In this election campaign, most progressives are pinning their hopes on an Obama victory as the best route to bring us meaningful health-care reform. His plan, of couse, is far more likely to lead to broad coverage and affordable care than the free-market nostrums of John McCain.
But pragmatists at the state level and in Washington are looking closely at the real-world political obstacles that have stymied health care reform in the past, and if progressives don't learn from past failures, we're doomed to repeat them again, especially in overcoming the resistance of conservative Democrats and Republicans in the Senate -- and greedy business interests.
Some of the smartest insights about these challenges come from the influential American Prospect journalist Ezra Klein and the grass-roots "Archimedes Movement " for health-care reform led by former Oregon Gov. John Kitzhaber. Today, Archimedes leader Liz Baxter and Ezra Klein talk about the real-world prospects for health-care reform on the "D'Antoni and Levine" show at 5:30 p.m. east coast time.
Recently, Klein has been focusing on the role of Sen. Max Baucus as the potential linchpin to any health care reform in a Democratic presidency. He's guardedly optimistic, but stresses that massive pressure for reform has to be focused on Baucus and members of the critical Senate Finance Committee. Klein points out:
This is where organizing matters. The argument of my article was that the Senate Finance Committee (and, for that matter, the Senate) is the key body for health reform. Absolutely enormous amounts of energy -- including by me -- have been expended pushing the presidential Democrats towards better positions in campaign proposals that won't be implemented. That was useful insofar as it effectively conveyed the importance of health reform to the Democratic base. But that message has been conveyed, and the organizing energy now needs to shift to the Senate. As I wrote in the piece, "By publicly asserting jurisdiction on health reform, the Finance Committee is also taking responsibility for it. If the effort fails, it will be on their heads. And none will receive more blame then Baucus." The question is whether he, and his colleagues on the Committee, will fear failure and the consequences of blame, or whether they'll figure a couple irritated editorials will be better for their careers then sticking their neck out on this issue.
At the end of the day, for better or worse, Baucus is the key figure here. Progressives can't have him as an enemy, or there simply won't be health reform. But nor should they assume him an ally. They need to watch, organize, and agitate. They need to make it easy and rewarding for him to do the right thing, and hard and dangerous to fold before industry. If comprehensive health reform ends up being the right political play for Baucus, he'll happily make it. He's not ideologically opposed to the issue. But nor is he likely to lead in the absence of such an environment.
That's where groups like the Archimedes Movement come in -- organizing a grass-roots, democratic movement for health-care reform. They're banking on creating a "shared vision" of reform that will lead to changes in the health care system to make it affordable, accessible and emphasizing prevention. Will that be enough to build change? Not by itself, but in alliance with groups such as the Campaign for America's Future and Families, USA, along with those organizations' grass-roots allies, they can start to make a difference and bring about change.
It's a realistic vision worth achieving:
The Political Environment
Navigating the Current Political Environment
It is important to acknowledge that our current health care system was not designed to prevent illness or manage chronic disease, two issues that are at the heart of our health care crisis. Our shared vision has to have elements that are focused on:
* improving population health;
* reducing per capita cost; and
* improving the patient's experience, measured in health outcomes, safety and satisfaction.
The political gridlock comes about becaue we're askign the wrong questions. The entry level questions aren't 1) how do we preserve Medicare; 2) how do we fix Medicaid; or 3) what do we do about employer based insurance?
What we should be asking is this -
What would the optimal system look like that could improve population health, reduce per capita cost and improve the patient's experience regardless of their category, how care is financed, a person's age, income, race or gender?
We have to acknowledge that:
* Millions of jobs depend on the current structure of the health system and no one wants to lose their job.
o 1 of every 11 jobs in the US are in the health care sector;
o 1 of every 7 dollars in the US economy is related to health care.
* While 16% of Americans don't have health insurance, 84% do and they're not going to give up what they have without having a chance to fully consider what they would get in return.
* There is a lot of 'trapped equity' in the current system - buildings, technology and reimbursement, that no one is going to walk away from without making sure that their economic interests are addressed.
Once we acknowledge that we cannot politically or economically move from the current system to a new system overnight, then the dialogue shifts to what happens during a transition period.
It may sound too gradualist to some liberals, but they describe such a transition period as necessary to bring about sustainable reform:
Acknowledge The Need For A Transition Period
In order to successfully put together the politics of health care reform, we have to be able to separate the process of agreeing on the vision - on deciding what the purpose of the health care system should be; and on what we want it to do - from the process of realizing the vision through the political process.
In other words, we have to acknowledge and legitimize the politics and economics of reform and make them explicit.
And if we can do that we are then in a position to design a series of incremental steps which, over time, can gradually shift the trapped equity in the current system to one that is more effective, efficient, equitable, sustainable and more aligned with the long term interests of our nation without disrupting either the delivery system or the economy in the process.
Dr. Don Berwick, founder and CEO of the Institute for Healthcare Improvement, describes this challenge by comparing the Vision of a new system (the future state) and the current system (current state) with the economic burden on the various stakeholders involved. If we could move from the current state to the future state while reducing economic burden on the stakeholders, the politics would be simple and straightforward. Everyone would win.
The problem is that - because of the significant trapped equity in the way our current system is organized and financed, the economic burden is likely to go up for most stakeholders during the transition period. And, as described earlier, these stakeholders all have a significant influence over the political process and are able individually and/or collectively to block anything that will adversely effect their short term economic interests.
The challenge for us is to make the politics and the economics of this transition period explicit by starting with an agreement on the future state.
This will allow us to move beyond the political gridlock by shifting the focus of our discussion and our energy away from the narrow debate over how a particular reform strategy will effect a given economic stakeholder to a broader discussion:
* first, of what we want our health care system to do - what we want it to deliver us as individuals and as a society; and,
* second of how the economic impact of these changes on any given stakeholder can be mitigated during the transition state.
However, without first agreeing on where we want to end up, there is no political pathway for us to get there.
The Archimedes movement's assertion: Leadership Starts With Us
Without such a grass-roots movement, one that an Obama election could help promote and strengthen, there won't be any real change on health-care reform. But, in my view, unless grass-roots activists and organizations hungry for affordable, accessible coverage unite with those responsible business interests that want to curb skyrocketing health-care costs -- and then work together to overpower the health-care and insurance industries, not much will be done.
But as Klein points out in his latest article on "The Elusive Politics of Reform":
"It will be a tough road. But look at the numbers. One way or another, reform must come. We really don't have any choice."