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ObamaCare: American Incrementalism
There's been a great deal of debate this cycle about the relative merits of the candidates' health care plans. The key point seems to be the issue of mandates - Obama would require that all children have health insurance, Hillary would extend that requirement to every American. Whatever the abstract merits of the competing proposals, one thing seems clear - Obama has yet again demonstrated his superior understanding of the American temperament, and that bodes well for the plan advanced by the presumptive nominee.
I would sum it up like this. Hillary may have abandoned the truly-sweeping changes she proposed during her husband's first term, but her plan remains ambitious. It is her aim to enact reforms that would, in one fell swoop, extend coverage to every American (that is, to every citizen and legal resident - she would still exclude millions of those in the country illegally). She and her advisers argue that only truly universal coverage can be economically feasible. Obama is proposing a plan that might, in any other year, seem ambitious - but stacked up against Hillary's seems relatively cautious. He would mandate that every child be covered, but not every adult. If it turns out that the numbers don't add up, he's said, he'll reconsider universal coverage. It's a relatively incremental approach. I'm not qualified to pass judgment on the economic merits of the proposals; smarter folks than I have already written thousands of column-inches on the subject. But I do think that there's another way to gauge the two plans, and that's to consider the visions of change that they embody.
For centuries, Americans have proven resistant to governmental provisions of welfare. The quintessentially American ethos of self-sufficiency and independence leads many voters to recoil from the very notion that the government should take a prominent role in their lives. Many Americans would prefer to shoulder greater risks and maintain their independence, than to surrender their freedom of choice and gain greater security. But there has always been an important exception to this general rule. Americans feel a collective obligation to care for the vulnerable and the defenseless. When proposals are advanced to care for those believed unable to care for themselves, they have almost always enjoyed tremendous support. Moreover, almost every major expansion of the welfare state has followed the same path - reforms initially proposed to benefit the most vulnerable are gradually expanded to benefit all Americans.
Let me offer a few examples. It was in the wake of the Civil War that the federal government first entered the welfare business; an enormous bureaucracy provided benefits for the wounded, and pensions for veterans and their widows and orphans. Governmental regulation of wages and of working hours was first held to be constitutional only insofar as the government acted to protect the vulnerable (women and children), and only much later extended to the workforce as a whole. Modern personal-injury law has its origins in the railroad accidents of the late nineteenth century; the courts initially moved to protect and compensate women, who were seen as dependent and vulnerable, but gradually expanded those protections to men, who were every bit as much at the mercy of machines. Modern product liability and consumer safety protections date to a series of accidents in the mid-1950s, in which poorly designed products led to the maiming or deaths of scores of small children, and were gradually expanded from that narrow base.
In other words, the courts, the legislatures, and the electorate have always been far more supportive of efforts to protect the vulnerable than they have of efforts to expand governmental authority over the able-bodied and the independent. But when those initial efforts have proven effective, they have often cleared the way for more sweeping programs that have followed in their wake.
There's a new NPR Survey out this morning that suggests this holds true for health care, as well. Let me quote Harvard Prof. Robert Blendon, a co-director of the survey:
There was extraordinary support in this poll among all groups — Democrats, Republicans and independents — for the idea of requiring that every child has a health insurance policy and then provid[ing] help to parents that can't afford it. And we don't have as wide a consensus for what to do about adults. So it's the childrens' side of this which offers the possibility of a very quick breakthrough in the next Congress.That's an important message. Obama has intuited where the American people stand on this issue, for better or for worse. His proposal is consonant with the long history of reform efforts in this nation, which extend help first to the most vulnerable. When the efficacy of those efforts is clear, the rest of the population has often come to support extending the protections. We've already seen this with S-CHIP, which succeeded where HillaryCare failed. It remains immensely popular, and has inexorably expanded in many states to cover increasingly broad segments of the population.
Obama's approach may not please economists, but in some sense, that's immaterial. He can unite the American people in support of his vision, and it's likely to lead to something approaching universal coverage in fairly short order. That ought to cheer critics of the proposal, and even dejected Clinton supports, concerned that her defeat will hamstring efforts at health care reform. If history is any guide, Obama's approach will prove far more politically feasible, and lead us to the same ultimate destination.
Comments (31)
Wow. Excellent analysis of how Obama's appeal is based not merely in blind adulation, but in the concrete sense that his approach shows a better understanding of how progress takes place in American culture. This just happens to be embodied most clearly in the contrast of his health care proposal, but you can see this understanding of American culture at work in all of this policy ideas. This understanding, as opposed to the empty rhetoric Bush mouthed in 2000, is the substance behind Obama's case for electing a unifier.
February 29, 2008 12:37 PM | Reply | Permalink
Once again, it's all about judgment. Excellent post.
February 29, 2008 12:44 PM | Reply | Permalink
As usual, FlyOnTheWall, top notch analysis. I've been thinking about Obama's policy as a palatable first-step toward universal coverage, but you have the explanation down pat.
It seems that many people still have a bad taste in their mouths--left over from the unrebutted condemnations of socialized medicine in the early nineties--about government involvement in health care. If an incremental approach can erode this suspicion, then five to ten years from now people will be willing to take the next step.
Sweeping health care reform and a 100% government-financed health care system implemented next year sounds great to me. But the American public isn't on board with that yet. They need to be convinced by a system that works.
And as those children with the mandatory coverage grow up, they will be more and more willing to continue their mandated health care.
February 29, 2008 12:45 PM | Reply | Permalink
"deprivation research" - being without your analysis for a bit has only made us yearn for and appreciate this post even more!
February 29, 2008 12:50 PM | Reply | Permalink
By the way, you suggest, Fly, that Obama's approach may not please economists. Actually, there is now a branch of economics called "behavioral economics," which, I believe has research that supports the Obama plan. Indeed, one of the reasons Paul Krugman is against Obama's plan has to do with ongoing arguments within the field of economics - the older view, such as Krugman's, and a younger cohort, more persuaded by the behavioral economics research.
February 29, 2008 12:54 PM | Reply | Permalink
Do you have any juicy links regarding this dispute re: Krugman?
March 1, 2008 2:49 AM | Reply | Permalink
Very lucid and well put. Too bad you are an Obamanicultbot...
Kaizen
Things need to happen in increments, not in sudden swings. One could compare it to the effectiveness of the socratic method. You might not agree with the end point of the argument unless you go through the incremental steps it takes to get to said point.
Thanks
February 29, 2008 1:07 PM | Reply | Permalink
i agree, the difference in the mandates speaks to a different approach to the solution, and i think obama's more measured approach will gain broader support. as folks ahs said incremental changes can be more effective and you sure don't want to break down before you even get out of the gate.
February 29, 2008 2:47 PM | Reply | Permalink
Clever and insightful as usual, fly. I was wondering what happened to you.
One question about your approach though. You cite a few examples of cases when incrementalism has worked and ambitious change has failed, but that doesn't establish the thesis that incrementalism works better than comprehensive reform in this country, as there have also been cases of successful comprehensive reforms, e.g. social security, antitrust laws, abolition, prohibition (not that it worked or was good, but it passed), etc. And one of your examples, labor law, may have gotten off a slow start among the most vulnerable, but when it happened for everyone, it happened pretty fast.
Of course, comprehensive reform has to have precursors--a groundswell of demand requires time to build up--but you could argue that between medicare/medicaid, the Clinton administration's first attempt, and movement towards universal health insurance in the states, we've been headed in that direction for some time already.
I don't have a strong opinion on this, but I do suspect that true universal health care would be better for the country, and while it may not be able to survive congress, it seems too soon to make that judgment call. There could be a Democratic sweep in November, which would make it much easier to pass a comprehensive plan. It seems to me that it would be smarter to aim higher and pare down the plan if compromise turns out to be required.
I'm still surprised that Obama chose to eschew mandates. Had he adopted something closer to Clinton and Edwards' plans, he would have deprived Clinton of one of her biggest arguments against him.
February 29, 2008 2:54 PM | Reply | Permalink
Genghis,
I tend to shy away from universals, prefering to note trends. But let's take a few of the examples you cite. Prohibition followed a century of temperance advocacy, centered on a common theme - that alchoholism led men to neglect their duties as providers, and victimized helpless wives and children. It was aimed at protecting the vulnerable, and the Volstead Act came after many towns, cities and counties across the country had long since gone dry. Abolition was likewise an incremental process - the importation of slaves was banned, many northern states that had once had sizable slave populations phased out slavery or eliminated it directly, Lincoln then emancipated slaves only in territories controlled by the Confederacy, and finally all slaves were freed. Social Security followed a similar pattern - Theda Skocpol's book, to which I linked in my post, makes the case better than I can. Antitrust law, I'd argue, falls into a different category, but that's a discussion for another day.
None of which, of course, addresses the two central questions you raise: (1) Haven't we already had enough incrementalism to take the final leap? (2) And isn't it better to aim high and then settle for what you can get, than to abandon the ideal before you start?
I think the NPR Poll speaks to the first point. Public support for universal mandates is, at best, uncertain. And that's before the attack ads and the scare-mongering. Realistically, I don't see the support being there.
So why not try it and find out? Well, I think the Clintons learned the hard way that there are risks to aiming too high with a central feature of a campaign platform. They enjoyed solid majorities in both houses and yet never uncovered from the unraveling of the initiative. But there's a second point to make in this context. It's not at all clear to me that Obama regards universal mandates as an ideal. He places tremendous stress on individual responsibility and the need for private initiative. What he's looking for, I think, is universal access - not necessarily universal coverage. I think he's genuinely hoping that people, presented with affordable and reasonable options, will responsibly choose of their own accord to enroll. He admits that this may not work, and would then be willing to consider stronger options, but I do think this represents his ideal solution, and one he'd like to try even if he had the votes to do something else.
It's my own surmise that ObamaCare, if enacted, will ultimately lead to universal mandates and coverage. It's not Obama's prediction, nor indeed, a vision that he's ever articulated.
February 29, 2008 3:32 PM | Reply | Permalink
Thanks for the reply, fly. I certainly agree that in a democracy, comprehensive change doesn't spring out of thin air. There has to be popular support which, except in extreme circumstances, evolves gradually. When there is such support, you're likely to find localized instances of reform first. The localization could occur by community, by state, by industry, by demographic, or other categories. Certainly protecting the vulnerable, especially children, is popular, so reform that involves such protection is easier for people to swallow.
But then, at some point, there's often a big jump from localized reform to the comprehensive reform. That jump is not incremental. So I would say that prohibition, abolition, social security, etc. were comprehensive reforms that were preceded by incremental reforms.
Which gets to the nub of the question. Are we ready for comprehensive health insurance reform?
I don't think the NPR study you quote indicates that we're not. First, it's not clear to me that a majority of the population has to be behind reform for it to succeed, though there would certainly need to be at least a sizable minority. Second, both of the first two proposed plans in the study mandate insurance. The primary difference seems to be that the second also mandates that employers cover insurance and bars insurance companies from rejecting applicants. (The wording is weird; I had to stare at it for 10 minutes myself to figure out the difference.) The first plan had 47-44 in support. The second had 59-33 in support. And the third, which mandates children only, had 65-31 in support. Note that all three plans have majority support, and the second plan, which mandates coverage for adults, is pretty close to the third, which does not.
But leaving aside the study, have we had enough incremental change to prepare us for comprehensive reform? We already do have federal health insurance in the form of Medicare and Medicaid for some vulnerable demographics--elderly, disabled, and poor families. We have one state with universal health coverage and other states, like CA, flirting with it.
Is that enough? I don't know. I do think that we could go further incrementally before switching to comprehensive, and I agree with you and Obama that we can always improve it later (though keep in mind that it could be decades later). But I also don't think it's clear that we're not ready for mandated insurance. Clinton's first attempt failed for a number of reasons, and we shouldn't assume that the situation will be the same this time round.
Finally, I agree with you that Obama may not himself believe in mandated coverage unless absolutely necessary.
February 29, 2008 5:21 PM | Reply | Permalink
I've taken a vow of silence until Wednesday morning. If Senator Clinton wins the popular vote in Texas and Ohio on Tuesday, I'll respond to this and other comments in support of the "presumptive" candidate. If she loses the popular vote in either of those states, I'll stop in to say adios to some people I've come to respect, including the writer, and get back to the world. Like the Clintons, I made the mistake of thinking this campaign would be wrapped up on Feb 5. I've learned a lot around here, and I won't be sad to see the race go all the way to Pennsylvania. But I won't be sad to see it end on Tuesday either.
February 29, 2008 2:58 PM | Reply | Permalink
Don't leave us, Billy. There's a whole general election to argue about after the primary is done. Seriously, you're a welcome contributor, and I always appreciate your uncommon perspective even when I don't agree with it.
February 29, 2008 3:15 PM | Reply | Permalink
I'd second that. Elections come and go, but the issues that animate them remain. TPMCafe is in the process of building a community of intelligent, informed, and respectful users - it'd be a shame to see one depart. Stick around, Billy.
February 29, 2008 3:34 PM | Reply | Permalink
So the race ends on Tuesday if and only if Hillary Clinton does not win?
February 29, 2008 7:41 PM | Reply | Permalink
What is best in life? To crush your enemies, see them driven before you, and to hear the lamentation of the women.
You will be the first to eat your words if she does win. :)
February 29, 2008 8:13 PM | Reply | Permalink
If you say so. I take all of this far less personally that a lot of other people here seem to and my feelings about Clinton have to do with the fact that I disagree with her politics, not her personality.
I'm not even a Democrat. I'm 'caucusing' with them this time around because I think the stakes are high. Obama isn't my first choice, but he isn't my last either.
I have no burning desire to see Hillary Clinton fail, I just don't agree with her politics. As far as eating words go, I'm as surprised as many people are that Obama is within striking distance at this point. I consider it lucky that there's a Democrat I actually feel like I can vote for.
As someone who is not a Democrat, I find the vitriol toward Obama completely puzzling and from an outsider's perspective it looks to me much like the vitriol the Clintons have faced from the right for years. Many Clinton supporters, especially those here, don't seem to be excited at all about the abundance of political fortune and options they currently have on the table in front of them, but rather seem pretty pissed of that Clinton isn't winning. It's a phenomenon that I don't understand and thusly I'm curious about it. You seemed to be indicating that you share this perspective and I thought you might want to share why.
My comment wasn't a jibe. It was an honest question, but as per usual you seem to prefer to feel clever and address the person instead of the argument. From my view, it's unfortunate because you're an able communicator, but it results in my getting little out of engaging you other than finding a fellow fan of tales from the Hyborian age.
But perhaps that's just your way.
February 29, 2008 9:04 PM | Reply | Permalink
Don't be upset with Billy. He can't help it; he's dyslexic.
February 29, 2008 11:30 PM | Reply | Permalink
Ha! And I was wondering what we'd do with ourselves when we have a Democrat in the WH, a majority in the House, and a FILIBUSTER PROOF Senate!
February 29, 2008 5:58 PM | Reply | Permalink
It's not just judgment about what the American people are ready for. It's also about whether or not to make oneself unnecessarily vulnerable in an election. Obama gets to say that he makes health care available to everyone, so he can claim the mantle of universal health care. However, he does not allow McCain to claim "Barack Obama will use BIG GOVERNMENT to FORCE you to buy health insurance and take away your freedom of CHOICE." Obama's position is politically saavy on multiple fronts.
February 29, 2008 6:00 PM | Reply | Permalink
I would argue that this is not part of the American ethos, but part of a mythology of the right used to manufacture consent. I see the Volksgeist as essentially empty- a lie that holds whatever the patriot desires. Here are a few examples:
"I am patient and resolute." vs. "The American people have great patience and resolve." (Feel free to substitute "the American people" with "the French people," or "the Korean people," or anyone...)
"I am impatient and want results." vs. "The American people are a people of action! We want results, and we want them now." (Feel free to substitute "American" with "French," etc.)
I think the "incrementalism" you speak of is not a testament to the character of the American people,; rather it is a testament to the power of oligarchs to resist the popular will.
March 1, 2008 12:16 AM | Reply | Permalink
Interesting commentary. Is your avatar John Cale?
March 1, 2008 2:48 AM | Reply | Permalink
So close! It's Ric Ocasek- as I've said before, I'm here to drive people home.
March 1, 2008 4:41 AM | Reply | Permalink
Interesting analysis--& here I was holding back on Obamamania precisely because I didn't think his health-care platform is workable OR effective. Turns out that's very clever on his part!
But as I see it (agreeing with Joe Petit and also Little Black Propaganda along the way), with a nod to the savvy "incrementalist" approach, I conclude that it doesn't much matter whether Americans like to think themselves strong, independent & self-sufficient, it's that Obama can SAY he thinks it, and "fortunately" the economy is self-evidently tanking, jobs with full benefits have gone the way of the Edsel in America, rising energy costs, & even the AMA trying to get more vigorous action re insuring the uninsured, private health insurers blatantly cherry-picking their clients while raising premiums & diluting coverage (throwing sick people under the bus), big Pharma manipulating drug trials, etc. etc. it's as if the stars & planets are all aligned! The truth is, we've got to be hurting badly on a personal level before anything like a major revamping can occur, & goodness sakes, we are!
IF he can outlast the last remaining GOP ideologues in Congress or find some way to otherwise get around them, we can all remain insular & smug & avoid having the conversation how so many other democracies manage universal health care. (When will business wake up & realize it's in their best interests to have it--oops, doesn't matter now--they're all gone overseas.) Other than that last thing, it's the best of all possible outcomes!
March 1, 2008 3:34 AM | Reply | Permalink
Let's consider that maybe Democrats get 2 years of a majority in Congress. Then quite possibly whatever gains we get in those 2 years will be rolled back later. Consider that we might have a single-term Presidency. Consider that Carter suffered from the Russians invading Afghanistan, the oil embargoes, the Iranian hostage crisis and stagflation - none of which were his fault.
Please don't be too optimistic that we'll get to take the second step. There's probably more acceptance that our health system sucks than there ever has been, though even there the right keeps dredging up the anecdote about MRI's in Canada as if that's the only health issue that matters. We managed to not expand SCHIP last year. Many of the same resistant politicians will still be around.
FDR gave us Social Security, and it works well for everyone and the right wingers are still angry as hell about it and trying to roll it back. The best thing we can do with health care is get a universal system that works as best as we can make it, and then defend that system against all attacks (of course modifying it if there's something that obviously isn't working well in practice). Many of the problems we deal with are specifically because we don't have universal health care, so there are huge gaps in coverage and irrational counterproductive requirements to stay insured.
We can get universal care by subsidizing those who initially can't afford it. Why not go for the best? Just say it - "Yes we can".
March 1, 2008 4:17 AM | Reply | Permalink
These are good points. I agree with FlyOnTheWall that there is something pragmatic and politically realistic to Obama's approach; however, I agree with Demon Princess and Desidero that this pragmatism may be short-sighted.
March 1, 2008 5:20 AM | Reply | Permalink
And as those children with the mandatory coverage grow up, they will be more and more willing to continue their mandated health care.
Ooooooh, such a sneaky remark!
The good ol' "Teach 'em when they're young"-approach! You know, that might just work.
Be advised, that some European states are backpedalling from universal health care in part.
Germany is eying their "testing ground" Holland like a hawk, since the Dutch have made universal health care more expensive. In short, you're not covered anymore or a lot less, for a lot of things you used to be covered for.
Dental stuff is only covered for maintenance stuff.
The pill used to be free, they tried to make every woman pay for that, but they had to settle for just over-21s: for all younger women, the pill is free.
So Germans are very resistant to welfare reforms etc.
General wisdom among economists here says too, that Obama's plan is worse than Clinton's.
And Fly might be right about the political vs. the economic realities. It all depends on how well repubes can sabotage the plan, by pointing out free-rider options to the people.
I also don't know a lot about the economic technicalities, but I suppose that making it only universal for high income peeps would help a lot.
Personally, I think it's crazy to let govt pay anything for peeps earning about 300,000 a year.
They earn so much, they can darn well pay their own way.
But that's just me.
March 1, 2008 9:14 AM | Reply | Permalink
My question is whether T.C.E.O. is a "Coloured European," a "European Observer," who just happens to be coloured, or an "Observer," who chooses to restrict the field of his observations to observing coloured Europeans.
Enquiring minds want to know.
March 1, 2008 10:34 AM | Reply | Permalink
It's the "the" that disquiets me. I picture a whole committee of observers with other members that include The White South American Observer, The Yellow Middle Eastern Observer, etc.
March 1, 2008 1:14 PM | Reply | Permalink
Very interesting post and lively debate!
We’ve analyzed voters' support for Clinton and Obama healthcare plans , based on polling data from Select2008 . One of our findings is that only a slight majority of voters supports universal health care , which hints at a spirited debate as we move into the general election phase.
March 2, 2008 8:28 PM | Reply | Permalink
Personally, I've just had it with the disorganized & seemingly completely random, illogical & fiscally insane state of health care in the U.S., & I'm sure I'm not alone (I may be more opinionated than most, having had 4 different health insurers in the last 6 years). I just know at this point that I don't think a series of band-aids & patches on an already- leaky lifeboat is going to help anything very much.
I personally think we as a nation have to rethink our laissez-faire approach to healthcare as just another consumer product. I'm all for a revolution at this point.
March 3, 2008 5:16 AM | Reply | Permalink
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