attempt to get some Republican votes, this thing would have been wrapped up by last Thanksgiving at the latest.
Obama also never seemed to have much of a strong picture of what exactly he wanted in the bill; he said he preferred a Public Option but never really fought for it. Without a blueprint from which to negotiate, the Senate and House versions became different and this again caused delays and painful after-passage negotiations (especially after Scott Brown's victory) that easily added on a couple of months to the passage process. My reading would be that Obama basically wants a skeleton of a system in place that guarantees universal coverage and from which future reforms can be based. The exact details of the current plan don't seem to have been any great concern for him instead of making sure a plan passed.
There's a certain amount of sense in realizing that, given the unknown future, arguing over details that are likely going to changed in five years anyway is counter-productive. On the other hand, a lot of people cared about these details now and it slowed the bill down (and, without the public option, enraged his left flank). It was only once Obama became seriously engaged in the process after the Mass. special election that the passage efforts began to get traction. I'm not really sure where party bosses fit into this picture; it seems much more of a case of Obama trying to do post-partisan and be above it when instead he should have been engaged in the details.
Ultimately, I think this bill is about as small 'c' conservative a way as possible to reach universal coverage (and only in American would proponents of this approach be called "Socialist Fascists"). Basically, it gives subsidies to those without care to get it, and changes some regulations in the insurance market. It doesn't fundamentally alter the structure of the American medical system at all (for better, or probably, for worse) except for possibly the exchanges, which won't really have any serious impact until 2018 (at which point states can allow any size business to buy their insurance from the exchange). I wish it were politically possible to do otherwise, but if you had told me four years ago that Democrats were able to enact legislation giving significant subsidies to expand coverage to 30 million uninsured, I would have thought it to be an unmitigated good.
I'd note that it's easy for us to imagine a world in which people we know might be too lazy to get insurance (those in the 26-maybe 36 bracket). But for anyone with a family or anyone over 35, in which chronic medical conditions are an issue, jumping through the hoops of getting the subsidies will be very high on their list of things to do. Welfare, SCHIP, jobless benefits, and other government programs also have a fair number of hoops through which one needs to jump to receive the benefits, yet, precisely because of the lifeline nature of these programs, are that undersubscribed by the eligible.
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Regarding the party bosses, I know it was J's point but my take on it is this: Obama chose to defer to the committee heads to shape the bill, so as to not bruise egos or whatnot. There wasn't just a House and Senate bill, but several committees had their own versions: Baucus' (Finance), Waxman's (Ways & Means), etc. (in total, 3 from the House, and 1 from the Senate, and I guess the GOP had one or two later crappy bills of their own, where only 5M or so uninsured would get covered). Plus Obama and his staff don't have much rapport with the big lobbying org's and trade groups, so they needed to rely on the party boss intermediaries. Baucus is a big pal of pharma and helped them cut the secret deal, as a previous email described. Basically, I don't think Obama was really leading the effort until things turned sour. I know that may be his leadership style, to delegate and monitor from a distance, but sometimes you have to take the reins.
Each version was different, with varying degrees of public option-ness. Obama laid out his vision for the bill in January, 2010. I am not sure if he had that plan all along, or if he just cobbled together popular/passable aspects of the Congressional versions. But if he had the plan in his pocket since election day, he should have unveiled it much sooner, before the sausage/deal making in Congress turned off the public.
A president has to have a plan and vision, not just "get a health bill passed so I can fulfill my campaign promise, make history, and I don't care what's in it". I disagree that arguing about the details was not important, and the future is not so uncertain with regards to health care. We know that premiums will continue to rise and Medicare/aid will get closer to going broke, as more expensive drugs and treatments are prescribed more frequently (and the Boomers retire). The trends have been there, especially with anti-depressants and Caesarean births. Medicaid reimbursements were falling more and more behind the going rate, and Medicare drug coverage needs major reworking. Sure some health systems like Mayo and Kaiser show improvements (like all-digital medical data and doctors paid a fixed salary), but also some inner-city ER hospitals were closing their doors. These problems were known and out there, but the Democrat/Obama effort barely addressed them.
The administration had to decide whether they were trying to achieve universal coverage, new restrictions on the insurance industry, and/or comprehensive reform. They kept giving the public and Congress mixed signals, so of course the party leaders and their friends would try to include different things into their versions of the mammoth bills depending on their priorities. If they scrapped their ambitions of true reform on the road to single-payer, then the current bill could have been passed in a couple months without all the vitriol. Maybe in his second term Obama could have tried for more reforms. But it ended up as a strategic mess all around (like Hillary's presidential campaign), though fortunately they have something to show for it in the end.
As you said, this bill was the most conservative possible way to achieve almost-universal coverage. Maybe that is all we could have reasonably hoped for in 2010, but as you said, if some decisions were made differently in 2009 we would have had a public option and Scott Brown would still be at his former job. Of course it's a good thing to help 30M people get coverage who would otherwise be excluded. But what did you have to sacrifice to get there? His poll rating plummeted, millions of man-hours and dollars spent, other national agenda items had to be delayed (job creation!), Congress turned even more deadlocked and partisan, and right wing media spread anger, misinformation, and paranoia across the nation. If Obama pulled out of Iraq last March (unfeasible, but humor me for argument's sake), he would have saved America $144B over 12 months. America spends about $6k per capita on health care (could be higher now, since that was a 2003 stat), so covering the uninsured would total $180B per year. So by pulling out of Iraq a year ago, we could have covered the uninsured over that time period instead. The resources are there, but gov't just has to decide what it wants to give up in order to make it happen.
I would rather have this bill than the status quo, but I just worry about the future. If this bill doesn't show clear, measurable healthcare improvement for the public and our national debt gets under control, the GOP will attack health reform as ineffective and wasteful, making it harder to move towards single-payer. In other words, this was their one big chance in a generation to cram in as many improvements as they could, and they didn't deliver much (in terms of cost controls and quality of care). On the other hand, if the bill is successful, then future administrations will have an easier time building on it. Time will tell I suppose. But you can bet that in the meantime, the insurance companies will be strategizing how to defeat any future reforms and do what they can to show America that these new regulations on their industry are bad. Already the GOP are twisting the bill as an assault on freedom, which is obviously idiotic.
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