Thursday, January 26, 2012

Obama, Healthcare, And Progressive Critics

The following review essay was just published in the Nation

It is hard to read Remedy and Reaction, Paul Starr’s remarkable chronicle of the hundred-year effort to legislate universal health insurance in the United States, without recalling Robert Gibbs’s tortured quip that Democrats who’ve denounced the Obama White House for having knuckled under to Republican principles or intimidation “ought to be drug-tested.” Nobody with a sense of history—that is, nobody who reads Starr’s book—could doubt how sensible and brave was the president’s effort to drive the Patient Protection and Affordable Care Act of 2010 through Congress. Nobody with a feel for the present moment should doubt how imminent is the threat to the act, how urgent it is for progressive Democrats to rally around Obama—and without all the condescending qualifications that “independents,” who flock away from allegedly weak or incompetent leaders, interpret as contempt.

Starr, who teaches at Princeton and, with Robert Kuttner and Robert Reich, founded The American Prospect, has written 300-plus pages of tightly woven policy description, narrative and polemic; but one needn’t be a wonk to benefit from the tutorial or detect an occasional sigh between the lines. Literary scholars speak of a pathetic fallacy, the idea that inanimate objects have intentions and feelings. Starr makes clear that various political commentators have been susceptible to a somewhat different fallacy, pathetic in its own way, that America’s desires can be fathomed through polling and that the president must somehow be at fault if a desire is not fulfilled, as though flawed legislative institutions, entrenched political forces, conflicting popular incentives, regional rivalries and sheer corruption do not shape political outcomes.

Starr learned his lessons the hard way. He closely advised the Clintons on health strategy in the early 1990s (he still knows and has debriefed key Congressional staffers). The centerpiece of Remedy and Reaction is a long section, full of illuminating asides, on the frustration of the Clintons’ plans. Starr shows that, even as Bill Clinton submitted his bill to Congress, some 70 percent of voters subscribed to the principles embodied in the legislation he proposed. Yet the bill didn’t come close to being enacted. True, Clinton was losing altitude by then, but to suppose his failure was largely a matter of leadership—you know, that he didn’t use his bully pulpit forcefully enough, the sort of gripe heard relentlessly on MSNBC, the Huffington Post and Daily Kos about Obama and the “public option”—is to suppose that willows really weep.

Obama’s actions were cannier than Clinton’s, but they also amounted to a profile in courage. When Obama came into office, Starr explains, only 11 percent of Americans thought reform would have a “negative personal impact,” but by August 2009 this segment of the population was trending to 31 percent. Both Rahm Emanuel and Joe Biden were urging retreat. Starr writes, “Obama not only resolved to go ahead; in September and again in the new year, the president took charge of the effort to steady the health-care initiative and prevent it from careening off the tracks.” Nor was the final bill anything less than what might reasonably have been expected, filling as it did the negative space left by four generations of government programs and serial compromises. Starting with clean sheets of paper was never realistic when one-sixth of the economy was at stake.

Starr’s great fear is repeal of the Affordable Care Act, which would not only deny healthcare to more than 30 million people but would cast doubt on whether “Americans will ever be able to hold their fears in check and summon the elementary decency toward the sick that characterizes other democracies.” Obamacare, in short, was healthcare reform’s best—and last—shot, and it would be unconscionable for liberals to remain cavalier about its defense, or Obama’s, for that matter. It’s past time to discard the misguided assumption that in a better economy, or with more of “a fighter” in the White House, something like a Canadian-style single-payer system might have been (or might sometime fairly soon be) enacted.

Read on at the Nation's website. Or download a pdf.


Potter said...

True, Clinton was losing altitude by then, but to suppose his failure was largely a matter of leadership—you know, that he didn’t use his bully pulpit forcefully enough, the sort of gripe heard relentlessly on MSNBC, the Huffington Post and Daily Kos about Obama and the “public option”—is to suppose that willows really weep.

Willows do weep and so do we.

I don’t understand how you can be so unfair to progressives- a label thrown at you here as well. Progressives have different opinions on this issue. It’s disappointing if not insulting to read that you call this criticism “fashionable” as though it were not deeply felt, or real, or had maybe to do even with a moral position.

The push (and discussion) coming from progressives, in this divided country, I am grateful for. It has to be there to counter the extreme Right push to let everyone fend for themselves and even die in the process.

Why are the Huffington Post or D Kos readers (if they really are all of one mind) Obama’s problem? I don’t think he has to worry about them.

This is a good “progressive” discussion. I am with Bob Kuttner.

Mitchell J. Freedman said...

I've read Starr for nearly 3 decades. This new book is not much different in its structure than his first major book from thirty years ago, The Social Transformation of American Medicine. I say that because I vehemently disagree with you that leadership doesn't make a difference--and Starr and Ure Reinhardt and David Himmelstein taught me enough to stand up to anyone on this issue, including you.

You and Starr can wish as much as you want, but Obama passed Orrin Hatch's plan from 1993-1994. That's the individual mandate.

And while it is true that insurers have to cover me for a pre-existing condition, most folks can't afford the price the insurers gouge for such folks--and Obama's plan in 2014 is to subsidize Blue Cross gouging pre-existing condition customers. What's that sound like, you ask? Republicans' Medicare Part B in 2004 for prescription drugs which is dragging down Medicare more than any other single factor.

So Professor, let's stop this nonsense. You are really afraid folks on the economic left like me won't vote for Obama later this year. Yeah, that could happen, but the Republicans are scary enough as dumb bankers to make people like me feel we have to vote for the smart banker, i.e. Obama.

Potter said...

Part two:

Obama, like the Clintons, worked behind closed doors. Obama who had promised transparency was seen giving way to the insurance and the drug industries. Both Clinton and Obama came up with complicated plans that were hard to explain or understand- especially for the elderly or less educated. This left the opening for fear mongering and mischaracterizations. And that needed to be counteracted. Obama, like the Clintons allowed such campaigns to define and characterize health care reform… still to this day. Leadership, education, does need to come from the bully pulpit directly to the people. And in the face of this kind of barrage, it needs to be ongoing. Why did we not hear loudly that the death panels we already have are in the form of the insurance companies? You have a baby, you have to take care of it, make sure it survives.

Obama on the campaign trail is not missing now. He knows how to do it. I would like to hear him talk about the healthcare plan we wound up with, not avoid talking about it and why we have what we have.

What do people know or experience about the health care reform that was recently passed beyond that it is “Obamacare”? Most of the benefits kick in in several years. In the meantime the anti-mandate forces are having a field day politically. People know the realities; health care costs have gone up. They know we do not have universal health care. They know that the rich get better care.

If the mandate gets declared unconstitutional by SCOTUS, if this reform collapses, we may, looking at the bright side, have a chance to get rid of the insurance companies ( or begin to), get rid of the profit motive in healthcare all together. No loaf in place of half a loaf may bring real reform. I am with Bob Kuttner.

It is about leadership: using the tremendous power of the executive; using it ongoing. This is the same power that is used to conduct war and diplomacy. This is about, at the very least, pushing for an outcome, pushing for popular support and not retreating because it is believed to be unattainable, or politically costly.

Obama did, at one point at least, say that he would rather be a one term president and do what was right for the country didn't he?

Bernard Avishai said...

I want to thank Potter and Mitchell for their comments, much as I disagree with many of their claims. I'll add here only that I still consider Bob Kuttner (my old racquetball partner from the 1980s) a friend, as does Paul Starr, though we differ about many things: the make-up and voting impulses of the American electorate, the power of the presidency, the architectures and competitive strategies of global companies in an age of network effects, the legacy of FDR--many things. What we all do believe in is the urgency of government action to set the rules of competition, stimulate growth through investments in infrastructure and education, and make social mobility real in the classical democratic sense. We differ, that is, about facts, not values. Then again, we need a president who reflects those values, and it seems short-sighted to believe that our solidarity in his defense has not been crucial to his reelection. The stereotypes are still endemic: food-stamp government, affirmative-action president foisted on us by the same people who gave us bussing--not really one of us. I fear that ad hominem attacks on his competence, where his own views were always defensible (if not just plain correct)--the left's specialty--have wounded him. Can we not learn from 28 years of Republican presidents since Johnson that we can get sent back into internal exile pretty easily?

Mitchell J. Freedman said...


You are still talking past us. We recognize what is oozing out of the Republican candidates. Our point about Obama is that he is not like Bob Kuttner nor even Paul Starr. He is soaked in the assumptions from his friends at the University of Chicago economics department.

We are also not crucial to Obama's re-election. We who voted for Nader in 2000 voted for Kerry in 2004 and it made no difference whatsoever. None. We don't count is what folks like me have to face--and the lovers of Obama should recognize even more.

The reason Obama may lose is if the Republicans nominate Jeb Bush and the 20% of low information voters (called swing or independent in corporate media) will say, "Well, things didn't really get better for me or people I know. The rich are still richer than ever, and I'm screwed, as are my kids. Might as well vote for the other guy," meaning Jeb.

I am tired of being given a power I don't have to defeat Obama or any other corporate Democratic poobah. I am tired of being attacked for not clapping loudly enough, and yet willfully and cynically ignored when I speak of New Deal/Hamiltonian solutions to pressing public policy problems. It's too bad the wrong comedian is running for the Green Party nomination...If it was Colbert, Stewart or Maher, I'd go with them in a New York minute. So I sit with Obama, the smart, nice banker and pray he doesn't destroy the country as fast as the Republicans, with their dumb, mean bankers, want to do.

You are kind in your comment above, but we both know there are others far less kind out there. And frankly, when confronted with such vitriol, I respond in kind and show little mercy....:-)

Potter said...

Thank you for your response Dr. Avishai. And for Mitchell: I never considered voting for Nader and I still consider that those who voted for him did their part in bringing us GW Bush and our present woes when we might have had Gore. Dr. Avishai now maybe considers criticism of Obama similarly, as a “wound”.

Dr. Avishai: I still believe in the electorate, that they will go the right way, once they are shown the light, once their “better angels” have been awakened. They voted for Obama, a decisive victory in 2008. Maybe this is the crux of the matter- the willingness on the part of staunch Obama defenders, those of them not willing to criticize at all but to blame the criticizers. I take it that you take other impulses out there as a given, a fact, immovable. This is not the working for the change promised—where it must begin. Nor does it show audaciousness. So how- those of us who believed and saw the energy that Obama was able to summon in the populace-- how not to be disappointed? Sure the presidency has limitations, but my sense is that we have not seen the presidency used to it’s utmost at all. Sure the stereotypes are endemic- that is because they have been allowed to go unanswered! They have been allowed. You seem to do what Obama seems to do: understand the state of mind on the other side as a “fact” that must be dealt with somehow, compromised with, not maybe transformed. What Obama did in 2008 was transform independents. These are the people who he needs now again… nevermind the progressives. In fact, the opposite of wounding him, it is the progressive dissatisfaction that may be giving Obama some credence with the middle. Progressives, as the zany, misguided and dangerous far right feel so strongly, must hold the line. Progressives have a right and a duty to do that. I just do not understand your seeming wish that they disappear or salute.

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