a curious Yankee in Europe's court

In a recent e-mail exchange with a friend in the U.S., who is a political science scholar, we discussed the stunning Democratic Party loss in Massachusetts on Tuesday, and the crisis it has created for the proposed health reform process. I asked for some guesstimating, looking backward, on these questions:

Why is it that Obama approached health care from the perspective of a grand overhaul? Why didn’t the White House look at the problems, and choose one or two immediately effective things to change — openly speaking of it as the beginning of a complex process? For example, had they just gone for a limited public option — limited in that it would be a prototype program in one state or another, or with a certain selected group — they could have passed it with a little horse trading, and it would have been a great warning shot across the bow of the private insurers. Once this program was shown to be working well, it could have been used as evidence in proposing further legislation. Why not?

I suspect that Harry and Nancy initially told the President that if he would sit tight they would bring him a comprehensive health reform bill, take all the heat, and let him take the bows, and he consented to that.  In addition, I suspect they told him that it would be quick, and done in the background in a low profile process until ready for a vote and signing, and he liked that idea, as well.  He liked that, since he could then focus on the rest of the big agenda and make those actions high profile until the health bill was ready.

Instead what happened is that the health reform bill writing process became the fight that drew the crowds, drew the media, and made the most thunder, and took over the Administration’s image, leaving all hands on deck explaining, explaining, explaining instead of doing, doing, doing.  The jobs issue looked like it was and is being sacrificed, even willingly put last in line, in the whole agenda.

And keep in mind that the bill did three hugely hazardous things. It proposed financing much of the costs on the backs of those who, as with many labor contracts, have the best employer insurance coverage, and it touched the third rail by implicating Medicare and Social Security issues in the mix. In addition to all of this, the bill quickly became such a catch all of complexity that it confused and puzzled and permitted imaginations negative and positive to go wild.

As to why not a piecemeal bill instead of an omnibus, comprehensive bill?  Well, this was Harry and Nancy’s one big thing in life, and they wanted it big while the getting looked gettable.  I wonder if the two of them are not in a frame of mind that this administration, probably this Presidency, is not their career cap, and they are willing to go down and out with that legacy?

As for why the decision to do health bill during the President’s first year, one has to see that the economic crash, especially the financial system crisis, was not anticipated. So the Administration and congregation found themselves on too short notice with too many imponderables to come up with a new plan, so they just tinkered with the old plan, and still are doing so.

In addition, there is that idea of not taking the eye-off-of-the-prize thing about their plans, which means not changing priorities even though jobs are the priority for the public, and the immediate priority on top of that.  So, what they have done is rationalize their old plans, and actually in an underlying way, as jobs programs — you know, health care reform as a jobs program, as an economic recovery program, as an economic growth program, as a re-industrial program.  There is an ideologue-like attitude about the old plan, I suspect.

I think the Obama Administration, partly by their righteous good nature about rationality and non-partisanship, and partly because they assumed their majorities made it less relevant, forgot that the Presidency, when successful, is no less a political campaign than was the election campaign. Governance is a campaign thing at the governors’ and at the Presidential level.

I learned a hard lesson myself (when I worked for a while in a state job)  — it was that the other political party is always the opposition, always, always; so to be the big spirited guy and assume there is a spirit of common team goodwill and attitude in any project is to let one’s guard down and to get skewered for sure. That’s what the founders wanted, and that is what we got: competing interests, balances of power (read that as opposing forces), and loyal opposition all around.

The best we can hope for in this system is common civility and some measure of public courtesy in the eternal punching match of the process, in the eternal one-upmanship of it all.

Some American critics of the United Kingdom’s universal health care system (NHS), I’ve noticed, have pointed to it as a primary example of why it would be a mistake for the U.S. to move its reform efforts toward any such public plan. Curious as to the validity of these boos and hisses, I recently queried an English friend of mine on the subject.

Some context for the witness: 1) She and her family are financially comfortable and, therefore, are able to choose between public or private care; 2) They also lived in the USA for several years a couple of decades back, and so are familiar with the American private system; 3) My friend leans conservative in her political views, and rates Margaret Thatcher’s leadership highly.

Here is a slightly edited transcript of our email Q&A last month on health care:

Q: Notwithstanding legitimate concerns and criticisms of the UK’s national health plan, would you approve of it being repealed and the country returning to a fully private health care system, without government funding except for retired people and the very poor?

A: No – in short.

Q: May I ask you to describe you and your family’s use of the public system together with private health care in terms of the mix — i.e., what percentage of care you receive from the public plan versus your recourse to private care?

A: We have always used both, through job based private insurance and now by self-funding, if we need elective or immediate ‘serious’ investigations. However, when it comes to the actual treatment, we might well revert to NHS care. Emergency and life threatening situations result in the same care, whichever way you go, albeit maybe in greater comfort in a ‘private’ facility. But as with all things in life, what really counts is doing your homework and knowing your options. I would say it’s been about 50/50, given that none of us have had a chronic problem, which usually would be too expensive and eventually precluded from insured private care. In my parent’s generation, until late in life when they could afford it, all the care was NHS.

As a final comment, our system cannot be described as either ‘very bad’ or ‘highly rationed’. It is neither. What it is is HUGE, and difficult to manage fairly. Often it’s a bit of a zip code lottery. Some hospitals are wonderful, others are not. It also depends a great deal on HOW the individual interacts with the system. It is abused and overused because it has become the accepted route… people don’t think for themselves anymore. We have created the system we deserve. There is huge waste. But there is also life saving, life changing work being done.

There is no short sound-bite answer to this. We could talk about it for days!

It could be the most amazing system in the world, but it needs a complete overhaul in management terms. Like all other walks of life, you have management consultants meddling in it with no clinical or patient experience, and they are screwing with the training that they give to Doctors and Nurses also. It’s become a Big Business, with hugely wasteful contracts going out to private companies.

But I would never advocate going back to a wholly privately funded system. A more carefully worked out combination would seem to me to be the way to go… to allow the system to work better for those who need it most.