Earlier tonight a reader wrote to ask me to post some thoughts after the vote. My head is swimming—partly due to a case of the flu—so I don’t know if I can cover everything in one post.
To be honest, I’m not sure that my fevered brain can come up with words sufficient to the occasion. Ted Kennedy wrote before his death that universal health insurance was the major piece of unfinished work of our society. I have always agreed. One can certainly debate the appropriate scope of the modern welfare state, but I would argue that health insurance is a foundational part of it. It’s been clear for some time that the private health insurance market was going to collapse without significant reform and that this reform could not be pursued apart from efforts to reform our existing public insurance programs and transform our health care delivery system. Today’s legislation will not solve all the problems we face in health care, but it goes a long way toward solving the most important ones.
I also need to say for the record that I was wrong. I wrote a post in January where I said that health care reform had—once again—been defeated. I wrote that in the midst of the Democratic strategic meltdown in the wake of the Massachusetts Senate election. Based on my past experience, I thought the legislative window had closed. I was wrong.
It’s pretty clear that a significant amount of the credit for keeping the window open goes to Nancy Pelosi. From all accounts, some of President Obama’s chief advisors were advising that he start over with a more incremental bill. Pelosi argued with the White House in favor of a comprehensive approach and argued with her own caucus members who deeply disliked the Senate bill.
I would also say that—ironically—some of the credit for keeping the window open belongs to the Republicans. Their unified and unyielding opposition to any serious reform legislation convinced many moderate and conservative Democrats that the Republicans simply weren’t serious about reform. If even a few Republicans had been willing to break ranks—either last summer or after the January Senate election—they could have convinced enough moderate and conservative Democrats to embrace less sweeping legislation. The Republicans are hoping to be vindicated in the November elections, but there is no question they have suffered a stunning legislative defeat.
The historical irony of this is that—in many ways—this is a very Republican bill. Many of the elements of this bill—health exchanges, individual mandates, subsidies, etc—were embraced by President George Bush during the 1992 presidential race. While the financing is public, the delivery system and the insurance system remain private and the bill tries to leverage consumer choice and market forces to improve cost and quality.
There is a lot of implementation work that needs to get done now. One of the challenges the new law will face is that there are a lot of moving parts—setting up the exchanges, setting up the structure to administer the subsidies, getting rolling on the various Medicare pilot programs on delivery system reform. There is a lot of anxiety out there, so public education is going to be a critical component.
Nor are the politics completely over. I don’t think repeal is an idea with serious legs, but a number of Republicans plan to run in November on it. There will also be a number of court challenges, particularly on some of these state laws that have been passed to “nullify” certain aspects of reform. I tend to think that issue was settled at Appomattox 150 years ago, but the possibility of an activist decision from the Roberts court cannot be completely ruled out.
There are two people who are in my thoughts tonight who have gone to the Lord and who I wished were around to see this. The first is a guy named Bert Seidman, who was for many years the Director of Employee Benefits at the AFL-CIO. By the time I got to DC, Bert had retired and was serving as an advisor cum organizer for the National Council of Senior Citizens. Bert had been working on health care going back to the Truman Administration and had lived through many failed attempts at health care reform. After reform went down to defeat in 1994, I thought of Bert a lot. I figured that if Bert could keep working for this after so many failed attempts, I shouldn’t complain. Bert died in 2004.
The second person who is in my thoughts is the woman who first got me interested in health care, Peggy Connerton who was Director of Public Policy at the Service Employees International Union. She hired me right out of graduate school in 1993. The funny thing is that she promised me that I’d be able to work on policy issues other than health care, which was not my major interest at the time. Peggy was a little economical with the truth there, because I was swiftly swept up into the campaign for health care reform and there was little time for anything else. But I had the time of my life travelling around the country, going to the White House for meetings, and writing reams and reams of Congressional testimony and briefing papers. I would not be working in health care today if not for that experience. Peggy was diagnosed with breast cancer in 1995. She died only three years later, and it was hard to lose someone who had been both a mentor and a friend.
So Peggy and Bert, this one’s for you. You were footsoldiers in America’s army of conscience. We couldn’t have done what we did tonight without you.