We are closer today to meaningful healthcare reform than at any time since 1965, when Medicare and Medicaid were created.* If and when a 2009-10 bill is signed into law, credit will be deservedly shared among President Obama, Speaker Pelosi, Senators Reid and Kennedy, and many others. Regardless of the specific contents of the bill, it will be a momentous achievement that represents the tireless efforts of several great leaders, and one of which all Americans can justifiably be proud. But just for a moment, I would like to question the initial play, called by Candidate Obama more than a year ago: To make this reform effort, first and foremost, about money.
The political calculus was (and still is) compelling: In the face of an exploding federal deficit and a burgeoning Great Recession, the Obama campaign's rhetoric of healthcare reform was tied explicitly to cost. It was notably
not a discussion about healthcare as a basic human right.** This trend has largely continued in the Obama White House, and by the transitive property of political communications (tm), in Congress and the media as well.
Perhaps the Obama campaign wanted to avoid the mistakes of the 1993-4 Clinton reform effort; perhaps the campaign didn't want to open itself to the inevitable smears about "socialists" and "liberals," although those smears came anyway. I'm sure it was argued that it would be easier to sell reform on the mathematical rubric of cost than on the murkier terrain of morality. The campaign was probably correct on that point.
But let's step away from the real world for a minute. What would have happened if Obama had gone all-out
Rawls during the election? He is the greatest orator of our generation. What if he had said, "Of course healthcare reform will save money. It will reduce your premiums. It will help pull the economy out of this recession. And it will prevent the federal government from going bankrupt. But
even if it didn't, it would still be worth it, and here's why: Because access to healthcare is as fundamental to a good life as a warm home and plentiful food, as essential to our democracy as freedom of speech, and as critical to our collective welfare as national defense. The vision of the Founders cannot be completed in today's America without universal healthcare.
Life, liberty, and the pursuit of happiness require it." This is an admittedly hand-wavingly historical interpretation of healthcare as a right, rather than a legal or philosophical one. (It's also pretty bad writing; I never claimed to be
Jon Favreau). I don't think the American public has the patience for an actual Rawlsian argument. Nevertheless, if Obama had decided to go this route, he would have had an uphill battle but he still could have sold it. This is largely because most of the opponents of reform were going to oppose the current effort regardless of how he framed the debate. As a result, Obama discarded an important element of the rationale for reform, and he gained almost nothing in return. For the last ten months, if not longer, he's been fighting with one hand tied behind his back. He lost the chance to make this is a transformative and engaging national debate, and instead he allowed proponents to get buried in numbers while leaving the rhetorical energy to the
death panelers. And in foreclosing a serious discussion about single-payer healthcare, he shifted the debate to the right before it even began.
So what would have happened in our thought experiment? I'm not sure. I can't help but think that real, universal health insurance would have been in the mix from the beginning, not the watered down, opted-out, restricted, triggered and neutered public option that may-or-may-not pass for "universal" today. I think the race to the bottom, in which the CBO-scored costs of the bills went from $1.3 trillion to $1 trillion to $900 billion to $800 billion -- mostly by cutting, limiting, and delaying proposed benefits -- would have been attenuated. I think some of the opposition of center-right Democrats would have been neutralized, and maybe even some of the Republicans' arguments about rationing and Medicare. And I think the final bill would have come out stronger, with closer-to-universal coverage and a better benefits package. For what it's worth, I think this hypothetical bill would also save substantial amounts of money, but that's not really the point right now.
Healthcare is a basic human right, and it ought to be treated as such in the United States. When people ask me, "That's nice, but how are you going to pay for it?" my first response is, "You're asking the wrong question." Of course cost is important: It's the immediate barrier to entry for many Americans, and it's the source of the long-term instability of the entire system. But we don't restrict free speech even when it costs too much, so we shouldn't restrict access to healthcare because it costs a lot. To those politicians and pundits who bloviate about healthcare as a right while simultaneously wanting to limit access to cut cost, it's time to put up or shut up: Either you believe healthcare is a right, or you don't. If it is a right, you should stop arguing primarily about cost. It's probably too late to change the dynamics of this year, but at the very least I'd like President Obama to say, "Forget about my $900 billion limit. Send me the best bill you can. I want every single American covered and covered well. That's my priority, and that's our nation's priority."
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*You knew an asterisk was coming: A few cranky roadblocks named Landrieu, Lieberman, Lincoln, Nelson, and the entire Senate Republican caucus are still in the way. More on that in a later post (I promise).
**To preempt some of the inevitable worms I just released from the proverbial can: First, I'm talking about access to healthcare, not health itself. Second, I'm talking about a decent minimum of healthcare, not universal access to Botox and Viagra. Third, I'm talking about wealthy, industrialized nations in general, and the United States in particular; although I believe everyone deserves access to quality healthcare, delivery of care in other parts of the world entails an entirely different set of issues. I'll probably write more about all of this later, too.
