Why Health Care Is a Losing Issue for the GOP

On March 10, 1994, less than four months after Bill Clinton's health care plan was introduced in Congress and half a year before it would die its bitter death without ever coming to a vote, the Wall Street Journal published the results of a poll and focus groups they had conducted on the Clinton plan. The article explained that although only 37 percent of respondents said they supported the Clinton plan, when various health care options were read to them without identifying their sponsors, 76 percent said the Clinton plan had either "a great deal of appeal" or "some appeal," making it more popular than any of the competing proposals.

Voters had no idea what was in the Clinton plan, but they knew they didn't like it. Among many of the focus group participants, "the most memorable source [of information on the Clinton plan] has been health-insurance-industry commercials strongly criticizing elements of the Clinton plan, including the famous 'Harry and Louise' ads that depict an 'ordinary couple' worrying about the White House bill." The Journal's story was titled "Many Don't Realize It's Clinton Plan They Like," and it would stand as a testament to the smashing success of one of the most extraordinary campaigns of misinformation in recent history.

As the 2008 presidential campaign accelerates, we see once again that health care tops the list of domestic concerns, and once again Democratic candidates are hoping to begin a debate on the issue. They know, as do their counterparts across the aisle, that on few other issues do Democrats start from such an advantageous position. To take just one example, an NBC/Wall Street Journal poll in July found that only 13 percent of respondents said they trusted Republicans more than Democrats to handle health care.

But if they want to actually get something enacted -- and let's assume for the moment that the Democratic nominee wins the White House next year -- they'll have to be willing to directly engage conservatives on the issue and be willing to have a debate about fundamental philosophy, not just about health care in particular but about government itself. If they don't, we could see another ambitious plan go down to defeat and another 15 years pass before momentum readies the ground for real health care reform.

The need, and opportunity, to have that philosophical debate has grown because of a subtle shift in Republican rhetoric on health care. It isn't that they have abandoned their old arguments, but they have added a new set, one that reflects a striking degree of extremism.

As Jonathan Chait argues in his new book The Big Con: The True Story of How Washington Got Hoodwinked and Hijacked by Crackpot Economics, the leaders of today's Republican Party have signed on wholeheartedly to a set of economic ideas that actual economists, even conservative ones, regard as utter nonsense -- not only logically loopy but empirically false. Foremost among these is the notion that not only do tax cuts (preferably for the wealthy) always and everywhere increase revenue, but that tax policy is virtually the only thing that has any impact on the economy. The fact that they are proven wrong again and again has had little effect on their ardor and certainty. (If you want a good laugh, go back and read the Republican prophesies of doom that accompanied the passage of Bill Clinton's 1993 budget, which raised taxes on the wealthy, passed without a single GOP vote in either house of Congress, and preceded the addition of a mere 22 million jobs to the American economy.)

That the current crop of Republican presidential candidates has embraced this philosophy is becoming increasingly clear. At a debate in Iowa last month, Rudy Giuliani was asked whether his party's refusal to raise taxes made it more difficult to address infrastructure needs. Giuliani responded that the question was based on "the sort of Democratic, liberal assumption" that the way to generate additional revenue is to raise taxes. "The way to do it sometimes is to reduce taxes and raise more money," he said, to the applause of the crowd. We can have our cake, in other words, and eat it too. If only it were true.

The GOP candidates seem to adhere to an almost maniacal free-market fundamentalism across any number of issues that suggests that the ghost of Milton Friedman is dancing from the house of one candidate to another each night, whispering sweet laissez-faire nothings into their ears. When it comes to health care, they've stopped arguing simply that government is bad. They are now actually arguing not just to maintain the status quo, but for an even more conservative approach to health care than the one we currently have.

Though their offerings on health care are perfunctory at best -- people who think it would be a priority for any of the Republicans once in office are kidding themselves -- the GOP candidates are at least presenting a window into their thinking.

When they talk about health care, today's conservatives seem to be speaking of some strange parallel universe where Homo Economicus lumbers across the landscape, rationally subjecting his every decision to a careful cost-benefit analysis and maximizing economic utility above all else. That this picture bears little relation to our actual world seems not to matter.

You can hear it in the buzzwords, particularly "choice," something that markets allegedly bestow and government doesn't. The truth is, though, that our current dysfunctional system -- which limits choice in numerous ways government health plans don't -- is a product of the market. As David Brooks recently wrote in the New York Times, "Some liberals, believing that government should step in as employers withdraw, support a European-style, single-payer health care system. That would be fine if we were Europeans. But Americans, who are more individualistic and pluralistic, will not likely embrace a system that forces them to defer to the central government when it comes to making fundamental health care choices." Just which "fundamental health care choices" Brooks is referring to is unclear -- perhaps the choice to pay out-of-network penalties, or the choice to get rejected for coverage because of a pre-existing condition.

My favorite new conservative argument is that the problem with progressive approaches is that they don't allow you to "own your own health care." The people who sold us the "ownership society" seem to believe that there is nothing that cannot be owned, and one must necessarily gain when one moves from a state of not-owning to owning. But the idea that we would "own" our health care is positively nonsensical. What if I told you that the problem you have with car repairs is that you don't "own" your tune-ups and oil changes? Or that you'd be much better off if you could "own" your own protection from fires instead of relying on that big-government fire department? You'd quite rationally conclude that I was some kind of idiot, and you certainly wouldn't take my advice on much of anything.

Amid all the cries of "socialized medicine!" and "government bureaucracy!" that will accompany any progressive attempt at health care reform, we'll be hearing paeans new and old to the magic of the market. Democrats shouldn't be afraid to engage them directly. Do conservatives believe that markets can ever fail? And if so, is there a clearer example than health care? If government health care can't work, why is Medicare so much more efficient than private insurance? Do you want to dismantle Medicare?

When Bill and Hillary Clinton tried to reform health care in 1993, they believed that if they devised a plan that enhanced the role of HMOs and maintained the profit-driven nature of the American health care system, the forces that might oppose them would be appeased. What they got instead was a blitzkrieg of opposition for which they were woefully unprepared. That opposition was extraordinarily well-funded and well-coordinated, appallingly dishonest, and brutally effective. The fact that the Clintons had accepted most of the conservative premises about health care made no difference, and the result was that any progressive effort at reform was discredited for years.

If a Democrat wins the White House, there will be another chance to make changes to the world's least efficient health care system. As I have written here before, not in decades has the political soil for progressive solutions been more fertile. Let's hope we don't miss the opportunity.

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