On Political Books

November/ December 2011 Sisyphus Gets to the Top

How America's forbidding political landscape made health care reform impossible for Clinton and nearly so for Obama.

By Harold Pollack

Although 50 million people remain uninsured, American health policy has thus fostered the rise of what Starr calls “protected publics.” As Cornell professor Suzanne Mettler has described in these pages (see “20,000 Leagues Under the State,” July/August 2011), these large constituencies often do not perceive the full costs of the substantial subsidies they receive. The present discounted value of Medicare benefits for seniors far exceeds what most beneficiaries have contributed to the system, and holders of employerbased coverage benefit from substantial tax expenditures which they scarcely know exist.

These protected publics also have reason to regard themselves in competition with other groups. Starr argues that millions of seniors, veterans, and others have come to see themselves as having earned their benefits, and many believe that their claims to public resources are more morally worthy than those of Medicaid recipients or the uninsured.

No comprehensive health care reform that would harm these protected publics is politically feasible. (Not coincidently, Starr argues, no other advanced democracy has followed such a trajectory, establishing separate programs for the elderly before pursuing broader efforts for near-universal coverage.) The combination of vested constituencies and a political system designed to thwart comprehensive reform locks liberals into incremental measures that attach new protections, new coverage, and new costs and quality control efforts onto an already complex and inefficient health care delivery system. These political realities hinder efforts to craft sound policy and lead instead to reforms that are incremental, ideologically moderate, forbiddingly complex, and unlikely to generate grassroots excitement. The resulting encyclopedic legislation invariably exposes political vulnerabilities. Difficult compromises must be struck through precisely the kinds of sausage making that voters disdain.

A fragmented health system particularly hinders efforts to deploy government’s bargaining power to control costs—much to the benefit of many entrenched constituencies. Millions of Americans see reasons to resist measures that might constrain the care or benefits they receive, but because the full costs of health care are hidden, few perceive corresponding direct benefits to controlling these costs.

Given all of these realities, it’s remarkable that the Affordable Care Act was passed last year. The single most important factor in its success was the presence of strong Democratic majorities: President Obama enjoyed much broader and more unified congressional support than President Clinton did, even after Scott Brown’s victory deprived Democrats of their sixtieth Senate vote. Clinton’s reformers, Starr writes, also “lacked one critical element” that Obama and his team possessed: “an agreed-upon remedy.” As Starr writes in perhaps his most intriguing chapter, “Rise of the Reform Consensus, 2006-2008,” much political heavy lifting was done before and during the presidential primaries, as Democratic policy elites and the major Democratic presidential contenders coalesced around “minimally invasive reforms” influenced by recent efforts in Massachusetts.

By the time Obama entered office there was already a broad Democratic consensus on what health care reform would look like. Institutionally radical alternatives such as the Wyden-Bennett bill were effectively sidelined, since they threatened too many protected publics. Starr is cynical regarding the public option and Medicare buyin proposals, writing that they were politically valuable, to “bring the left within the fold.” Yet they faced fierce opposition from the supply side of the medical economy, as well as quiet opposition from many House members— some liberal—who worried about the impact such policies would have on providers in their districts back home.

Mobilizing a larger and more cohesive majority, Democratic congressional leaders shepherded the legislative process far more successfully in pursuing the Affordable Care Act than was possible in the Clinton years. The strong Democratic majority gave health reform an aura of inevitability that was an invaluable asset in striking bargains with insurers and with others. Because Democrats possessed a large majority, much of the cross-party negotiations that might otherwise have occurred took place within the party, between Democratic liberals and Democratic conservatives and moderates. (Starr cites with some irony the “bipartisanship within one party” that resulted in last year’s reform.) ACA provisions such as the individual mandate had appeared in past Republican bills—Governor Pawlenty’s ironic sobriquet “ObamneyCare” may provide the best description of the final outcome. Yet perhaps unintentionally, partisan polarization and Democrats’ subsequent intraparty bargaining gave moderate and conservative Democrats a strong stake in the bill. Figures such as Max Baucus and Kent Conrad were the marginal votes. Their personal reputations were on the line in securing its final passages. Republicans acquired no such ownership, with predictable consequences.

Starr finds much to celebrate in health reform, and much to worry about in pondering the ACA’s uncertain future. He lucidly describes Democrats’ most important political error: the extreme backloading of the program’s main provisions to 2014. The key provisions of the new law are highly unlikely to be repealed once health reform becomes part of the fabric of American life, but the law was designed so that at least two congressional elections and one presidential election will pass before pillars such as health insurance exchanges are fully implemented. As Republicans continue to profit from the nation’s economic woes, Obama’s reelection is in doubt—and with it, the fate of health reform.

Starr is one of many commentators to say that backloading was a consequence of the administration’s foolishly low ten-year budget targets. He also notes the more subtle reality that Democratic lawmakers, mindful of recent experiences in Medicare prescription-drug coverage, were leery of any policy that might produce embarrassing administrative glitches before the 2012 election. Whatever the motivation, the future of last year’s reform is dependent on the results of the 2010, 2012, and (in many cases) 2014 elections and beyond.

Starr is disgusted—as I am—that the ACA’s substantive moderation does so little to temper Republicans’ extreme and often dishonest attacks on the new law. He is also frustrated—as I am—that so many progressives are disparaging of this historic (albeit incomplete) achievement.

Starr ends with a sober observation:

Repealing that law would not just mean denying insurance to more than 30 million people. It would also be a confession of political helplessness in the face of a problem that has nagged at the national conscience for a century. The search for a remedy would continue, but it would proceed under a shadow of uncertainty about whether Americans will ever be able to hold their fears in check and summon the elementary decency towards the sick that characterizes other democracies.

I closed this excellent book doubly worried—about the uncertain fate of health reform, and about the political lessons this story teaches. President Obama embarked on health reform with virtually unique political advantages. He risked catastrophic defeat, sacrificed more than a year of his presidency, and, remarkably, succeeded. Thus far, however, health reform has brought him and his party little political benefit. As a friend of mine said recently, the ACA’s passage was a “catastrophic victory.”

Harold Pollack is the Helen Ross Professor at the School of Social Service Administration at the University of Chicago.