[Note: The current HCR debate has gotten so contentious within the various 'liberal/progressive' factions that it felt important to me to amplify my position about the importance of breaking through this first barrier with an imperfect bill, and why I believe the prospects for improving it over time are stronger, not weaker, if this bill passes.]
Enacting health care legislation is like threading 3-ply thread through a tiny needle eye
In the days before the filibuster was abused with regularity, Hubert Humphrey counted the number of obstacles before a bill became law. His conservative total was 28. At any one of those 28 intersections, it could die. In fact, most do. They die because someone wants something they didn’t get, or because there’s just a fundamental philosophical difference that can’t be surmounted. When a bipartisan effort is impossible, the odds of death increase exponentially. Humphrey went on to observe this: “At each stage of the legislative highway, a few legislators lurk, like the pirates of Tripoli and take toll of the passing traffic…”
When the legislation being contemplated is major, groundbreaking social legislation that has met a stone wall of opposition for 82 years by the same institutions over and over and over again, multiply the number of obstacles by a factor of 10, and figure there’s an armada of pirates waiting to ambush.
Incremental progress lays a pathway to the goal
Looking at the progress made from 1960-1965 when Medicare finally became law is instructive, too. Everyone thinks Lyndon Johnson introduced Medicare in January and strong-armed it through by July. In fact, it progressed in incremental fragments between 1960 and 1965. President Johnson had three extraordinary circumstances on his side: sentiment, an overwhelming supermajority, and public fervor and engagement stoked over five frustrating years of effort.
1960-1965, under the magnifying glass
A bit more detail about how things progressed. I mentioned in Part 3 that insurance covering hospital, medical and nursing home expenses for the elderly had withstood a Senate vote, but not a House vote. Drilling down, I see a pathway remarkably parallel to the one we’re on now.
I. The House
- March, 1960 – Pressure mounts for the Forand bill (integration of Social Security and medical/surgical/hospital/nursing home benefits for the elderly) to be reported out of the House Ways and Means committee. It is an election year, and all Democratic candidates have endorsed the Medicare/Social Security approach to covering medical expenses of the elderly. President Eisenhower initially opposes this approach, pivots toward it, then backs away again. As a countermeasure, the administration proposes federal grants to states to subsidize private insurance premiums for the low-income elderly.
- March, 1960 – The House Ways and Means Committee is forced via procedural maneuver to an up or down vote on the Forand bill. It fails by a 2-1 margin and does not leave the committee.
- April-June, 1960 – With public pressure mounting, House Speaker Rayburn and Senate Majority Leader Johnson take a united stand for the principles in the Forand bill: that health benefits should be an integrated part of Social Security.
- April-June, 1960 – Public pressure continued to build. There were public rallies, mail campaigns to Congressmen, a great deal of public discussion and media attention in a high-profile election year.
- June, 1960 – As public pressure intensified, Wilbur Mills tried to find a middle ground. His first proposal was to give seniors an opt-in choice: higher monthly Social Security payments or medical and pension, combined. That idea was rejected. Republicans proposed an additional allocation to states for subsidizing private insurance. That idea was rejected. Finally, after working to get the AMA to agree, he settled on a plan that would expand vendor payments under the current state-run public assistance program. He proposed to create a category called “medical indigency” and was intended to help those who were not on welfare, but couldn’t afford their medical bills.
From the Social Security history site, this step-through of the politics is instructive:
From the point of view of the members of Congress, the Mills plan had several merits: It was more modest in cost and scope than either the Forand bill or the Republican “subsidy” plan; from a technical standpoint it was a logical first step; it was a “Democratic bill” in a Democratic Congress and was sponsored by the respected Ways and Means Committee chairman; and, not least, it had the backing of the AMA.
In other words, a coalition could be built around a bill that fell far short of the goal but was still a victory. An incremental one, but nevertheless, a victory. It passed the House 381-23.
Much more maneuvering took place in the Senate committees.
- June, 1960 – First, the Senate modified the Mills bill to allow the proponents of the Social Security/Health Insurance approach to add their measure as an amendment to the now-dubbed Kerr-Mills bill.
- August, 1960 – In late August, candidates Nixon and Kennedy attended a session of the Senate where all three approaches were put to a vote. Nixon argued for the Republican “subsidy plan”. JFK argued for the “social security approach”. A third group of Democrats coalesced around the Kerr-Mills bill (expanded vendor payments).
- August 23, 1960 – The Republican “subsidy plan” falls on a strictly partisan vote, 67-28. The Social Security plan was defeated by Senator Kerr and the third group of Democrats 44-51. The final bill to be voted on was the Kerr-Mills bill for expanded vendor payments. It passed 91-2 and was signed into law on September 13, 1960.
Medicare’s defeat, Round 1
Fast forward to 1961. JFK is in office, is popular, but is dealing with a mild recession, some legislative setbacks, and an increasingly vocal and organized opposition to Medicare. Kennedy’s margin of victory was far smaller than previous Democratic presidents, causing Democrats to lose 20 seats in the House. Even with a Democratic majority, he could not get the votes in the House to move ahead with Medicare in those circumstances, either in the Ways and Means committee or the full House of Representatives. Faced with that reality, Medicare is pushed back on the agenda to the midterm elections of 1962.
Meanwhile, opposition to Medicare hardens. The AMA is organized; a political action committee established, and commercial life and health carriers align with the AMA and US Chamber of Commerce. On the other side, organized labor was pressuring for Medicare, reaching out to doctors and practitioners to unite with them, while other Democrats were reaching out to the elderly and helping them get organized.
In 1962, President Kennedy begins a major push for the passage of Medicare. From the Social Security history site:
The President was said to have concluded that the issue was popular with the voters (Gallup polls showed public support running as high as 69 percent); in the fall campaign, the President was expected to make Medicare his “cutting edge issue”– the symbol of his whole New Frontier program.
In the House Ways and Means committee, negotiations were taking place around eligibility and the question of what contribution seniors would make for premiums. There were differences between the administration and the committee as to the disposition of the Kerr-Mills program, benefits covered, and qualification for benefits.
In the streets, opponents of Medicare accused the administration of using senior citizens for partisan politics rather than sincere social legislation. Terms like “propaganda blitz”, “looting the Treasury” were used routinely by spokesmen for the AMA and insurance companies. Direct mail campaigns were in full swing against it. Despite the President’s appearance at rallies with senior citizens and the still-strong public support, the vote was close.
Medicare was defeated in the Senate on July 17th by two votes: 52-48.
Watch what happened next
In the wake of the 1962 Senate defeat, Medicare partisans, searching for scapegoats, fell to fighting among themselves. Some became pessimistic and concluded that Medicare was a lost cause. Others, especially those who were closely involved, viewed the setback as only temporary; as the months went by, the arguments in favor of Medicare were growing stronger.
As time went by, insurers were beginning to see the wisdom of a government program. After they had created special products to accomodate the elderly, they were feeling the pinch of adverse selection. Support was growing in Congress, and the successful end to the Cuban missile crisis gave Democrats a gain of 4 in the Senate.
But in 1963, Medicare took a back seat to growing civil rights unrest.
And then President Kennedy was assassinated. Amidst a national tragedy, legislative resolve hardened to finish his legislative agenda. When 1965 came around, the votes, the will, and the people were in place to push Medicare into being.
The parallels between the early 1960s and today are clear. The same arguments, the same rhetoric, the same opposition, and the same climate exists today. Add to that a deep recession, the likes of which we haven’t seen since the 1930s, the race factor as it relates not to a civil rights debate, but the nature of our President, and the same entrenched monied interests. It’s not hard to understand why the public option became the sacrifice, nor why a national single payer system wasn’t put on the table at all.
I do not believe there is a more incendiary issue than health care in the universe of social legislation or progress, nor do I believe we can afford to ignore the leap into the future the current legislation represents. Unlike the weak and ineffective Kerr-Mills bill that covered about 88,000 people at its apex, this bill will break the pre-existing conditions barrier and establish a right for all to have access.
When Dennis Kucinich is villified for seeing and accepting political reality; when those of us who have studied the progress of legislation like this are called cowards and in-name Democrats, the larger lesson is lost. Without breaking the first barrier, there is no prospect for reaching the goal.
Alan Grayson has begun Phase II of the reform process, by introducing a bill on the House floor permitting anyone to opt into Medicare (and pay for it). He has further qualified his proposal as an “unsubsidized option”, so that anyone choosing this option will not be eligible for the subsidies given to those buying private insurance.
What progressives need to understand is this: If the current legislation fails, there is no prospect or pathway toward their larger goal. If this bill passes, we’ve established the right to health care. A door opens. Alan Grayson has extended an invitation for Congress to take the next step. Just as in 1962, this will coincide with midterm elections. Democrats, Liberals, progressives, socialists, and all others on the left need to look at how Medicare progressed. Let’s take out the national tragedy part and figure out how, after this bill passes, public support and energy can focus to elect representatives who will stand with him and agree to his proposal.
Right now, we’re on square 28 of the first round of health care reform. Alan Grayson proposes to move us to square 1 of the next round, where there will be at least 28 more obstacles. But what history proves is this: success begets success. Winning this round builds momentum for the next one. Losing this round or calling a win a loss will not take us to square 2 of the second round. Only unity and resolve does that.