REALISTIC REASONS TO PLAY ALONG

I have a story line to share. It's fiction, but I think its ins and outs can be telling of our political system and its processes. Let us say the president is a woman – that a woman won the presidential sweepstakes back in 2008. She has a plan for a national healthcare program. It is one in which the national government copies a plan that already exists in one of the fifty states. That program calls on uninsured people to sign up for a health insurance plan by going online and seeing what private insurance programs have to offer. For people who can't afford any of the plans, there will be a subsidy provided by the federal government to help them pay their premiums. Adding to the appeal of this program is that it has been in effect for several years and works swimmingly well with the citizens of that state loving it. Also, the state plan was initially passed by a Democratically controlled legislature and signed into law by a Republican governor. That gives this program something very rare in our political environment: bipartisan backing. The fictional president, though, has several obstacles in nationalizing this state plan.

The first obstacle is from members of her own party. Her base support – that is, the support of her most committed backers – want a more government-controlled program. They want to extend, in effect, the existing national old age program (Medicare) so that it will be provided to the whole population. That is a program in which the government basically pays for all medical expenses (100% of hospital costs and 80% of doctors' fees) beyond minimal co-payments. It also mandates that all citizens must pay a healthcare tax that corresponds roughly to a modest insurance payment. This puts into the actuary pool people of all ages. By doing this, the pool will include people who are healthy, who happen to be the vast majority of the population. The resulting pool will, therefore, have enough money so that the expenses of the not so healthy can be covered. This is acceptable to the healthy because no one knows when one will change from being a healthy person to an ill person. By the way, this is the principle behind any health insurance program, private or public. This type of program relegates the middle men, the insurance companies, to a much reduced role and cuts back the fees they can charge. Therefore, for this and other reasons, healthcare becomes cheaper. The main objection to this program, though, is that this expands the intrusiveness of government in our healthcare system. At least, that is the concern of conservatives.

Short of this alternative is a mix between what the fictional president wants and what her base supporters want. That would be a program that mirrors the state program but offers, among the provided insurance choices, a “public option.” That is, the basic structure of the program is in line with what the president wants, but, in addition to all the private options, a person can choose a public option similar to the old age program. Again, this would probably be a program with fewer costs since it eliminates the private insurance companies when a person selects the public option. With fewer costs, the public option will have lower premiums and this would provide significant competition to the private options and, therefore, lower the overall costs of healthcare.

Up to now, this story sounds like what happened when Congress was considering healthcare a few years ago. At least, in its broad outline, it is what Representative Luis Gutierrez (D, IL) described the other day as being what was considered by President Obama.¹ But to return to my story line, there are three stated alternative approaches to reforming healthcare: private choices option (what the president wants and is aiming to have become law), the public option (what is a mix between what the president wants and what the president's party base wants), and single government payer option (what the president's party base wants). Our fictional president wants the private choice mainly because she knows there is a high degree of skepticism over the other two alternatives. The opposition party has been very successful in convincing people that any extensive role by government will have government determining what medical services will be available to people if either of these two options were to be put into effect. But beyond this obstacle, the president has another one. That is, she has an extremely hostile opposition party in Congress that, even though they don't have a majority in either chamber of Congress, they can still deny the president any ability to capture bipartisan support for any effort the president might attempt. Since this is such an important area of legislation, the president feels she must secure some opposition party votes in favor of any bill that would pass Congress.

So, and now we will vary from what actually happened; after consulting with her advisers, the president decides on the following strategy. The president will first, with much public fanfare, announce the administration's supposed healthcare position which is a single government payer plan. While this is not true – she is not aiming to get this plan through Congress – she makes the public argument for this option. She secures the support from key members of Congress who belong to the president's party. To some of these members, whom the president really trusts, she confides in them what the true strategy is and is about to be implemented. The president then calls a much publicized meeting which includes leaders from both parties to work out a national healthcare program. The opposition party members protest, but agree to attend. Since Americans want their government to address the fact that there are about 40 million Americans who can't afford health insurance and it is bad form to reject a presidential invitation, they agree to attend the meeting. There is also the added fact that everyone's health costs are being pushed higher than they should be since hospitals are passing on to other patients the costs of treatment for those who can't pay. These passed-on costs, on average, are costing the Americans an extra thousand dollars a year. In back rooms, the president's negotiators are able to talk a few key opposition members into supporting a plan that resembles the bipartisan program already existing in the one state mentioned above. They agree because the ideas for this program were initiated by conservatives and rely on private insurance companies competing for the uninsured people's business. But first, they are to propose and publicly insist that the administration adopt a set of provisions that are geared to lower health costs. One such provision would be to shift insurance markets from being organized at the state level to being organized at the national level. This would increase, they claim, more competition and lower insurance premiums.² When they do this, the administration balks, but states that instead of supporting the government payer plan, the president is willing to adopt the public option alternative. The opposition again publicly rejects that offer and holds that the administration should now adopt the existing state model in which private options are offered to people. All of these moves have been previously planned as public give and take between a few members of Congress from both parties and the president. The president agrees to this last offer and, in effect, gets what she initially wanted. While the president wins, she does so in such a way that everyone walks away with the ability to claim a victory. The nation has a national healthcare program, but it is a program that is based on ideas initially offered by conservative sources.

I hope you don't find the above story line as being too rambling a tale. The point is to illustrate an important aspect of our political processes and one that is probably part and parcel of any democratic system. That is, politics is made up of a lot of perceptions. I believe that one reason President Barack Obama has met with such opposition to his healthcare law has been the fact that it was passed with all Democratic votes in Congress. One can claim that the opposition, the Republicans, is mostly responsible for Democrats having to count on only their members to get a healthcare program. But from the Republican perspective, the President came up with the program and mostly jammed it down their throats. But if the President could have followed a scenario more in line with my storyline, then perhaps there could have been some Republican votes and those Republicans could have shared in some of the credit in passing legislation that finally provided healthcare to millions of Americans. Instead, Obama and the Democrats in Congress went it alone.

Some of you might be saying, he doesn't know what actually happened in the passing of healthcare – that there was a lot more involved with the actual events that led to the Affordable Care Act. Maybe I don't know all that went into that particular legislative process. After all, all negotiations do not happen in public. Perhaps what actually happened is the best we could have expected. I provide this story not so much to criticize the administration as to provide an alternative approach to policy making – one that illustrates potential give and take (even if staged) that can provide positive results for all involved. This might include some grandstanding, some staging, or some other manipulations to achieve what is politically possible. Is it an ideal scenario? Of course not, but it is a view that takes into account some less than ideal realities. As it is, while the Republicans ended up with a form of healthcare that reflected many of their stated principles, the way the law came about offered them few to no opportunities to claim credit. After all, they are in the business of selling themselves to the electorate as being worthy of credit and when that is deprived, they have no transactional reason to play along. And while it is common for people to expect a higher motivation on the part of their leaders, history tells us that on this account, they will probably be disappointed.

1The Representative gave this description during a meeting of the Judiciary Committee.

2It would also provide an incentive to all insurance companies to set up shop in the lowest regulated states.