Glenn Greenwald wrote a very good post on whether the Rahm healthcare strategy, "to ignore the demands of progressives on the ground that they would fall into line at the end no matter what," has been vindicated by the outcome of the health reform debate.
For almost a full year, scores of progressive House members vowed -- publicly and unequivocally -- that they would never support a health care bill without a robust public option. They collectively accepted hundreds of thousands of dollars based on this pledge. Up until a few weeks ago, many progressive opinion leaders -- such as Moulitsas, Howard Dean, Keith Olbermann and many others -- were insisting that the Senate bill was worse than the status quo and should be defeated. But now? All of those progressives House members are doing exactly what they swore they would never do -- vote for a health care bill with no public option -- and virtually every progressive opinion leader is not only now supportive of the bill, but vehemently so. In other words, exactly what Rahm said would happen -- ignore the progressives, we don't need to give them anything because they'll get into line -- is exactly what happened. How is that not vindication?
I want to be clear here: I'm not criticizing progressives who support this bill, nor am I criticizing those who insisted they would oppose it but changed their minds at the end. Unlike many progressives, I was never among those who advocated for this bill's defeat because, as loathsome and even dangerous as I find the bill's corporatist framework to be (mandating that citizens buy the products of the private health insurance industry), I've found it very difficult (as I said all along) to oppose a bill that results in greater health care coverage for millions of currently uninsured people. Whether progressives are doing the right thing in supporting this bill is debatable (there's a strong progressive case for the bill -- any bill that restricts industry abuses and vastly expands coverage is inherently progressive -- and a strong progressive case that it does more harm than good), but that's a completely separate question from the one raised by Smith.
What's not debatable is that this process highlighted -- and worsened -- the virtually complete powerlessness of the Left and progressives generally in Washington. If you were in Washington negotiating a bill, would you take seriously the threats of progressive House members in the future that they will withhold support for a Party-endorsed bill if their demands for improvements are not met? Of course not. No rational person would.
That's the dilemma plenty of progressives, myself included, face--seeing the serious problems with this bill--the mandate in absence of a public option, the very real rollback of reproductive rights for women, the lack of effective cost controls on pharmaceuticals and device makers and hospitals, the fact that it doesn't provide universal care--it provides access to insurance to citizens, leaving out millions of undocumented workers who won't even be able to spend their own money on insurance, should they care to.
In short, there are a tremendous number of trade-offs for a bill that doesn't reach system healthcare reform, that settles for insurance reform that is lacking the most effective element--significant competition. Way back last summer, Obama shifted his rhetoric on this bill to call it insurance reform, a key shift that signaled that the kind of comprehensive system reform many were looking for wasn't in the offing. Nonetheless, like Glenn, I can't bring myself to advocate for its defeat because the very effort at trying to curb health insurance industry abuses and expand coverage is progressive, and there's little hope that we can argue effectively for more and better reform if this one doesn't pass.
At the same time, though, trying to argue that the provisions in this bill signify a progressive victory is from my perspective, a negotiating mistake. There are some improvements to this bill over the Senate bill achieved by the House--and by labor--that should be recognized and appreciated, but I think it's worth noting that little that was added came from either the progressive caucus in the House or certainly from progressive activists, and that we really don't have laurels to rest upon if we want to keep fighting for real reform.
Some of these improvements: the expansion of Medicaid, a very necessary development given the rough economic time states are still having, happened because Nelson and Reid blundered so fantastically with the Nebraska deal, and had to find a way out. Bernie Sanders increased funding for community health centers is another significant addition, but he did that pretty much on his own with some smart negotiating that didn't include the activist community. His state waiver provision which could theoretically allow states to set up single payer is actually a bit of a double-edged sword--the ERISA waiver that would be necessary to allow states to do this wasn't included in Sander's provision, and it's not yet clear whether it's in the reconciliation package. What's more, that same provision was written loosely enough to allow states to also opt-out of Medicaid and Medicare, waivers that Republican governors might be able to get out of an HHS in the next Republican administration (counting on Dems to hold the WH for the next few decades isn't a safe bet).
For those who were looking for systemic, comprehensive health care reform, we didn't get it. Ending insurance company abuses is absolutely vital, and those provisions very important, but have to be enforced. The exchanges might provide a start for that enforcement, but that's a limited "might." The exchanges are going to be state-based, not national. Right now we're gambling on them to create real competition and some sort of structure for real regulation and oversight of the insurers. But that's going to be relying in large part on elected state insurance commissioners, and federal regulation writers. The Senate bill is written loosely enough to allow for regs to pick up some of the slack and for a significant HHS role, but again, that's something that the next Republican administration can undo.
I'd argue that it's bad politically and for future policy efforts for progressives to lose sight of the fact that we had some pretty big losses in this one. Who lost? Labor, though the excise tax is better, it's still there. Single payer or public option advocates, obviously. Women. Hyde will be law now, and the fight taken beyond public funding to private insurance. Latinos. Undocumented workers can't spend their own money on insurance. And in the offing we went from 48 million uninsured to 31 million uninsured because we won't count the brown people. Despite the fact that from a systemic public health perspective, getting them care will still cost money because hospitals and emergency rooms will still be legally obligated to provide that care--as they should be.
In other words, the job isn't done with this bill. Is this a step forward? Yes, to the extent that now Congress sees it can do something about health reform. Should it be passed? Yes. Absolutely. Millions of people will now have access to coverage, and to care, that they do not have under the status quo. That's a societal good.
But if the deficiencies--and they are significant--are going to ever be fixed, we can't make the case for doing so by saying this is a progressive victory along the lines of Medicare or Social Security. It's just not. If, as progressives have been told and are now repeating, this bill is just the start to reform, we can't lose sight of exactly where it is we're starting, and what still needs to be fixed. Congressional progressives are already in a bad negotiating position for future fixes--when as Glenn argues they've already shown how easily they can be rolled--by not setting down markers now for what still needs to be fixed.