Healthy choice

Barack Obama did not need the endorsement. But he got it anyway. A day after the final passage of the Health Care Reform Bill, Cuban leader Fidel Castro wrote of it as a miracle. What was miraculous about it, Castro wrote, is that it is really incredible that 234 years after the Declaration of Independence the government of that country has approved medical attention for the majority of its citizens, something that Cuba was able to do half a century ago.

Certainly, the passage of this Bill is remarkable. In January, when Republican Scott Brown won the Senate seat in Massachusetts, the air went out of the Obama reform balloon. The Republicans were gleeful. It appeared that they would now lie down on the tracks to stop the Democratic express. But congressional leader Nancy Pelosi refused to back down. She squelched pressure from Obamas Chief of Staff Rahm Emanuel to send a much narrower Bill to Congress. Pelosi led the defence of the relatively fuller Bill. Obama, it seems, agreed with her. They wanted to take the fight to Congress.

Arm-twisting of recalcitrant politicians and a few deals to appease the more right-wing Democrats (the so-called Blue Dogs) gave Nancy Pelosi and Obama the required majority in both Houses of Congress. The Bill went through by a whisker.

Obamas reform is moderate. Its provisions are similar to those of a Bill from Richard Nixons White House that was on the table. There is little in the reform that will bring the United States in line with Scandinavian social democracy, with English or Canadian national health, or with Cuban socialised medicine. It is less a Health Care Bill than an attempt to rationalise and regulate the health insurance industry. Certainly there are some very productive parts to this Bill, notably the ban on exclusions to pre-existing medical conditions, and it provides subsidies to the indigent to buy health insurance.

As Dr Marcia Angell, former editor of The New England Journal of Medicine, put it, What this Bill does is not only permit the commercial insurance industry to remain in place, but it actually expands and cements their position as a linchpin of health care reform. Not only does it keep them in place, it pours about $500 billion of public money into these companies over 10 years and it mandates that people buy these companies products for whatever they charge. This is a stinging indictment.

Despite the moderateness, the Bill has raised the ire of the countrys right wing. They are convinced that Obama has taken the country down the road to socialism. Several Republican members of Congress matched the vitriol of the Tea Party movement at every turn. Republican leader John Boehner went to the floor of Congress and yelled, Hell no you cant (this in reference to the Obama slogan, Yes we can). Other Republicans held signs that said, Kill the Bill.

Their partisans outside yelled racist and homophobic statements at Democratic members of Congress, and even spat on them.

After the Bills passage, many Democratic members received death threats, and someone cut the gas line to the house of the brother of one Democratic Congressman. Democratic leader James Clyburn called on his Republican colleagues to calm things down. This stuff is beyond the pale. People out in the streets get their signals or what they think are their signals from the people in positions like we hold, he said. Republican leaders, Clyburn pointed out, are aiding and abetting this kind of terrorism.

The political climate in the U.S. is decidedly right of centre. If a constrained reform of an out-of-control health care system can raise such ire, imagine what might have happened had Obama tried a more radical approach? Health care costs now account for 17.3 per cent of the U.S. economy, or in excess of $2.5 trillion. The U.S. spends more per capita on health care than either the United Kingdom or Sweden. Yet, it has a higher infant mortality rate and worse life expectancy.

The Robert Woods Johnson Foundation released a report in the midst of the debate, showing that as health care costs have risen, more and more people find themselves without health insurance. The rate of decline in insurance among the middle class was higher than all other groups (even as the highest total number of those without insurance come from low-income families). The latest figures showed that almost 46 million Americans had no health insurance (that is, over 15 per cent of the population).

Health care insurance costs have been borne either in private or by the employers. For the latter, this has become a huge economic problem, and as its bill rises, it makes U.S. firms much more globally uncompetitive. It would seem rational for the major corporations, therefore, to seek universal health care, just to get the health care insurance costs off their books. But they are not all inclined to this reform.

The main reason has little to do with costs and more to do with politics. Since the Reagan revolution of the 1980s, all government-driven policies that facilitate social solidarity have been systematically resisted by the business elite (whose American Chamber of Commerce and National Association of Manufacturers are resoundingly against health care reform).

Grover Norquist, the right-wing guru, wrote in Reason magazine (1997) that he rallied his troops in the early 1990s because of the sheer terror of [Bill] Clintons health care plan. The goal was to stop the government seizure of the health care industry. Had the Democrats taken over health care, I think we would have become a social democracy and we could never have undone it.

Health care reform would provide the impetus for more policies that produce social solidarity, such as, perhaps, public transportation and a more robust public education system. That Obama was able to get any reform on the table, and get this Bill passed, is a stick in the eye of the far Right, and this is why The New York Times David Leonhardt noted that this Bill is the centrepiece of [Obamas] deliberate effort to end what historians have called the age of Reagan.

In 1904, the U.S. Socialist Party endorsed health care insurance. The American Association of Labor Legislation (AALL) joined the fray, but from a different angle. The AALL was a social democratic trade union organisation with an interest in sickness pay rather than health care itself. Sickness led to poverty, and this hurt the economy, so the AALL organised to prevent sick workers from the poorhouse.

In 1916, the economist Irving Fisher addressed the AALLs convention, telling its members that some kind of insurance scheme was necessary to tide workers over the grave emergencies incident to illness, and also to reduce illness itself, lengthen life, abate poverty, improve worker power, raise the wage level, and diminish the causes of industrial discontent. This was all business-friendly. No talk of rights of workers for their own sake. Others, such as I.M. Rubinow, a socialist founder of the AALL, wanted more. He wished to use the discussion to reorganise health provision from individual doctor delivery to government-run group practice. This was squelched, largely by the growing power of the insurance companies (Metropolitan Life and Prudential).

The health care and insurance debate re-emerged in the 1930s, as part of President F.D. Roosevelts New Deal. Nothing budged the insurance giants. They had a lock on the policy. In 1965, the Democrats compromised with the insurance firms to pass Medicare and Medicaid, government programmes designed to insure the aged and the indigent. By this period, the issue of sick pay and poverty was long gone. The new debate was about the costs of medical care, as well they should have been (and the costs would continue to rise; from 1965 to 1991, cost of health care as a percentage of gross national product (GNP) rose from 5.9 to 9.1).

In 1927, reformers created the Committee on the Costs of Medical Care. One of its staff, I.S. Falk, drew a line against socialised medicine. Health insurance is not a system of medical practice. It is always and everywhere consistent with the private practice of medicine. Such a view exists to this day. There was no socialist movement strong enough to put national health schemes on the table. The Canadian story is also a bitter one, given that Canada too had no Left or labour party strong enough to carry the fight.

The closest the U.S. came to some kind of health insurance reform was in 1974, when Senator Edward Kennedy and President Richard Nixon agreed to a plan, with one of its centrepieces being mandated coverage by private employers (but with no cost controls and with little provision for the unemployed). A new spirit of compromise is in the air, said Senator Kennedy, but before the Bill could go forward, Nixons presidency crashed into the Watergate scandal.

The Reagan revolution was premised on an antipathy to government, and to the restoration of unfettered wealth for the elite. Policies set in play opened a vast inequality gap between the richest and the poorest, with the middle class on a gradual slide towards the poor. The various asset bubbles of the Clinton era were able momentarily to reverse the middle class downward trend, but not for long. Clintons health care plan never stood a chance. The Republicans were too combative to defend the gains of the Reagan years, and Clinton himself had too much fealty to Wall Street to stand up for the rights of the working majority. Obama might not share Clintons temperamental affinity for the bankers, but he is the leader of a party given over to corporations (the union element is much constrained).

Nevertheless, times are now different. Even the Business Roundtable came around to the view that some kind of health care reform was necessary. That provided the opening. Obamas insurance reform is far from comprehensive, and indeed with the presidential order that prevents abortions and other procedures that are a womans right, there are grievous restrictions to the Bill.

However, it is not the Bill that is important. The politics of it is central. The political Right has been outflanked. It has revealed both its legislative weakness and its capture by the unruly far Right. During the presidential campaign, Obama pointed out, The project of the next President is figuring out how you can create bottom-up economic growth as opposed to trickle-down economic growth. The stroke of Obamas pen has not solved the health care crisis in the U.S. But it has set back the Reagan revolution a little bit.