PHILADELPHIA REFLECTIONS
Musings of a Philadelphia Physician who has served the community for six decades

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(1) Obamacare: Spare Parts for a Book
Maybe these should have been included, but it was decided to leave them out.

Health Reform: Seen On the Mass Media

Both political parties in the 2008 election promised to revise healthcare financing and delivery; the nation was restless. It had been restless since a Republican Congress swept Newt Gingrich to Speaker in 1994. It soon swept him back out of power, but its ability to surprise reappeared in 2010 with Republican Senator Scott Brown's election to Edward Kennedy's seat, and then there was the 2012 Republican Congressional landslide, -- but on the other hand there was President Obama's 2012 re-election. One electoral mandate after another, often sending opposite signals. Only a King is allowed to be capricious, nations are described as undecided. When Democrat Barack Obama won his first election in 2008, a concrete proposal was eagerly awaited because it seemed likely to be radical; it disappointed, because it merely overpromised. He neglected the iron rule for leadership: underpromise, but overdeliver. In order to retain a free hand, the working elements of Obamacare were never concisely stated; in America, that is usually a misjudgment. After enactment, details can no longer escape systematic examination for what they are, and what they omit. We got rid of our King more than two hundred years ago. Capricious behavior is out of fashion. Over-deliver, that's the thing.

Political strategists calculate sweeping changes have best chance of approval immediately after a new president takes office. But for the Affordable Care Act, that slogan may still have been true but mis-timed; since overly brief sequencing gave interest groups responsible for Obama's election undue influence over the proposal, with undue sense of mandate from the elections they won. The resulting legislation, the Affordable Care Act, is heavily slanted toward rewarding the base, and the base expected a reward. With its momentum up, organized Labor, blacks and Hispanics displayed impatience about mitigating features the rest of the nation objected to. As Lyndon Johnson once said, the majority of Americans are non-black and non-poor. Political misjudgment increasingly characterizes Obamacare, which at first seemed so smart about politics..

Thousands of pages of uncoordinated proposals had emerged from four congressional committees in 2010, confusing the public about what the basic proposal was, and making it uncomfortably obvious that the congressmen themselves had neither written nor properly digested it. It was announced as a proposal to expand coverage to the whole population, uncharacteristically saving the resulting cost by eliminating waste and overutilization in medical care. That appealed to the public. But without more explanation about how these goals would be achievable, in fact whether the premises were accurate, the public could not see how program expansion and cost reduction were consistent, or how these two thousand pages made them so. Universal health insurance was said to be mandated, but in fact it doesn't say so. What it says is everyone has a choice between insurance and a small tax. Anyone with a pencil knew what to do next.

Furthermore, the public could not see what urgency justified delivering a stack of paper to congressional authorizing committees in the morning, and demanding an affirmative vote in the afternoon of the same day. Consequently, the conviction took hold that what was proposed would end up being a massive cut in Medicare benefits to pay for it. Soon after the voluminous bills were released, the Congressional Budget Office (CBO) further undermined trust in the proposal by announcing its assessment that it would add a trillion dollars to health costs in ten years, but still would only extend new insurance to about half of the uninsured population. That didn't sound like universal coverage at no added cost, at all. Furthermore the CBO had credibility, in fact was the only credible agency that had actually studied this massive legislation. The President immediately appeared on television, endlessly repeating the promise that the extra cost would not add one dime to the public debt. Therefore, fear of large impending Medicare cuts had to be entirely plausible if you believed anything the man said. Public uproar about an implausible idea thus became general before members of Congress had time to read it or devise soothing explanations; their floundering upset the public even more.

To rescue the deteriorating situation, the President attempted to go directly to the public with weeks of daily speeches. On one Sunday he appeared personally on five television talk shows. Naturally many speeches were ghost-written, containing misstatements or exaggerations, with the result that the harried President next resorted to heated oratory that would have been excessive even on the campaign trail. He was criticised as using rabble-rousing, undignified for a sitting President. Failing into a "trust me" approach, he actually was left with the difficult choice of withdrawing the proposal or being seen to ram it through Congress on a party-line vote. Party-line enactments of controversial legislation tend to justify the opposition party into repealing a controversial law just as soon as they return to power.

With the public bewildered as to what the proposal really was, enacting something certain to be reversed was even more unappealing. The alternative, a humiliating withdrawal of the proposal, seemed intolerable to its strongest supporters in the base. But reversal did not seem unreasonable to independent voters, who had wondered all along why there was such haste. The nation was fighting two international wars, both of them going badly, and was in the deepest economic recession since 1937. What's the hurry with this healthcare thing? It was a reasonable question, and the President did not help himself by darkly accusing opponents of delaying tactics.

* * *

In this analysis, the following three sections address 1) the proposal and its own flaws, particularly the savage strategy for getting enacted. 2) The growing consequences of flaws in health financing which had long pre-existed Obamacare and 3) An improved proposal, not so much radical, as extensive. For a century, conservative proposals of all sorts have been incremental, creating opportunities for mid-course corrections. Often denounced as hesitant and timid, a grand strategy often takes more time than a pitched battle, but usually advances farther and more enduringly. .

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