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November 17, 2013
David Warsh, Proprietor


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One Simple Step

The troubled roll-out of the Affordable Care Act has added to the list of internal fumbles that have seriously undermined the public confidence in Barack Obama’s ability to manage the second term of his presidency. These include former aide Lawrence Summers’ highly public campaign to be nominated the Federal Reserve Board and Secretary of State John Kerry’s behind-the-scenes campaign to intervene militarily in Syria.  Granted, the Republicans have sought to sabotage the ACA in myriad ways. Still, Obama’s team of managers could scarcely have bungled the introduction of their website any worse.

There is a simple step with which the president can begin to re-establish his authority. He should recognize that “Obamacare” is a highly prejudicial term and henceforth describe the measure at the center of the act by its rightful name: the individual mandate.

It is a commonplace that the power of language to structure political opinion is very great. The Rhetoric of the Right: Language Change and the Spread of the Market (Routledge, 2013), David George, of La Salle University, argues that systematic analogizing by economists, hippies and libertarians over fifty years has transformed citizens into consumers at every turn and privileged markets (and advertising) over governments (and political discourse).  You don’t have to agree with all the particulars of the argument to see his point.  An entitlement to you is a safety net to me.

“Obamacare” was a brilliant rhetorical invention of the ACA’s enemies. It implies a hidden long-term agenda (“death panels!”) and obscures the goals that the measure seeks to accomplish.  These are mainly to extend insurance to those previously unable to obtain it because of some existing condition, and to provide medical care to those previously unable to afford it. The expectation is that, in increasing numbers, they will take responsibility for their health, instead of going without medical advice until they are in dire need of it, knowing that eventually they will be treated in emergency rooms, or by Medicare, no matter how bad their health issues have become.  I’ll leave it to Professor George, who knows his way around various newspaper databases, to see if it can be traced to Karl Rove and Rupert Murdoch.  My hunch is that the word was designed to be pronounced with a sneer.

What accounts for the ferocity of the opposition to the individual mandate as a means of assuring that all citizens are medically insured? What’s at stake here, I think, is the Republican Party’s wish to be seen as the party of reform. Traditionally, conservatives in US politics have been those who seek to defend the status quo, good and bad, whatever it is, while reformers are those who promise to improve matters, one way or another. Ronald Reagan was the master of these traditional conservatives, content as he was to affirm the achievements of the New Deal and the Second World War, but ready to insist that they had gone far enough, at least for a time.

It was only after Reagan left office that young Republicans eager to occupy the White House sought to present themselves as the party of reform, House speaker Newt Gingrich with his “opportunity society,” George W. Bush with his “ownership society.”  These reforms had to do mainly with curtailing or eliminating altogether measures that had been adopted in the past, the Social Security retirement system chief among them, in the name of aggregate economic efficiency and growth.

The individual health insurance mandate is an invention of those times. It was proposed twenty-five years ago by Republican strategists at the Heritage Foundation, a conservative Washington think-tank, partly as a means of dealing with the problem of those who cannot obtain or cannot afford medical insurance. Essentially, it was a public health measure, tantamount to creating a new personal responsibility to have a doctor and, presumably, listen to him or her to some degree (don’t drink those half-gallon sodas).

Massachusetts Republican governor Mitt Romney put the individual mandate  into practice in 2005 as a step toward a presidential campaign. But in 2008 the Democrats wrested the reform impulse away from the Republicans and, IN 2010, passed the measure themselves.  The bitter mood of the present day has everything to do with whether the Democrats or the Republicans are to be viewed going forward as the party of practical reform.

It is true that the individual mandate involves some degree of income transfer, those subsidies for the uninsured poor are obtained mainly from slightly higher premiums from the better off. If you listen to conservative columnists like Christopher Caldwell, of The Weekly Standard, it is the “haves” who have “wised up” and thrown off the yoke of deception. It didn’t happen in Massachusetts, though, where the young and healthy chose in adequiate numbers to buy insurance (rather than pay a fine), and it hasn’t happened yet in the states where the individual mandate is about to get the fairest test – Kentucky, Texas, California.

There is, in fact, a long-range vision behind the expert thinking that has guided Obama on health care reform.  It has to do with obtaining some measure of cost control in a system that otherwise threatens before very long to bankrupt the nation  (Americans currently spend about twice as much as citizens of other industrial democracies – 17 percent of GDP and rising). The plans Obama took over as president were those sketched by former Senate Majority Leader Tom Daschle of South Dakota, after he was defeated for reelection in South Dakota in 2004. They envisage the creation of a decentralized regulatory system for health care providers loosely modeled on the Federal Reserve System, which since 1913 has overseen the banking industry with gradually improving success.

A Health Care Fed, or something like it, is almost certainly in the future, as the problem of Medicare become more acute with the aging of the Baby Boom generation.  It would not hurt to say as much, recognizing that the legislative battles are far in the future (a couple or three presidential campaigns, anyway). In the present day, Obama’s battles with the Republicans over the Affordable Care Act are a little like the strange jiu-jitsu match between Bill Clinton and Gingrich that occurred during the mid-1990s. Those battles could still turn out either way.

But in just a couple of months the president has gone from a crossroads to a cusp to the edge of a dangerous precipice. He has one last opportunity to turn the match to his advantage – but only if he can change the narrative of his troubled second term.  “Mandate” makes a better word than “Obamacare” for headline purposes. should make it clear that he understands how charged and partisan the latter word has become.  He should announce a series of new senior appointments, then give a proper speech.  He should illuminate the ACA for what it is, a modest attempt to improve the system as it has evolved without changing it very much at all, and then stick with it, state by state, until it succeeds.

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