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The Way Forward on Health Care

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Democrats in Congress are between a rock and a hard place on health care, and so, too, are the American people.

On the one hand, if Democrats do not pass health care legislation, they will be seen, rightly or wrongly, as unable to deliver on anything of substance to the lives of everyday Americans despite a Democratic president, a supermajority in the Senate, and an overwhelming majority in the House. The American people twice voted to "throw the bums out," in 2006 and then again in 2008. Bush and the Republicans had done more damage in eight years than any president since Herbert Hoover, and the American people had had enough of the ideology of unregulated greed that was the core philosophy of the Republican Party during the Great Depression and remains their core philosophy today.

To his credit, the president pushed through a stimulus bill that prevented us from falling off the cliff. But he refused, as FDR had done, to brand the crisis that had occurred as the direct result of Republican ideology and governance. He refused to explain to the American people why deficit spending in times of a crashing downward spiral is a virtue and not a vice. And he refused to call out -- let alone even answer -- Republican politicians attacking him from his first days of office for deficit spending, although they had just created as much debt in 8 years as in the previous 200-plus with enormous tax breaks for the wealthy and a trillion dollar war "off the books," neither of which they even considered paying for. As a result, he got little credit for having prevented another Great Depression, and now there are two competing narratives, that the stimulus saved us and that it was a waste of taxpayers' money.

With all the talk of hope and change, the American people were expecting something very different from the new Democratic majority. The president insisted on bipartisan solutions for problems Republican "solutions" had created, for which the imaginary bipartisans on the other side have not, and will not, cast a single vote. Making matters worse, at a time when Americans are -- and should be -- deeply suspicious of big business, these "bipartisan" solutions consistently seem to gravitate toward that golden mean between the public interest and the special interests (in this case, of the health insurance and pharmaceutical industries).

The American people watched as Democrats insisted on 60 votes for every piece of legislation, despite the fact that the Republicans "jammed down our throats" (to use a current Republican talking point) one substantial piece of legislation after another for eight years when they had far less than 60 votes in the Senate. The result of what looked to Americans (fairly or unfairly) like a cross between cowardice and dysfunction was what George Will aptly called the "serial bribery" of senators. All of them could step up and demand whatever they wanted to water down the bill or load it with pork for their state whenever it was their turn to become the 60th senator.

But Democrats have no choice but to pass health reform legislation of some kind and finally use the reconciliation mechanism that could have allowed them to construct a good bill in the first place. Otherwise, they will appear completely unable to govern -- while leaving millions of Americans without health insurance and 15,000 people a day losing it.

That's the rock. Now for the hard place.

The polling data are clear that 75% of voters, despite the concerns that led them to support health care reform so strongly during the 2008 campaign, now prefer to start from scratch or kill the bill. Democratic pundits take solace in quoting the statistics on how voters feel about individual components of the bill, which they largely support. But that's not how voters' minds work. They were presented with a strong GOP message on health care reform: that it's a government takeover of health care, that it will put a bureaucrat between them and their doctor, that it will negatively impact the health insurance of the 85% of voters who currently have it, that it will threaten Medicare, and that it will increase costs to middle class taxpayers. As the White House now acknowledges, it "lost control of the message" somewhere last year. In fact, it never had a coherent message. It was never clear to the American people precisely what problem, or problems, reform was intended to address, and attacks from the other side -- and an emerging narrative about big government and big deficits -- went unanswered throughout the summer. As a result, the average person's "gut feeling" about this legislation was, and is, that it isn't worth the risk -- and it's that gut feeling that drives voters.

In recent weeks the president has retooled his message and shown a willingness to take some very effective swings at his opponents. At the "bipartisan" health care summit, he manhandled John McCain by reminding him who had won the election, and he showed a strength the American people have waited a year to see by essentially rolling his eyes at Minority Leader Boehner's attempt to turn the summit into a talking points tit-for-tat and suggestion that we "start over," essentially cutting him off and asking if anyone had a real question to ask. And in recent days, he has effectively argued that we have heard everything there is to say about health care and health reform and that the American people deserve an up or down vote.

Had President Obama led like this a year ago, Democrats would likely have passed health care legislation months ago, would have shown that they could take on major issues like financial regulation and jobs, and would not be heading for a likely debacle in November. And members of Congress would not be deciding right now which is worse -- voting for a grossly unpopular bill that will in essence be a jobs creation bill for their Republican opponents -- or voting against the bill and driving the president's approval ratings down (a strong predictor of electoral failure in midterm elections), demonstrating that Democrats can't govern when they need to move onto what matters most to the American people at this point, namely jobs.

The question is whether there is a way to move forward that does what the American people asked the Democrats to do when they handed them the keys to the government, and that makes it likely that they can drive their agenda out of the Capitol Hill garage.

I believe there is, and it can be done within the president's broad up-or-down framework of reconciliation, but it will require not only the right message, but the right policies. In a democracy, you want good messaging to flow from good policy -- to decide what you think will work best and then to figure out how to talk about it so that what you are saying is compelling to the average voter. But sometimes in talking about an idea with the American people, you actually learn a few things about what good policy might be. This is one of those times.

Having led the messaging efforts for the major nonprofits working on health care reform during the primary election campaign season of 2008, we didn't know whether Obama, Edwards, or Hillary Clinton would be the nominee, but they were all offering variations on a theme. We learned, however that what appealed to Americans were essentially two things.

The first was a clear aspirational statement of what we wanted to accomplish with "health care reform" (or its latest rendition, "health insurance reform" -- two phrases that have about as much emotional resonance with voters in the center as "universal health care," "single-payer," or "reconciliation"). One statement stood out, because it appealed both to what people want for themselves (their interests) and to their moral sense (their values): "I believe in a family doctor for every family." That, after all, is what this debate is really about.

If you start with an aspirational statement of that sort, it serves not only as a positive message but as a powerful weapon against any moral reprobate who opposes it. In fact, Republican leaders in Congress do oppose it, and it would be a lot harder to squirm out of opposing the simple value statement that people who work for a living ought to be able to take their kids to the doctor when they're sick, or that Americans should have a human connection to someone who is taking care of their health, than to "health insurance reform."

The second thing that appealed to Americans was a relatively simple set of principles. If you offer voters a set of legislative provisions (whether 12 or 2400 pages), they will argue with you about each one, particularly when those provisions include things like taxing and ultimately eliminating high-quality insurance plans, particularly when no one knows whether that provision applies to their plan.

If you find yourself arguing at that level of detail to the American people, you have already lost the battle. Ours is not a direct democracy. We have a representative democracy (or republic) for a reason: Things are complex. Except for a handful of people, none of us is a fulltime legislator, and what we choose every two to four years at the ballot box are people we trust to take our values to Washington (or the state house) and to let them work out the details as to how to implement those values, with the expectation that they will be informed about the details in ways we simply cannot be.

The research my colleagues and I conducted in the run-up to the election of 2008 pointed to three principles that led Americans to agree that it was time for comprehensive health care reform rather than a band-aid:

(1) If you like your doctor or your current health care plan, we will never take it away from you.

(2) Americans know best what's good for their families, and so they should have more choices rather than less, including the choice of at least one plan the insurance companies don't control, which will keep plans competitive and comprehensive, including preventive care like cancer screening.

(3) We will no longer tolerate 40 million Americans without health insurance and rising, with insurance companies arbitrarily deciding who should be denied coverage because they have a "pre-existing condition" or who should be cut off because their current treatment for some current condition is costing the insurance company too much money.

The simple aspirational statement -- "I believe in a family doctor for every family" -- and those three simple principles -- beat anything the other side could say by a 2:1 margin. That should have been the Democrats' message. And it should be their message now.

Instead, the White House offered three principles, two of them virtually identical but one very different: that our first goal should be to cut costs. That was an enormous mistake, for three reasons.

First, no one really knows how to cut the costs in the health care system in a politically feasible way, especially if you take off the table the most effective cost-containment mechanism for insurance premiums, namely making private insurance companies compete with a plan like Medicare (perhaps the most popular government program of all time, up there with Social Security).

Second, cost has been part of the core conservative narrative since Ronald Reagan -- that Democrats have never seen a tax they didn't want to raise and a government program they didn't want to fund. "Bending the cost curve" is certainly an important goal, but to make that the first principle of health care reform was to invite a he-said/she-said about how much this or that provision would cost and to send plan after plan back to the CBO for scoring -- not where you want to be if your goal is to convince the public of anything.

But third and perhaps most importantly, if a key goal was to insure another 40 million people, the idea that you could do that and simultaneously cut costs simply bends the curve of imagination too far. Sure, there will be cost savings if 40 million people get preventive care, don't end up in emergency rooms, and aren't already having the tab picked up for much of their medical care by the rest of us. But someone is going to have to make up the difference, and that someone could be the health insurance and pharmaceutical industries (who the public would be happy to see cough up something other than phlegm in this debate), the upper 1% of the population (whose share of our national wealth has skyrocketed in the last decade, and who polls consistently show are popular people to look for revenue by an electorate hungering for fairness after years of declining median wages), or the middle class.

Unfortunately, the president decided to cut a deal early with the health insurance and pharmaceutical industries by taking any meaningful contribution from them off the table, to damn competition of public and private plans (like the competition between public and private colleges and universities -- which, last I looked, has worked out pretty well) with faint praise for the better part of a year, and to choose the Senate bill's tax on working and middle class Americans over the House bill's millionaire tax, on the theory that that would make middle class people think twice before getting an extra medical procedure (not something that seems a laudable change on face value, especially while talking about the virtues of preventive care and screening).

Whether or not a bill with these provisions passes, every Republican will run against every Democrat in November with the theme, "they raised/tried to raise middle class taxes," and they will be right -- well, in 2018, anyway, when the provisions finally kick in. They will argue that "they cut/tried to cut your Medicare," and they will also be right, at least to some extent, and it won't matter that they've been trying to cut Medicare ever since they opposed it.

So is there a way out?

Yes. Go back to the core principles that Americans are enthusiastic about for a reason, and go back to a plan closer to what the president campaigned on that matches them. It can be achieved through reconciliation, just as can the current White House plan. And Democrats just might keep the House.

Principle 1: If you like your doctor or like your current plan, this plan won't affect you. You can keep them. We will not tax middle class plans or set up incentives for insurance companies to eliminate high-quality plans. To cover or subsidize working Americans or those who've lost their jobs and can't afford quality insurance, we will impose a progressive tax starting with individuals who make $500,000 or more or families with earnings above $1 million per year, allow reimportation of drugs from Canada, and negotiate prescription drug prices for people on Medicare just as we do in the VA system. Much of that is in the House bill.

Principle 2: We will give Americans more choices, rather than less, starting with high minimum standards for any company wanting to sell health insurance, including an end to discrimination against people for being sick, arbitrary termination of coverage for people who have been paying their premiums but have gotten sick and now actually need their insurance, or arbitrary rate hikes. We will allow people to shop around among private insurers in whatever ways maximize competition, and allow any American to buy into Medicare for a competitive price. We know that Medicare works and gets high approval ratings from our parents and grandparents. There is no reason to create any new "public option."

Principle 3: No man, woman, or child in America will ever have to worry again about being without health insurance or medical care. People who have lost a job, own a small business or employ others in that business, or work full-time but can't afford health insurance will be able to buy a plan on an open exchange that includes both private plans that meet high minimum standards and Medicare. If a co-op can create a competitive plan, let it create a competitive plan. If a union or the Chamber of Commerce can create a competitive plan, let it create a competitive plan. Subsidies for those who need them will be funded by the insurance industry (which will have millions of new customers), the pharmaceutical industry (which will have millions of new customers), and millionaires (who were favored disproportionately by the Bush tax cuts and are doing just fine, thank you). Plans that meet the standards for participation in the exchange should be vetted and available by January 2011, not 2013, and Medicare should be available for purchase by the same date. Children whose parents can't afford health care will remain covered by the children's health insurance plan signed into law a year ago, which is already paid for, which will keep additional costs down for those who need subsidies.

This simple proposal -- three principles, three paragraphs -- is not all that different from the president's plan, except that it is fair to the middle class, pays for itself immediately (not in 2018 when the "Cadillac tax" kicks in, presuming some Congress and president at that point decide it's in their interest to pay a debt created by a Congress and president nearly a decade earlier, which is highly unlikely), and would be widely popular. It is easier to understand and easier to implement. It is also rooted clearly in values -- choice, fairness, competition, a healthy life for all Americans -- that make it very difficult to attack.

It is difficult to imagine a Democrat voting against it. And it is equally difficult to imagine a Republican attack on it that "sticks." But this time, it might be good to prepare just in case.

Drew Westen, Ph.D., is Professor of Psychology and Psychiatry at Emory University, founder of Westen Strategies, and author of
The Political Brain: The Role of Emotion in Deciding the Fate of the Nation.