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What Social Security Teaches Us About Health Care

Paul Begala has an op-ed in this morning's Washington Post that's the most important argument you'll read today. I'm going to quote a nice big chunk of it here.

I think my fellow progressives ought to give Max Baucus and other members of the Senate Finance Committee a little breathing room as they labor to produce a health-care bill that can garner enough votes to pass the Senate.

Progressive politics is, in my view, a movement, not a monument. We cannot achieve perfection in this life, and if that is our goal we will always be frustrated. The right has far more modest goals: At every turn, its members seek to advance their power and protect privilege. I've never seen the Republican right oppose a tax cut for the rich because it wasn't generous enough; I've never seen them oppose a set of loopholes for corporate lobbyists because one industry or another wasn't included. The left, on the other hand, too often prefers a glorious defeat to an incremental victory.

Our history teaches us otherwise. No self-respecting liberal today would support Franklin Roosevelt's original Social Security Act. It excluded agricultural workers -- a huge part of the economy in 1935, and one in which Latinos have traditionally worked. It excluded domestic workers, which included countless African Americans and immigrants. It did not cover the self-employed, or state and local government employees, or railroad employees, or federal employees or employees of nonprofits. It didn't even cover the clergy. FDR's Social Security Act did not have benefits for dependents or survivors. It did not have a cost-of-living increase. If you became disabled and couldn't work, you got nothing from Social Security.

If that version of Social Security were introduced today, progressives like me would call it cramped, parsimonious, mean-spirited and even racist. Perhaps it was all those things. But it was also a start. And for 74 years we have built on that start. We added more people to the winner's circle: farm workers and domestic workers and government workers. We extended benefits to the children of working men and women who died. We granted benefits to the disabled. We mandated annual cost-of-living adjustments. And today Social Security is the bedrock of our progressive vision of the common good.

Health care may follow that same trajectory. It would be a bitter disappointment if health reform did not include a public option. A public plan that keeps the insurance companies honest is, I believe, the right policy and the right politics. I believe subsidies should extend to as many Americans as need help and that the hard-earned health benefits of middle-class Americans should not be taxed. I believe insurer abuses like the preexisting-condition rule should be outlawed. The question is not whether I or other progressives will support a health-reform bill that includes everything we want but, rather, whether we will support a bill that doesn't.

Baucus and the others working on health care have earned the right to take their best shot, and we progressives should hold them to a high standard. I carry a heavy burden of regret from my role in setting the bar too high the last time we tried fundamental health reform. I was one of the people who advised President Bill Clinton to wave his pen at Congress in 1994 and declare: "If you send me legislation that does not guarantee every American private health insurance that can never be taken away, you will force me to take this pen, veto the legislation, and we'll come right back here and start all over again." I helped set the bar at 100 percent -- "guarantee every American" -- and after our failure it's taken us 15 years to start all over again.

I would disagree on one point: The original Social Security legislation wasn't "perhaps" a "cramped, parsimonious, mean-spirited and even racist" program. It simply was those things. But it was something else, too. A start. Over the next 50 years, it was built upon. But not only by Democrats. Some of the largest advances came when Republicans saw political opportunity in strengthening the entitlement. Begala implies that progressives eventually added cost-of-living increases to Social Security. In fact, it was Richard Nixon who signed that bill. Similarly, whether you like the structure of Medicare's prescription drug benefit or not, it was a massive expansion of an entitlement program, and it was proposed and signed by George W. Bush.

The trickiest part of my job right now is to balance the desire for a better bill with the need to argue that the bill that's likely to emerge still makes for a better country. You don't want to ease the pressure on Congress too early, but you don't want to see your allies forget that this is about more than the public option. Imagine for a second that health-care reform looks exactly like the House bill, but the public option is excluded. What will be easier over the next 10 years? Passing a simple piece of legislation that establishes a public option? Or starting from scratch with a 1,000-plus-page bill that spends $1.3 trillion expanding coverage, and regulates insurers, and creates health insurance exchanges, and reforms the delivery system, and cuts payments to the private insurers overcharging Medicare ... and all the rest of it?

You don't want to compromise too early. But nor do you want to realize that you should have compromised only to learn that it's too late. I don't know where we are along that continuum. But Begala has seen this fail before, and it has taken us 15 years to return to the place where we can conceive of passing a worse piece of legislation. He's worth listening to.

By Ezra Klein  |  August 13, 2009; 4:14 PM ET
Categories:  Health Reform  
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Next: A Floor, Not a Ceiling


I always thought the Clinton's and Obama as well should have started off with insuring every child then allowing 55-65 to buy into Medicare. It would have been a far easier sell thus avoiding the rabid mobs and would eventually lead to univeral coverage.

Posted by: MerrillFrank | August 13, 2009 4:29 PM | Report abuse

There are two huge differences:

First: Social Security didn't need 2/3 majority voting for it.

It's very, very depressing that the Dems would rather water this thing down instead of pushing Ben Nelson to vote against the bill *and* against a filibuster. But, it's also predictable with Reid and Baucus running the show, and Obama unwilling (so far) to push back against the Group of Six. There is never a push toward the left when money and power automatically pushes legislators to the right.

Second: legislation does not naturally grow. We've seen that in welfare and countless other redistributive policies. THAT is why the public plan is important and scary for Republicans -- because it creates a natural constituency that will continuously push for a better, cheaper program. Without such constituency, it'll be torn down and slowly drowned in a bathtub. With such a constituency, it'll slowly improve and be the new "third rail."

Posted by: Chris_ | August 13, 2009 4:35 PM | Report abuse

Yes but if liberals announce publicly that they will support any bill, while the Blue Dogs threaten to vote against a bill they don't like, guess whose preferences end up codified in the bill?

Liberals need a credible threat of failure in order to get any concessions.

Which of course is a fine tightrope to walk, as no sane Democrat, either Blue Dog or liberal, actually wants the bill to fail - and yet if they don't threaten to vote against it, they'll each end up with what they regard as a crappy bill.

Posted by: tyronen | August 13, 2009 4:40 PM | Report abuse

Well stated, Paul Begala. And likewise, Ezra. What is the optimal timing for compromise? And how much compromise to keep everyone on board. Was it LBJ who said, "Politics is the art of the possible?" While it is true that the Dem. Party, if it were uniform in its loyalties, should be able to pass this thing. But it is a coalition itself, and much more diverse than the GOP. A bill establishing a right to health care will change public consciousness and expectations. From there it can be improved and broadened, just as Medicare and Social Security have been. There is a broad public consensus now, tea-baggers aside, that health care is the missing part of our social safety net, and it should be corrected. Building on that consensus with a policy in place, is essential this year.

Posted by: cmpnwtr | August 13, 2009 4:43 PM | Report abuse

Don't overlook the "free rider" provision. This is such a terrible idea. It is practically the being of a permenate underclass. I really do think health care with the free rider provision would make a country worse than no health care bill.

Posted by: JonWa | August 13, 2009 5:04 PM | Report abuse

But Ezra, I simply don't believe any of the current viable proposals will work. Let me make two objections. First look at cost. The present bills will not pick up the $500 Billion every year that Medicare for All would. The savings from reform of medical practice as advocated by Gewande et al in the Times today will be very difficult to get as he should well realize after seeing how the doctors in McAllen reacted to his New Yorker article. We cannot afford to give everyone decent health insurance while keeping all this waste.

Two, please explain to me how we are going to eliminate the pre-existing condition problem if you don't do something like they do in Switzerland and the Netherlands, namely require all insurance companies to offer the same basic government written plan to everyone (& require everyone to have at least this plan) and have the price set by the government. If you don't, even with an individual mandate, companies will offer very cheap policies with high deductibles or low caps with the understanding that people will switch to a better plan if they get sick. You will never persuade me that this will work. It will be even worse without an individual mandate.

So tell me how it will work?

Posted by: lensch | August 13, 2009 5:21 PM | Report abuse

How about if we take the House Bill and everywhere a rule is stated or a benefit granted, we add the words, 'if the insurance providers at their discretion choses to provide it'. We'd have a bill that's good, right? Better than nothing!

And it could be improved over time. Also.

It is a strange strange world where the supporters of a plan are ignored, and those pledged against it are negotiated with and praised.

This is climate change without climate change. Defense without defense. Logic without logic. Effectiveness without effectiveness. Stupidity WITH more stupidity.

Posted by: JimPortlandOR | August 13, 2009 5:27 PM | Report abuse

Begala proclaims as a feature what conservatives see as a bug: once a government program is instituted, it tends to grow, to slide down the slippery slope, or to move the rest of the camel into the tent, depending on which metaphor you prefer.

Posted by: ostap666 | August 13, 2009 5:42 PM | Report abuse


More than two thirds of the American people want a single payer health care system. And if they cant have a single payer system 76% of all Americans want a strong government-run public option on day one (85% of democrats, 71% of independents, and 60% of republicans). Basically everyone.

AND NO INSURANCE MANDATES WITHOUT A STRONG GOVERNMENT-RUN PUBLIC OPTION ON DAY ONE! An insurance mandate without a strong government-run public option choice on day one, would be a DISASTER! And it would be worse than the GREED DRIVEN PRIVATE FOR PROFIT HEALTH INSURANCE HORROR! SHOW you have now. YOU MUST MAKE CERTAIN!! THAT DOES NOT HAPPEN AMERICA.

The healthcare reform bills released by the first two committees of the House Of Representatives are excellent bills as I understand them. They are bills with a strong, robust, government-run public option, and an intelligent, reasonable initial funding plan to cover almost all of the American people. They are carefully written, and thoughtfully constructed, informed, prudent and wise. These bills will save trillions of dollars, and millions of your lives. They are also now supported by the AMA.

These are the type of bills that all Americans can feel good about. And these are the type of bills that have the potential to dramatically improve the quality of healthcare for all Americans. Rich, middle class and poor a like. Democrats, Republicans, Independents, and all other party affiliations. These bills have the potential to dramatically improve the quality of life of every American.

The house healthcare bills released by the first two committees should be viewed as the minimum GOLD STANDARD by which all other proposed healthcare legislation should be judged. All supporters of true high quality healthcare reform should now place all your support behind these healthcare reform bills released by the first two committees of the United States House Of Representatives, as the minimum Gold standard for healthcare reform in America.

You should all now support the first two committees bills with all your might, and all of your unrelenting tenacity. These first two House committees healthcare bills are VERY, VERY GOOD! bills for all of the American people. Fight tooth, and nail for every bit of these bills if you have too. Be aggressive, creative, and relentless for these bills.

From this time forward, go BIGGER and DEEPER with the American people every day until passage of healthcare reform with a robust, government-run public option.

FIGHT!! like your life and the lives of your loved ones depends on it. BECAUSE IT DOES!


Senator Bernie Sanders on healthcare (

God Bless You

Jack Smith — Working Class

Posted by: JackSmith1 | August 13, 2009 5:48 PM | Report abuse

There is a confusion here between what Congress and the Senate might/should do and what people on the ground might/should do. Begala is saying: Line up behind your leaders in Congress and the Senate. I don't think that is a prescription for change in the area of health care finance.

I do believe though that the public option has been oversold. It only makes sense as what Democrats say that it isn't: an entering wedge into single payer.

I don't think the analogy with Social Security holds much water though I wasn't alive at the time to judge. The basic policy mechanism seems to have been from the start what we would all endorse as a tax-supported public pension, the only difference being that groups that were at the time considered "out-groups" that now are not considered "out-groups" were initially excluded. The SSA Act didn't transform America all at once into what we now acknowledge to be a more just balance of power and benefits.

But the health care proposals that Begala and you, Ezra, are saying are analogues to Social Security are baroque concoctions that have a great chance of failing of their own weight when enacted and not because of any particularly strong political or other opposition. They are corruptible.

So, yes a health reform bill that substantially changes the way insurers are regulated would be a good thing if it is sold as such and is functional. But let's not kid ourselves or let ourselves be kidded that it will both allow universal coverage and control costs. Only really stringent regulation of the type not proposed in any bills (except HR 676 which really says "we can't regulate these guys; we have to push them out of the basic health insurance business".) will have this effect.

People pushing for this kind of regulation is only going to sharpen up anything that is going to be enacted into law.

Posted by: michaelterra | August 13, 2009 5:53 PM | Report abuse


We chose Obama over Clinton because we didn't want to be burned by the lessons of the 90s, and left to pursue a crabbed, chastened echo of an agenda.

We gave Democrats control of the White House, control of both houses of Congress, and a 60 vote majority in the senate. What more do we have to do to get an actual health-care package passed that gets us universal coverage for every American?

Posted by: adamiani | August 13, 2009 6:25 PM | Report abuse

So Ezra, does this mean you're going to stop dumping on Ben Nelson?

Posted by: tomtildrum | August 13, 2009 6:58 PM | Report abuse

"At every turn, its members seek to advance their power and protect privilege."

Is Begala kidding here? It's so ridiculous I'm not sure. How many Democrat politicians willingly retire while in office? How many fly around in private jets? How many go to work for lobbying firms for sick amounts of money?

“The left, on the other hand, too often prefers a glorious defeat to an incremental victory.”

Hahahahah. I get it now. He was joking. He is painting the right as evil and greedy winners and the left as righteous and noble losers. Hyperbole at its finest…

Posted by: kingstu01 | August 13, 2009 7:28 PM | Report abuse

Extremely well put. And as someone who would prefer Medicare-for-all, I must say that we Progressives need to bend on the public option and the employer mandate so we can get the deal done. I do not want to see all the other good features (that have bipartisan appeal) get thrown out over intransigence over these issues.

Is the coop as good as a public option with Medicare rates? Nope. But it is a very good start and I doubt you can extend Medicare rates into the under 65 population anyway. The squuze on providers would be too great.

Is the free rider tax as good as an employer mandate? Nope. But it is a start. And I do not think that it would create systemic discrimination against lower paids. Most emplyers just don't think that way. Besides, how do you know how much my wife makes?

Posted by: scott1959 | August 13, 2009 8:25 PM | Report abuse

lensch....the bills that have been floated so far have minimum benefit standards so that insurance companies can not meet the no pre-ex, no underwriting rules by offering cheap plans. There are gold, silver, and bronze plans where actuarial equivalence (ie, not actual deductibles/copays but overall benefit package payments) must be met.

Posted by: scott1959 | August 13, 2009 8:28 PM | Report abuse

Thanks scott, but I am sorrry I don't get it. I was referring to the problem where it would be advantageous for a person to get a low cost plan until he got sick, and then switch to a better one when he got sick. Why pay high premiums when you are not sick?

Maybe what you said solves that problem, but I don't get it. Explain please.

Posted by: lensch | August 13, 2009 10:14 PM | Report abuse

"The right has far more modest goals: At every turn, its members seek to advance their power and protect privilege. I've never seen the Republican right oppose a tax cut for the rich because it wasn't generous enough; I've never seen them oppose a set of loopholes for corporate lobbyists because one industry or another wasn't included."

LOL. You libs truly have no clue what the right is all about. Completely clueless.

Posted by: whoisjohngaltcom | August 13, 2009 10:42 PM | Report abuse

Social Security was a stand alone piece of legislation. Health care reform is interconnected. Legislation that does not include a public option risks raising overall health care costs which could set back any effort at passing additional legislation.

Reconciliation offers a way to enact the best possible bill. Dems need to utilize it.

Posted by: newjersey_lawyer | August 13, 2009 11:02 PM | Report abuse "You libs truly have no clue what the right is all about. Completely clueless."

That's quite a jump: taking one comment and attributing it to "you libs." Should I take Jerry Falwell's comments and attribute his beliefs to all conservatives?

This is a serious downside to online discussion. The most passionate and partisan are the most likely to post, and those who disagree will take those statements as representative of an entire community. Groups are not monolithic, and we'll have far more productive discussions if we start from the premise that if people disagree with us, they probably have reasons even if we think they're wrong.

Posted by: dasimon | August 13, 2009 11:14 PM | Report abuse

"Unwilling (so far) to push back against the Group of Six. There is never a push toward the left when money and power automatically pushes legislators to the right."

I *somehow* continue to be surprised @ the White House's unwillingness to push back against the Baucus bill: . It's frustrating.

From the article: "Mr. Obama and his top aides have immersed themselves in the Senate Finance Committee process. The president talks to Mr. Baucus several times a week, people briefed on their conversations say. Mr. Obama has also held a few calls with the panel’s ranking Republican, Senator Charles E. Grassley of Iowa."

This thing has felt locked up from the beginning, much like the election did. All the pieces were put in place from the beginning, and we're just going through the motions........

Yes, reform will get done. Yes, the bill is much better than the status quo. This is all great and wonderful. But, could it have been done with an aggressive president, 50 votes in the Senate and a liberal House -- even with Big Pharma/Insurance/AMA opposition? I believe it could have, and that's what's depressing to me. There's absolutely no attempt at pushing the envelope.

Posted by: Chris_ | August 13, 2009 11:35 PM | Report abuse

That's quite a jump: taking one comment and attributing it to "you libs."

I didn't take a comment. That was from the original post. A post which completely mischaracterizes whatever the right does in order to measure the value of what the left does.

Posted by: whoisjohngaltcom | August 14, 2009 7:47 AM | Report abuse

So. Big Pharma spends 6-12 million on an add campaign for "reform" and promises to be nice this time. 32% of Doctors (mostly rich specialists) help out as well (while most of their colleagues want a public option or universal plan). This to essentially maintain the status quo (if you factor in the shared pain of real reform)? Sounds like a business deal made at someone's expense. "Obama's Drug Deal" to quote CNN.

Who pays the real life costs of profit and rent-seeking in healthcare? I know, we are not Canada or the UK, but nor are we the Netherlands or Switzerland. So instead of expanding Medicare and laser focusing on costs/incentives, we have this process, this piggy sausage making that Begala and Ezra are trying to decorate with really sincere, dogged, and incorruptible looking lipstick.

Posted by: perhapsnot1 | August 14, 2009 9:14 AM | Report abuse

lensch...if you are still reading....this is a standard pricing exercise the industry has dealt with for years. What you are asking is how to avoid adverse selection. Simply put, if you think the actuarial value of the lowest plan is $.90 and the value of the highest plan is $1.20, that is NOT what you charge for them. The lowest plan would get priced at say $1.00 to cross subsidize the losses (and adverse selection you mention) of the higher valued plan.

The other controls are only letting people switch once a year (most of us don't know we are going to get appendicitis next year, etc).

That help?

Posted by: scott1959 | August 14, 2009 6:16 PM | Report abuse

Open letter to Paul Begala: I have a little problem with your "Progress over Perfection" approach to health insurance reform which endangers the public option. Perfection from the Right would be the status quo or perhaps the privatization of Medicare and Medicaid. From the Left, it would be the single payer system. We've already made the compromise of abandoning those who favor single payer. We've also let go of the benefit for optional senior care counseling with a doctor because Palin and Grassley (Grassley, the guy that the post-partisan Obama insists is a cooperative partner) convinced the less savvy crowd that their grandmother would be forced to see a panel of non-medical judges, one of them holding a syringe and a vial of lethal compound. Now is not the time for guys like you and Dick Durbin to get soft. The public option is the essence of real reform, not a bargaining chip. We should fight for it as hard as the other side fights to confuse Americans.

Posted by: ray20 | August 16, 2009 1:52 AM | Report abuse

First there is no money in social security because the government has "borrowed" it. Since its exception social security has been changed from what was supposed to be a savings account that a person could pay into that would be paid back after retirement.

Over the years the system was changed and abused. The ability to borrow from it should never have been allowed, and it was this scam that allowed many administrations the illusion of having a "balanced" budget ala Clinton. Bush drained the last of it so there is no more money to borrow.

Another abuse was allowing people to draw from social security that never paid into it. I have several neighbors. One was in the Navy for 12 years and then worked for 40 years and retired. Another is a Russian legal immigrant. The Russian draws about $400.00 a month more than my other neighbor, but the Russian never paid a dime into the system.

A government run health care system would be a disaster. Our government cannot be trusted to do the right thing by its citizens, they will always sell out to the highest bidder.

Posted by: Bubbette1 | August 16, 2009 5:46 PM | Report abuse

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