Ellen Shaffer, PhD, a health policy analyst, advocate and researcher, responds to the comments of Uwe Reinhardt, PhD
Here is why Uwe Reinhardt's comments, and Norm Ornstein's, are cynical, unanalytical, demoralizing and wrong:
Whatever nods they may offer to the actual structural political obstacles to achieving universal health care in the U.S., the ultimate villain is the stupid American populace (teenagers, plebes, what have you - surely not the well educated, who read this list).
And the econometrician's solution to engaging these dunderheads is: make them pay more! Then they'll pay attention and we can really get somewhere. Economic shock therapy for the ailing of America. Great news for insurance companies, hospitals, doctors and employers. Defined contribution plans will finally make Americans real consumers, with direct control over their health care choices. Then they can really call up that doctor and tell her to conform to national standards of quality, balancing over- and under-service. Yes indeed. (Or maybe the theory is that once they have realized the futility of becoming individual consumers, Norm Ornstein will lead us in calling for rescinding the tax rebate, and funding federal enforcement of national quality guidelines, as well as universal coverage.)
Well, yes, power does flow in many directions between the ruling/corporate elite and the rest of us, and sometimes our side wins. (Medicare. Medicaid. Happened at a time when many of us were inspired and united by the civil rights movement, not demoralized by invective.) Specific analysis of particular political events needs to inform us, and determine when we are mistakenly blaming the victim, and when instead we can rightly blame a stratum of society for intentional and heartless pursuit of self-interest. People are regularly abused and treated unfairly by those with more power, whether raped and slaughtered, unfairly fired, or given a bad grade; some fight back, many don't, usually successful organizing and intelligent leadership helps. The prevailing rules and institutions societies develop over time (very long periods of time) to safeguard justice also play a role. Without dwelling on some lapses in bonhomie among certain Europeans during the 20th century, it is important to recognize that in the case of the failure of universal coverage in the U.S., the problem lies not primarily in failures in the national character of the American population, however amusingly this elitist view of our people is served up. If Uwe wishes to make the case that this is really the central problem, he might present some evidence that links cause and effect, or at least a logical line of argument beyond observations about spoiled stockbrokers in the Hamptons. (If the American people really were that stupid I'm not sure that yelling at them to get off their duffs would be very effective.)
Uwe has already well described the failures of our systems of financing and organizing politics and politicians. Will imposing further financial hardship, e.g. through defined contribution plans, truly mobilize the populace to overcome these obstacles? What is the evidence that this would be the best or even one effective stimulus to political activity in the case of health care? (If it were, we should be seeing armies of the uninsured waving their hospital bills in the faces of policymakers, rather than retreating into defeat, homelessness and bankruptcy.) What is even the analytical connection? Is there precedence for this in the US or elsewhere?
Truly, Americans have a proclivity towards individualism. Additionally, many of us do not vote, (As Jim Hightower has noted, if God intended us to vote she would have given us candidates.) How does this factor balance against the immense financial and political power of the private insurance industry, with its attendant ability to command publicity and the fealty of politicians? No other nation has had to face and overcome this force. This is not a reason to give up; it has to be done. It is a difference between the US and other countries that we must acknowledge and address. Further, health care is a difficult stand-alone organizing issue in industrialized countries, absent other national crises: most people are healthy, poor people have other pressing priorities, sick people are sick; both problems and solutions are complex, and the industry has far greater access to the media than do reformers.
What is the actual position of the American people on universal health care, through single payer or any other means? Uwe tells us the vote against single payer in California was definitive; in this case the electorate was swayed by a last-minute, well-financed campaign by the insurance industry alleging huge resulting cost increases. This was a false allegation, this kind of tactic is not unexpected, and activists need to be able to confront this kind of thing. But it is far from the last word. Kip and others point out alternative results through polls, the Maine legislature, the Jefferson Jury, and countless local ballot initiatives. The answer is murky, and often depends on the point the presenter is trying to make. I like to ask people whether they would prefer the current for-profit, market-driven, inequitable system of health care that leaves 45 million people without coverage; or a fair, publicly financed, publicly delivered and equitable system of universal coverage that would provide high quality health care to all. Usually gets a pretty good response.
Ok, how do we address the myriad obstacles to health care reform in the US, including developing support among our fellow citizens, besides further impoverishing them? Whoever knows this for sure is likely to be rich or assassinated but here are a few points of departure: 1. It may take some time. 2. Undermine the credibility and power of the opposition (why the fight over the patients' bill of rights is a good thing). 3. Incremental programs like Healthy Families are failing to recruit and retain members; call for states to pay the full premiums, for good. 4. Link the fight for a just health care system to other calls for social justice, and thereby ally with political movements with some clout. Opposing "free" trade in health care via GATS and FTAA would be a start. 5. Point the finger at powerful forces like businesses that prefer to give away their profits to the insurance industry rather than turn the enterprise over to the government as enlightened capitalists do abroad. 6. Demand some rigor from ourselves and our leaders in analyzing successes and failures, and figuring out which forces are required to and likely to do what in order to advance the issue. (Did Bill Bradley's campaign really fail because he championed a tepid proposal to expand health insurance coverage? Is that what scared the Democrats into the arms of Al Gore? Fascinating!) 7. Get Uwe to write us a polemic from time to time. Apparently some readers found his comments bracing and challenging. It's a good opportunity to think through why they are misleading, though appealingly presented.
It's frustrating to have been propounding an intelligent and effective solution like single payer for all these years, and not to be getting very far. It is worth examining why not, and what we might do differently. I look forward to seeing us all move forward.
Ellen