The Health-Care Time Warp

For all the partisan back-and-forth over the measures Barack Obama has taken to address the economic crisis, the biggest battle of his first term -- and the one that could determine whether he gets a second -- is just now ramping up. If Obama can reform this disaster of a health-care system and do what Bill Clinton couldn't, then his place in history will be assured. It already appears that the administration has studied the failures of 1993. But what will really determine health care's outcome is what reform opponents do, and the contours of their campaign are starting to take shape.

To put it simply: Republicans hope to kill Obama's health-care reform, just like they killed Clinton's 15 years ago, and their current playbook looks remarkably similar to the old one. But they have some serious weaknesses that they didn't suffer from the last time around.

In 1993, the Republicans were unified under a single congressional leader -- Newt Gingrich -- and a single, simple strategy: oppose, oppose, oppose. There was no question who was giving orders, and no question what those orders were. Furthermore, they had a strong and unified business community behind them, with the representatives of big business (like the Chamber of Commerce and the National Association of Manufacturers) and representatives of small business (like the National Federation of Independent Business) firmly committed to destroying the Clinton plan. The insurance industry paid for the infamous "Harry and Louise" ads, which featured a couple expressing their fears that the Clinton plan would take away their choice in doctors, raise their premiums, slash their tires, kill their dog, and herd them into an Arkansas gulag (just about, anyway). In the end, the plan didn't even come to a vote in Congress.

But things are different today. The GOP is leaderless, and the business community seems far less likely to mount a scorched-earth campaign against the Obama plan. Presently, the opposition is almost silent -- the only group airing ads against reform is Conservatives for Patients' Rights, the creation of Rick Scott, the disgraced former chief of the hospital corporation Columbia/HCA. Scott is evidently egotistical and stupid enough to put himself in the ads, thereby making it easy to reframe the issue around him, as a progressive group gleefully did in their own response ad. Obama is no doubt hoping that he will continue to be blessed with such enemies.

Not that the insurance industry and its allies are going to roll over without a fight. As is becoming clearer by the day, the big conflict will be over whether the bill that emerges will contain a public option, a government insurance plan open to anyone who wants to join it.

As I've noted before, the insurance companies' great fear is that the public option will actually work. They are terrified that it will offer good coverage at good prices, and therefore many Americans will choose to enroll in it instead of giving their business to the insurance industry. Like lots of progressives, the industry believes that the public option could be the single-payer camel's nose under the health-care tent. If the program really works as it could, more and more people will choose it, until the day eventually comes when all Americans have government health care. Whether you think this would be a blessing or a curse depends on whether you're an American who wants health security, or an insurance company that wants to maintain its profits.

But everyone will at least be pretending to want reform, just as they did in 1993. That year, William Kristol, conservative man-about-town, wrote a memo to Republicans that has become a kind of Rosetta Stone of the GOP health-care victory. In it, Kristol warned against any compromise:

The Clinton plan is … a serious political threat to the Republican Party. Republicans must therefore clearly understand the political strategy implicit in the Clinton plan -- and then adopt an aggressive and uncompromising counterstrategy designed to delegitimize the proposal and defeat its partisan purpose. … [Passage of the Clinton plan] will relegitimize middle-class dependence for 'security' on government spending and regulation. It will revive the reputation of the party that spends and regulates, the Democrats, as the generous protector of middle-class interests. And it will at the same time strike a punishing blow against Republican claims to defend the middle class by restraining government. … The first step in that process must be the unqualified political defeat of the Clinton health-care proposal.

The 2008 version of the Kristol memo comes from GOP word meister Frank Luntz, who recently emerged from a series of focus groups with a message for Republicans that looks remarkably similar to Kristol's advice. "You simply MUST be vocally and passionately on the side of reform," Luntz writes in his memo. "The status quo is no longer acceptable. If the dynamic becomes 'President Obama is on the side of reform and Republicans are against it,' then the battle is lost and every word in this document is useless." (All bolding, underlining, and italics in original -- subtlety is not Luntz's style.) The rest of the document is about ways to attack whatever plan the Democrats offer, featuring Luntz's signature "Words that Work" boxes and heaping portions of baloney.

In the coming days, whenever you hear Republicans warning against "a government takeover of health care," and "politicians getting between you and your doctor," rest assured they're reading Luntz's talking points. Luntz notes the unpopularity of insurance companies, so he advises Republicans to "call the Democratic plan a 'bailout for the insurance industry.'" Perhaps the Republicans could use some of the $25 million in campaign contributions they got from the insurance industry last year to run ads to that effect.

Luntz's main point is that Republicans should attack the eventual Democratic plan by talking about government bureaucrats or politicians denying you care. This argument is deeply, deeply stupid, since it presumes that in the current system, no bureaucrat ever makes a decision to deny someone care. Of course they do, thousands of times every day -- only these bureaucrats work for insurance companies. But the fact that an argument is ridiculous has always been little hindrance in American politics.

If you want to see Luntz's recommendations put into practice, you can read a column Sen. Jim DeMint, a Republican from South Carolina, penned for National Review last week. It's got all the Luntz catchphrases, like "patient-centered solutions" and "politicians and bureaucrats in Washington," not to mention scary visions of people with metastasizing cancer dying on government waiting lists (I kid you not).

If there's anything encouraging in this debate as it unfolds, it's that the conservative arguments against the public option -- where the most heated battle will be fought -- look decidedly weak. As Luntz notes correctly, the most persuasive arguments on either side do not concern the system but are instead personalized. In 1993, Kristol wrote, "The target of Republican policy prescriptions must be the individual citizen, not some abstract 'system' in need of ham-fisted government repair." And in 2009, Luntz writes repeatedly, "Abandon all references to the 'healthcare system'." The right has its systemic arguments about the public option -- that it will hurt insurance companies or that it will drive down doctors' incomes -- but conservatives run into a brick wall at the word "option." They could say that the plan will stink if you're in it -- but no one is going to be forced to enroll. I think I speak for a lot of people when I say that if there were a government plan available, I'd choose it over private insurance in a heartbeat. Maybe you wouldn't, but that's what's appealing about choice -- if you want to put yourself in the insurance company's hands, be my guest.

So Republicans are left to argue that the option isn't really an option. It'll work so well that everyone in America will choose it, insurance companies will be driven out of business, and then there won't be any option. See the problem with that argument?

The health care debate is just getting started, and it’s perfectly possible that the insurance companies, hospital companies, and business lobbies will get their act together and unify to kill the Obama plan. Witnessing the health care industry's recent dance with the president over whether they will commit to cost savings in coming years, the always level-headed Kevin Drum of Mother Jones said, “These guys are never going to be partners in any kind of real reform of healthcare. Never. Beneath the smiles and the photo-ops, I sure hope the Obama team understands this.” And what do you know – just yesterday we found out that North Carolina Blue Cross/Blue Shield is preparing a set of disingenuous ads trying to frighten people into opposing the inclusion of the public option.

The outcome of the health care reform battle will turn on whether the administration is prepared to overcome the opponents of reform – not reach out to them, not listen to them, not understand them, not compromise with them, but overcome them.

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