From: The Coffee House

By Maggie Mahar - April 8, 2008, 12:25PM

It is time, I think, to face the realpolitik of health care reform. This means asking a question few reformers dare to discuss: How will we win the Congressional votes needed to pass universal care?

The American Prospect’s Ezra Klein put this question on the table at “Take Back America’s” conference three weeks ago: “There are so many people in this town [D.C.] who do such smart policy thinking,” he observed, “but what we don’t give enough thought to is the politics of reform.” Yet this is a political problem. Without the votes,” Klein told his audience, “you don’t have a plan; you have a position.”

Some reformers seem to assume that if we elect a progressive president, he will “put the votes together” to achieve reform. But the fact is that even an optimistic, charismatic JFK wasn’t able to persuade Congress to unite behind healthcare for the elderly in the early 1960s—at a time when seniors were the poorest group in America. It was only after Kennedy was assassinated that a wily LBJ (who had grown up in Congress, knew where the bodies were buried on the Hill, and had won by a landslide) was able to leverage a martyred president’s last wishes to push Medicare legislation through Congress.

This time around, nailing the votes that would secure something like “Medicare for Everyone Who Wants It” will be much, much tougher. I see three major obstacles to reform:

--A Lack of Social Solidarity
--The High Cost of Care
--Lobbyists Who Will Resist Any Efforts to Control Costs

Success will depend on confronting these obstacles head-on. If we do that, I think we can win the votes needed to create a high-quality, affordable health care system for everyone. But we may need to reform Medicare first.

Different Groups Define “Health Care Reform” Differently

Begin with the problem of “social solidarity.” Polls show that the majority of Americans say that they want healthcare reform—but drill a little deeper, and you’ll find the polls show that different groups have very different priorities when they talk about “reform.”

For example, a Kaiser tracking poll released in October showed that 44 percent of Republican voters and 39 percent of Independents rated “reducing the cost of health care and health insurance” No. 1 as the health care issue that they would most like to hear presidential candidates discuss.

Only 21 percent of Republicans and 30 percent of Independents put “covering the uninsured” at the top of their list. By contrast, 44 percent of Democrats listed “covering the uninsured” first.

These responses are part of a trend. In poll after poll Republicans and many Independents define “reform” in terms of lowering the cost of care while Democrats identify “reform” with providing access for everyone.

Meanwhile, when pollsters Greenberg, Quinlan, Rosner asked, “Which Values Should Guide Reform?” in November, a solid majority of Democrats chose “healthcare is a fundamental right– every American should be guaranteed coverage that can never be taken away” as one of the two most important ideas that should steer change. Only 21 percent of Republicans and 46 percent of Independents agreed.

A Kaiser poll released just last month shows that this is not just a difference between Republicans and Democrats. When Kaiser surveyed different income groups, it found that a mere 27 percent of those living in households earning over $75,000 rated universal coverage as one of the two most important issues in the coming election. By contrast, 50 percent of those in households where joint income equal less than $49,999 named health care as one of their two top concerns.

This makes sense. Wealthier Americans are not as concerned about health care because the majority have employer-based coverage-- and in many cases, it’s free.

A surprising sixteen percent of all “higher-wage full-time workers” who participate in an employer-based plan are not required to make any contribution to their premiums according to a 2007 report from the Employee Benefit Research Institute (EBRI). Their employer pays 100 percent of the premium. By contrast, only 8 percent of “lower-wage workers” covered by an employer-based plan enjoy a free ride. (EBRI defines “higher-wage” workers as those who earn more than $15 an hour, or over $60,000 a year in a household where two adults are working full-time.)

Of course most employers do ask workers to contribute, but once again, the more you make, the less you are asked to kick in. On average, a higher-paid worker chips in only 27 percent of the premium for a family plan. Lower-paid workers are expected to cover 34 percent of their premiums.

And that’s if the lower-paid worker can afford the 34 percent—plus a deductible and co-pays. Only 67 percent of lower-paid workers who have access to an employer-sponsored plan participate. Many just can’t afford it.

No wonder households earning less than $49,999 are much more likely to name universal coverage as one of their two top concerns.

The Difference Between the U.S. and Other Developed Countries

When asked why the U.S. is the only developed nation that does not provide healthcare for all of its citizens, many experts say that it is because we are a more “diverse” society—a coded reference to our racial and ethnic diversity. The French are willing to provide generous coverage for all because they feel that nothing is too good for another Frenchman. We, unfortunately, do not feel that way about each other.

But the truth is that many countries have a large immigrant population. For example, fifteen percent of Germany’s citizens are not German by birth, and one-third of that group is Turkish. Yet Germany’s spreads out a social safety net for everyone.

What distinguishes the U.S, suggests Princeton health care economist Uwe Reinhardt, is that the gaps between the poor, the lower middle class, the upper-middle class and the truly rich are so much greater in the U.S.

Not long ago, I attended a World Healthcare conference where Reinhardt explained that countries like Germany, Belgium, Canada, France, Denmark the Netherlands, Switzerland, Sweden, and Norway are all “predominantly middle class.” This creates the solidarity which makes it much easier to agree on a universal health care system.

In countries where most people are “middle class,” groups living on different rungs of the income ladder still identify with each other. Some earn more; some earn less—but they are not living in different worlds.

By contrast, in the U.S, Reinhardt pointed out, the divisions are much sharper. “We have our fabulously wealthy ‘corporate aristocracy’—people who are not part of the U.S. They don’t participate in American life anymore; they have five homes all over the world.”

Then we have a class of families most would call “rich.” They aren’t billionaires, and they don’t have hundreds of millions of dollars socked away, but they may well live in a home worth several million dollars. They own second homes, drive the most expensive cars and send their children to private schools.

Finally, on the lowest rung of a five-rung income ladder, Reinhardt observes, “America has its very poor—these are the people who were in New Orleans when Katrina hit, and who receive no services.”

Following his lecture, I asked Reinhardt whether he thought that, if we made a real commitment to healthcare reform, the U.S. could build a system that provided a high standard of care for most Americans.

Reinhardt didn’t hesitate: “No, never.”

Why not? I asked.

“Because there is no social solidarity in the U.S.”

Reinhardt is predicting that we cannot—and will not—pull together to create and finance a high-quality healthcare system for all Americans because we don’t identify with each other. Instead, we live in our separate pods, defined, to a large degree, by how much we earn, and what we can afford to buy.

I’m not willing to accept that diagnosis.

Nevertheless, if we are going to face up to the “realpolitik” of health care reform, we must acknowledge that, as Dr. Ezekiel J. Emanuel, Director of Bioethics at the National Institute of Health, recently put it in The Journal of the American Medical Association: “Without controlling healthcare costs, any attempts at universal coverage will be transient. . . . Fortunately . . . those who count in [our] political process—voters, employers, governors, and others—are concerned about [the] costs [of healthcare] in a way that they have not been genuinely concerned about the fate of the uninsured.”

In my next post, I’ll explain what Emmanuel means when he says “Fortunately,” why cost is, in fact, the major barrier to universal coverage, and how “those who count in our political process” can be used to overcome the final obstacle to reform.