I am not a big believer in universal health reform at the state level. For reasons I've outlined at length elsewhere, states tend to be too fiscally unstable to make such plans work. Even so, the proposal currently snaking its way through the California legislative process is an impressive feat of policy construction and political compromise -- and it may point toward the sort of coalition that can eventually be created for national reform.
The California proposal will, in its broad outlines, be familiar to anyone following the policy releases of the major Democratic campaigns (that is to say, approximately 13 of you). The plan is built around an individual mandate that forces most everyone to buy insurance; new regulations that end insurers' ability to price-discriminate based on preexisting conditions and health status; and a system of subsidies and tax credits to increase affordability. It also expands a range of public programs, institutes new cost-saving measures (like authorizing the state to purchase prescription drugs in bulk), requires that insurers spend 85 cents of every dollar on actual health-care services, creates a public insurance option able to compete with the private insurers, and much more (a detailed analysis of the legislation can be found here). It even -- and admirably -- avoids easy demagoguery, refusing to deny care to the children of undocumented immigrants.
On some level, though, the actual policy is less interesting than the political compromises and coalitions pushing it toward viability. The impetus for the process required executive leadership: Gov. Arnold Schwarzenegger -- and yes, it's still weird, as a Californian, to type that -- made health care a top priority and kept pushing it forward. Months of negotiations with the California Assembly, notably with Speaker Fabian Nunez, produced legislation that accorded with the principles of Schwarzenegger's early offerings but allayed Democratic reservations about subsidy levels and the need to raise money through taxing business. Unsurprisingly, the need to raise money at all, for anything, ever, formed the basis of the state Republicans' implacable opposition. And because, in California, new taxes require a two-thirds majority, the legislature disentangled the financing component and made it a ballot measure that the populace will directly vote on in November 2008. So all the Assembly had to pass was the basic structure of the bill, which it did yesterday, on a party line vote of 46-to-31.
To reach implementation, the bill will still have to clear the Senate and the financing will have to win on the ballot. Supporters expect pretty significant efforts by industry stakeholders to derail both steps. But, unlike the national health-care reform effort of 1994, a coalition of supporters is actually committed to aiding the legislation's passage. It includes not only the usual suspects like SEIU, CalPIRG, AFCSME, the Children's Defense Fund, and AARP, but also corporate backers like Safeway stores and (mainly nonprofit) insurance companies like Kaiser Permanente and Blue Shield. So not only is labor on board but reformers have managed to peel off high-profile backers from the corporate community and the insurance industry, splitting groups who have, in the past, proven united in opposition to reform and ensuring that obstruction will not merely be the default position for the state's stakeholders.
This has given California's reforms a fighting chance. And the national implications are considerable. The Clinton administration's 1994 efforts lacked Schwarzenegger's intense collaboration with the legislature and forward-looking coalition building. Any successful reprise will have to include them prominently. But the national stage lacks the ballot initiative option: If a sufficient number of senators decide to filibuster, there's no way to reroute the legislation into one portion that simply requires a majority and another that goes directly to the people.
Or is there? (Without getting deep into discussion over budget reconciliation strategies, many health wonks believe it's possible to force budgetary matters in a straight up-or-down vote, bypassing the filibuster. But in the past, Sen. Robert Byrd has disallowed the strategy.) The actual theory behind the ballot initiative process is applicable to national health reform. Americans don't vote on legislation, but they can pressure legislators. Reagan understood that in 1983, when he exhorted voters to flood their congressmen's offices with calls and letters in favor of his tax cuts. The people did as Reagan asked, and few congressmen dared deny their wishes. Conversely, the 1994 health reforms were an inside strategy that relied on cutting a deal with senators of goodwill, not channeling public sentiment to pressure them into support. Indeed, it was quite the opposite, as the anti-reform forces channeled public sentiment to unsettle supporters.
A candidate who uses the 2008 election to build public support and enthusiasm for health reform could deploy an outside-in strategy for forcing congressional cooperation, ensuring that obstructionist senators, and there are a lot of them these days, understand that though the people could not vote for the legislation, every effort would be made to ensure they vote against those who blocked it. John Edwards has suggested that this will be his strategy, and it could be a wise one. If you can't make the people your Congress, as Schwarzenegger is doing in California, you can still remind the Congress of its accountability to the people.
