Obama’s supporters argue vociferously that Obama’s recycling of right-wing language and talking points is misinterpretation of his statements or (fall-back argument) just smart politics that doesn’t really reflect the character of the man, or how he would govern.
However, with respect to to healthcare reform (one of the top two priorities for most of us), I would argue he’s already done damage to the cause by elevating a bogus "mandates" argument. By so doing he has effectively "market-tested" and established a line of attack that those opposed to health care reform will, happily, add to their tactical arsenal.
Lets look (below the jump) at the argument in three pieces:
- Motive – why elevate "mandates" in the context of healthcare?
- Weapon – the origins of carping about "mandates"
- Fallout – how the bogus "mandates" debate poisons the chances of meaningful reform down the road
1. Motive – why elevate "mandates" in the context of healthcare?
I think Obama’s "mandate" gambit is part of his broader post-partisan / third-way politics positioning, and part of a broader pattern of leveraging right-wing talking points in pursuit of moderate votes – either among Democrats, or independents in the New Hampshire primary.
(Has anyone else raised this hypothesis? Just kidding...)
Given his positioning options, I don’t think Obama had any other choice than to adopt the moderate, post-partisan positioning he has, so it is hard to hold his overall strategy against him.
My beef started when his campaign got too clever by half in putting together a tactical battle plan – and then failed to recognize (or, perhaps, care about) how choosing questionable means would sell out noble ends (which I have no doubt Obama has).
With specific respect to healthcare, somewhere along the line, someone on his campaign recognized that on January 1, 2008 a requirement would kick in that everyone in Massachusetts have health insurance. Given the way Boston media dominates in New Hampshire, there was bound to be a decent amount of attention to the subject, perhaps with some indignant carping among the small minority for whom this causes irritation.
Even before passing the new "landmark" law, Massachusetts had the highest proportion of covered people in the nation – around 95%. So it is a small minority for whom it is even a potential issue. Given the compromises required to pass the law under a Republican governor, its hard to argue that the state has not provided reasonable options to people.
To be sure, the Massachusetts law was Romney’s riff on Medicare Part D (which in turn was the Republican Congress’s riff on the original Hillarycare proposal back in the early 1990s). It was the way that the Romney Administration framed this state-level healthcare reform effort – from a wingnut perspective – in the first place that even makes the carping about the "mandate" a possibility now.
In any case, with the extra focus on this requirement right on the eve of the primary – well, what a great opportunity to leverage the publicity the issue could attract to win over some New Hampshire independents (among whom any flavor of "big-government is coming to get you" paranoia still plays reasonably well)?
2. Weapon – the origins of carping about "mandates"
Of course, the whole origin of carping about mandates goes back to a right-wing effort in the late 1980s and early 1990s to reframe their radical anti-regulatory agenda.
"Unfunded mandates" and "takings" were two of the focus-group tested messaging hooks that the right came up with to oppose all variety of zoning laws, environmental regulations, consumer protection regulations, health & safety standards, etc.
Without getting side-tracked into all the damage done by these highly "successful" initiatives, let’s just recognize that the very language of "mandates" comes from the extensive focus-group testing of evil people looking to hide a radical right-wing agenda behind "common-sense" framing and terms that would slide more easily past the less-well-informed.
(Out of curiosity, who thinks Obama doesn't understand the history associated with this term?)
3. Fallout – how the bogus "mandates" debate poisons the chances of reform down the road
Healthcare reform works politically when it is framed as a fundamental right – a right not of employment (the way the left, unfortunately, framed it three generations ago), but a fundamental right of citizenship.
The right of citizenship perspective should be our explicit, or implicit, core framing every time we open our mouths. It axiomatically frames the core challenge as universal coverage – which is a critical attribute of needed reforms, and probably the one that will be hardest to achieve.
By making a big to-do about mandates, Obama has shifted the discussion away from one about securing a right of citizenship. Instead, he’s recasting it as a technocratic debate about the tedious particulars of insurance mechanics.
Which is your stronger impulse when considering the mechanics of insurance?
A. To wince in pain
B. To completely zone out
How many voters do you think want to wrestle with the details?
But Obama has implicitly argued that, unfortunately, the debate needs to go there because – look out New Hampshire independents! – there’s a big threat of a faceless bureaucracy loading you down with new, expensive obligations!
In other words, New Hampshire: Live free or die!
(Live free and die?)
Its seedy politics. But the really big, outrageous problem is the issue of mandates would be an utterly bogus issue if we got anything like the kind of reform we really need.
Let’s shift the debate back to the more appropriate framing (a right of citizenship) with a pop quiz about how we finance healthcare for the elderly – the group for which healthcare has become a right of citizenship.
Q: Who do you think pays for Medicare Part D, the prescription drug coverage for seniors?
A: The beneficiaries, through their monthly premiums? Please.
You do. (Assuming you pay taxes.) That’s right you.
The traditional split of user premiums and "general funds" (i.e., your tax dollars) for Part D (and Medicare Part B, the physician, outpatient, lab test etc. component) is about 25% / 75% – that is, we taxpayers pay the 75%.
Let me repeat: most of Medicare Part D – outrageous administrative fees, windfall-billion-dollar subsidies to employers who were previously financing retiree drug coverage on their own, obscenely overpriced drugs, and all – is paid for by you and me through regular old taxes.
For Medicare Part A, the hospital part of Medicare, most of the financing comes from payroll taxes – you again! – 81% in this case.
To be sure, though, seniors do have to pay some premiums for Medicare. Premiums to enroll in Medicare Part D average something like $30 a month (unless you are one of the ~8 million or so people – about 1/3 of total enrollment – who get their premiums subsidized), and there are also deductibles and copays for medications under most plans.
As a thought experiment, what would Obama’s position be on Medicare Part D premiums and copays? That we must liberate our seniors from these vicious Medicare Part D mandates?
To be sure, eliminating premiums would actually be fine with me – it would remove the false impression that premiums pay for a significant portion of the cost. We could finance this for a long time by skipping just one or two of the idiotic supplemental spending bills (that Congressional Dems supposedly oppose) that we keep passing to extend our futile occupation of Iraq.
By the way, the mechanism Part D includes to try to drive enrollment and avoid adverse selection / free rider problems is to ratchet up the costs of premiums a few percent for every month seniors delay enrollment after they become eligible. Outrageous?
For healthcare reform to really work and provide meaningful coverage at reasonable administrative fees, it has to be a government program financed largely from existing revenue streams – like Medicare. To the extent that the healthcare reform debate even strays to discussion of "mandates" –- suggesting that reform will automatically create a dilemma of requiring individuals to pay extra, new hefty premiums out of pocket -– we’ve already lost a major battle.
Major healthcare insurance programs – in this country and others – are financed mainly out of payroll taxes and general funds – consistent with recognizing healthcare as a right of citizenship.
Furthermore, there is good reason that critics of Medicare Part D refer to the MMA authorizing legislation -- technically the "Medicare Modernization Act" -- as the "Middleman Multiplication Act." We pay far more (as it turns out, for incompetent privatized bureaucracy) than do taxpayers in countries that have better approaches.
Which kind of brings us back to motive. In the narrow tactical sense, we can reverse-engineer why Obama has launched the mandate gambit. But how does his campaign not recognize the broader implications for the reform debate yet to come?
A quick Google search on key terms suggests some possible additional dynamics:
According to award-winning columnist Derrick Z. Jackson: "The hold of the healthcare industry on the top candidates is already apparent." According to the Center for Responsive Politics, the top recipient of campaign contributions so far from the pharmaceutical and health products industry is Republican Mitt Romney ($228,260). But the next two are Democrats Barack Obama ($161,124) and Hillary Clinton ($146,000). The top recipient of contributions from health professionals is Clinton ($990,611). Romney is second at $806,837, and Obama third at $748,637.
The Globe column also noted that the top recipient of cash from the insurance industry, which includes health insurers, is another Democrat, Connecticut's Christopher Dodd, at $605,950. Romney and Republican Rudolph Giuliani are second and third, with Clinton and Obama fourth and fifth. Even though Obama is in fifth place, he still has collected $269,750 from individuals with ties to insurance companies.
I guess its only pragmatic, post-partisan politics to recognize that providing universal coverage necessarily requires paying off private sector insurance companies to not oppose the new scheme, and to allow them to milk taxpayers in perpetuity as a tribute for their tolerance.
Summary Argument
Our healthcare reform fight should be about delivering fundamental rights and setting fundamental priorities.
When a bogus discussion of mandates becomes a big part of the debate, we’ve already backslid toward oblivion:
- By reframing the discussion as a technocratic debate
- By specifically, implicitly assuming that some off-budget, out-of-pocket-premium-based financing (a mechanism unlike Medicare, and unlike Medicaid, for that matter) is the implicit answer of choice
- By leveraging and extending a pernicious Republican code-language that has already helped enable extensive damage to individual and community protections – that is, even using a "mandates" attack further validates the language and the overall frame that we somehow need to resist intrusive government in the sphere of providing things like healthcare. (Worrying about intrusive government in the context of illegal surveillance is another matter.)
- By specifically market testing and establishing the mandate argument, I guarantee we will hear it again as healthcare reform gets viciously transformed into Frankenstein’s monster by its enemies in 2009.
Regardless of what happens in Iowa or New Hampshire, for shifting the energy of the healthcare reform discussion into a debate about "mandates," I’m sure all those opposed to healthcare reform would like to (secretly) thank Mr. Obama. He’s already delivered them a victory in helping to cement a narrow scope of debate about reform – essentially reducing discussion of expanded coverage to something people will have to pay for separately, with extra money out of their own pockets – and gee, wouldn’t that have to therefore be optional (undermining the actuarial logic of insurance, and opening up a free-rider problem – a topic others have covered well elsewhere)? – rather than something people get as citizens for what they already pay in taxes (like Medicare coverage – about 75-80% of every dollar, anyway – already is).
Obama's campaign has also weakened the apparent broad consensus behind the general acknowledgment of universal coverage as a goal of reform -- this type of doubt-instillment was also a significant part of defeating Hillarycare 15 years ago (recall the efficacy of the famous Harry and Louise in seeding doubt about the whole thing).
Narrowing the scope of the reform discussion is a key step in ultimately scuttling meaningful reform – which we all agree is the clear objective our opponents. (Of course, opponents to reform would happily "sit at the table" and have big checks shoved into their pockets to provide crap coverage at inflated prices with obscene administrative fees, if we as a nation want to go that way; I'm not sure the Chinese will be willing to finance that one.)
To be sure, other campaigns have made similar mistakes in the overall framing of their healthcare proposals. But the Obama campaign has done the most to create fissures in the generic reform proposals and principles around which there previously seemed to be clear consensus, and, in the process, to undermine the prospects of meaningful achievement, overall -- whether its under his administration or someone else's.
I hope Mr. Obama takes satisfaction in the votes of any of the New Hampshire independents he’s pitching to with the "mandate" crap. (And – hey – note to the campaign: be sure to give your pollsters and political consultants a bonus if enough of those independents show up to make a difference next week!).