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The big picture

Some reasons why health care reform is such a tough sell

As we move ever closer toward the passage of health care reform, public support for reform continues to tick downward; as reported in the latest NBC-Wall Street Journal poll, only 41 percent of Americans currently believe that changing the health care delivery system is the right course of action, while 44 percent favor the status quo.

We could debate endlessly about why the support for reform is so dismal -for instance, conservatives and GOP-leaning independents are worried about higher deficits and government intrusion; many liberals think the current Senate reform bill is a sop to the private insurers, and thus not worthy of passage; many pundits say that President Obama has failed to take the lead and clarify what he wants - but most of those diagnoses are predictably partisan, or otherwise framed too narrowly.

At this point, I'd like to yield the balance of my time to Walter Russell Mead, a leading American scholar who normally specializes in international affairs, but who, in a written rumination this week, offered what I consider to be the best big-picture perspective on why health care reform has been such a difficult domestic political sell. Here's a lengthy excerpt:

"Health care is probably the single hardest and trickiest problem American society faces. Economically, it involves about one seventh of the economy and everybody in the United States has a dog in this fight. Hospitals are the biggest and fastest growing employers in many communities around the country. Health care jobs are some of the best paid we have.

"People's expectations for health care are deeply irrational. Everybody wants to live forever, nobody wants to cut any corners for their own health care, and nobody wants to pay through the nose for everyone else's. When my grandma is sick I want everything possible done for her; when it's your grandma with the problem, I want the death panel to meet. Oh - and I don't want any politicians telling me that my expectations are out of line, contradictory, and on a very deep level foolish and vain.

"This is why health care reform is such an attractive quagmire. Everybody loves the idea of health care reform in the abstract, and everybody understands how important it is. But the more concrete the proposal gets, the more people turn away. Concrete proposals create winners and losers; they also create uncertainty. Any attempt to change the American health care system is going to be complicated; most people will have no idea how it will work out in practice."

Concrete proposals create winners and losers; they also create uncertainty...Mead got that right. No wonder so few presidents have gotten any traction on health care reform over the past 60 years; no wonder congressmen and senators have generally been terrified to push for it. Politicians don't like to create losers, because losers (or those who fear they might become losers) are bound to lash out on election day. Politicians don't like to sow uncertainty, because it's easy for the opposition party to exploit that mood. And even if the Democrats manage to pass an historic law this winter, the Republicans will be able to play on that mood of uncertainty during the '10 election season - and for several years thereafter, until the reforms finally kick in.

Mead's advice? Democrats should scale back on their most contentious ambitions and pass a reform bill with all deliberate speed, something "smaller and more targeted," that Obama would feel comfortable signing. In Mead's words, Obama and the Democrats should basically "declare victory and get out," and then map "a long-term incremental strategy" to codify further reforms. Having already exhibited admirable (or foolhardy) political courage in taking on what Mead calls "the single hardest and trickiest problem in America," Obama has no choice but to persevere. There is no going back.


I did an hour on Philadelphia NPR this morning, critiquing the political landscape with Rutgers political science professor Ross Baker. The show is archived online, here.