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Remembering Obama's campaign health-care plan

PH2009122000772.jpg"Though the American left and right don't agree on much," wrote Frank Rich over the weekend, "they are both now coalescing around the suspicion that Obama's brilliant presidential campaign was as hollow as Tiger's public image."

It's hard to imagine why. The health-care bill that looks likely to clear the Senate this week is not very close to the health-care bill most liberals want. But it is very close to the health-care bill that Barack Obama promised.

Thanks to the magic of Google, it's easy enough to revisit the plan (pdf) Obama campaigned on in light of the plan that seems likely to pass. And there are, to be sure, some differences. The public option did not survive the Senate. The individual mandate, which Obama campaigned against, was added after key members of Congress and the administration realized that the plan wouldn't function in its absence. Drug reimportation was defeated, and a vague effort to have government pick up some catastrophic costs was never really mentioned.

But the basic structure of the proposal is remarkably similar. Here's how it was described in the campaign's white paper:

The Obama-Biden plan provides new affordable health insurance options by: (1) guaranteeing eligibility for all health insurance plans; (2) creating a National Health Insurance Exchange to help Americans and businesses purchase private health insurance; (3) providing new tax credits to families who can’t afford health insurance and to small businesses with a new Small Business Health Tax Credit; (4) requiring all large employers to contribute towards health coverage for their employees or towards the cost of the public plan; (5) requiring all children have health care coverage; (5) expanding eligibility for the Medicaid and SCHIP programs; and (6) allowing flexibility for state health reform plans.

We don't know what the employer mandate will look like once the House and the Senate merge their bills, and the exchanges look likelier to be run by states or regions than by the government (though there will also be a national exchange overseen by the Office of Personnel Management), but those are really the only differences. And it's not even clear they're differences.

Nor were there aggressive cost controls outlined in Obama's white paper but abandoned amid the legislative process. The Senate bill is quite a bit stronger on controlling costs than the campaign paper, which makes no mention of prudential purchasing or the excise tax on high-cost health insurance or the Medicare Commission or specific delivery-system reforms. The paper promises investments in comparative effectiveness research and health information technology, and the Obama administration delivered on both in the stimulus.

But whether you love the Senate bill or loathe it, whether you're impressed by Obama's effort or disappointed, it is very hard to argue that the bill Congress looks likely to pass is fundamentally different from the approach Obama initially advocated. "The Obama-Biden plan both builds on and improves our current insurance system," the campaign promised, and on that, for better or for worse, they've delivered. You can debate whether Obama should have lashed himself to such an incremental and status-quo oriented approach, but you cannot argue that he kept it a secret.

Photo credit: AP Photo/Gerald Herbert.

By Ezra Klein  |  December 21, 2009; 9:14 AM ET
Categories:  Health Reform  
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Next: Godfather of the public option: Pass the Senate bill

Comments

Hey Ezra, can you answer one question I have about this? We face enormous doctor shortages today (http://www.nytimes.com/2009/04/27/health/policy/27care.html). Won't bringing millions more into the system make things worse? I don't raise this as a point against insuring more people, because I favor that, but this is the biggest dilemma I have on this issue. It is unrealistic to think we are going to be able to train enough doctors to match the increasing demand, and therefore we will face longer wait times. I know I am simplifying, but would you mind putting me at ease on this one?

Posted by: gocowboys | December 21, 2009 9:20 AM | Report abuse

The new Medicaid mandates on the States will require new state taxes, except in Nebraska and Louisiana.

Senators Durbin and Burris did not obtain anything for the State of Illinois and made our serious budget mess worse.

Shame on them!

Posted by: mwhoke | December 21, 2009 9:23 AM | Report abuse

Ezra,

Nice use of the passive voice in discussing how drug reimportation was defeated. What do you think the role of the Obama administration was in that failure? How similar was that role to the one candidate Obama seemed to promise on the campaign trail?

Posted by: bobjones6 | December 21, 2009 9:34 AM | Report abuse

I think that Progressives are frustrated by Obama for not more aggressively and more clearly supporting the things they want, some of which he said he wanted himself. I'm not faulting him much on health care reform. Making sure you get all 60 votes isn't easy, I'm sure. Maybe he could have done more, but I don't know that.

However, it's ironic that the first African-American President has done as little as he has to help an economy that has the African-American unemployment at over 20%. We have overall unemployment at about 10%. It's not like there's an excuse for not doing more. The "centrists" have been a problem for Obama, but when it comes to the stimulus I agree with Paul Krugman. The centrists were only going to carve out a chunk and call it their victory for their own personal responsibility. Obama didn't ask for enough.

Now, he has reappointed Bernanke, a person who has announced his own lack of concern about employment. Furthermore, I heard recently that the administration was helping CitiGroup play accounting games so that they could "pay back" TARP money by the end of the year. This is so that executive bonuses may be paid without the restrictions of TARP.

I'll be very surprised if we get anything substantive in the way of finance reform.

People are frustrated with Obama over health care reform because they are frustrated with everything he has so far done. It may be that health care reform is as good as we could have reasonably hoped. But, on these other issues Obama and his administration are falling down on the job.

Posted by: bcbulger | December 21, 2009 9:40 AM | Report abuse

Ezra,

You are very informative. Thank you.

One question - One study of 23 rich nations, including a non- nation Taiwan, ranks the US at 23. What will US rank after passing of this reform? My wild guess is 23.

I have good new and bad news for Mr. Obama's reelection. Good news is I will not vote for his opponent. Bad news is I will not vote against his opponent, either.

Fool me twice will be shame on me.

Posted by: puweita9368 | December 21, 2009 9:41 AM | Report abuse

president obama was more honest and pragmatic than all of the other candidates.
clinton and edwards made promises about health care that would have been undeliverable. they were hollow pleas and promises.
look at what it took to get many of the senators to act like grown-ups...and the numbers of senators who should be totally ashamed of how they represented their constituents by voting against health care reform.
we saw the worst in human nature over the past few weeks.

people may not have liked president obama's position on health care and afghanistan during the campaign....but he didnt promis anyone the moon...he was pragmatic, steady and his position were well-known.
he took the heat even then....but he stayed steady.
and that is how we will get health care reform.
obama was the only one with steadfast principles.
every one of the other candidates hasnt even added so much as a WHISPER, in support of their once impassioned commitments to health care reform. they have abandoned it entirely.

hillary clinton, who could have led this fight for health care, abandoned it.
and even to think of john edwards now, and his impassioned pleas, makes one wince with shame.
sarah palin has made a travesty out of american politics and her magnificent state of alaska,
and john mccain has shown himself to be completely unprincipled and deaf to the sufferings of the american people.
thank you to everyone who worked so hard for barack obama. or we would not be standing on the threshold of health care refom today.


Posted by: jkaren | December 21, 2009 9:48 AM | Report abuse

Wow, what a whitewash of what happened.
The individual mandate, which Obama campaigned against, was added after key members of Congress and the administration realized that the plan wouldn't function in its absence, breaking his campain promisses of not raising taxes on people who make under $200K. Drug reimportation was defeated. After Obama soldout to the drug companies.

Posted by: obrier2 | December 21, 2009 10:06 AM | Report abuse

I agree with your assessment, but its a caution against disingenuous, overheated political rhetoric.

-- Public option. If you believe the political rhetoric about insurance companies being a key part of our problems with health care generally (even though that isn't the case), and you were sold on the public option as a-- wink, wink, nod, nod-- backdoor to single-payer, then you've got reasons to be upset. A level-headed policy analysis of the resulting reform would say that many of the problems with insurance companies-- recission, benefit caps, etc.-- have been addressed. But that was never how it was sold-- during the campaign or during 2009. The insurance companies were always the bad guys in this story, always THE REASON that we needed health care reform, so you have to excuse the liberal base for being confused that they should be content with a solution that solidifies their place.

-- Drug reimportation. This one is even easier. There isn't a policy analysis around that suggests this has any meaningful impact on health spend. And those analyses don't even factor in the likely consequence of pharma companies restricting drug supply to lower-price countries to levels that solely meet their constituents' needs, thereby preventing reimportation to even be practically implemented. This was always about populist, anti-big business rhetoric, not supported by the actual policy merits. It was an easy concession by the Obama administration because of the negligible impact from a policy perspective. But you wouldn't know that from the campaign speeches. Again, easy to blame the liberal base who listened to Obama and the other Democratic candidates. But the blame again lies on rhetoric not consistent with the policy specifics.

Posted by: wisewon | December 21, 2009 10:17 AM | Report abuse

And the turd-gilding continues apace.

It was clear that Obama was not as invested in healthcare reform as the other main primary candidates. That was potentially offset by the number of people in Congress who were, but the result of the particular negotiation path -- in particular, Obama's habit of negotiating with himself -- has brought forth a healthcare bill that looks like it was shaped by people who have an interest in profiting from healthcare but not people who care about providing it.

We'll see how much of the legislation survives to the implementation dates.

Posted by: pseudonymousinnc | December 21, 2009 10:22 AM | Report abuse

Currently, you pay your health insurance premium. The insurance company takes your premium and covers administration, markets & advertises, pays bonuses & lobbies against your interests, and uses a portion to provide you with health care should it be needed. What’s different in the Senate’s ‘reform’ package? Answer: You are mandated to pay health insurance premiums, your taxes will subsidize the health insurance industry by paying for those who cannot afford health insurance and health insurers can use 20% of your premium on non-health care (see administration, etc. above). Comment: As with the financial industry, the bill promises ‘heavy regulation’ of the insurance industry. Democrats, you are going to be pilloried by the voters. You must not pass this.

Posted by: theworm1 | December 21, 2009 10:41 AM | Report abuse

To follow myself up: the mandate will surely survive, but the subsidies are an easy target for the advocates of Healthcare Calvinism, where the ability to pay premiums is an indicator of one's moral worth, and thus one's worthiness to be receive good care. And the parasites and skimmers have bought themselves about another decade of dining out on people's ill health.

Posted by: pseudonymousinnc | December 21, 2009 10:48 AM | Report abuse

Joe Klein on Swampland had good criticism of Frank Rich's column. That column was washout. As I said earlier:

"The problem with Rich is he thinks good column is like a brilliant act on a drama stage or some kind of ephemeral song belted out by a Diva - it works or does not work. He treats political commentary too much as a 'free art form' - let us try to throw something on the canvas and see if it sticks or not and see if that pattern looks great or not...."

Anyways enough with Rich because equally on occasions he writes phenomenal columns. Besides, taking risks with your columns is part of good political commentary.

Your second part is different - how the current legislation resembles or differs with what Obama offered on the campaign trail. Ezra's case is right here - I do not think people are going to take fault with President Obama in terms of what he brought in this legislation compared to his promises; it is on lines what he talked about.

But things change. As things change, generally people are perplexed about:
- in Great Recession, keeping the priority of HCR still as is and
- as deficits are becoming the hot issue; whether Obama needed to be more cost vigilant.

I believe, these are the things on which people will evaluate President Obama. Chances of 'positive effect' of legislation flowing towards people in next couple of years seem to be dim; based on the proposed schedule. This means circumstantial assessment will trump over the true impact of the bill.

Posted by: umesh409 | December 21, 2009 11:02 AM | Report abuse

Barack Obama campaigned for President on the idea of a public health insurance option, and he was against any mandates.

The bill passing now contains no public option and does contain mandates.

Drug reimportation was also something he was in favor of but now has dropped.

You admit all of this, and somehow claim that what he campaigned on and what he pushed for now are "remarkably similar"?

Can you define "remarkably"? Or the word "similar"?

Because you keep using those words, but I don't think they mean what you think they mean.

Posted by: BillEPilgrim | December 21, 2009 11:18 AM | Report abuse

Ezra -- Several questions: The senate may have provided more or less what Obama prescribed; I don't recall anything in the Obama/Biden plan that allowed states to restrict insurance options available to women, though. Is the WH likely to fight to remove the "abortion compromise" during reconciliation or should women start scouting out comfortable spots under the bus? Also, where's the tough regulatory oversight and cost controls that should go hand in hand with the individual mandate? So far, it looks like the middle class is going to be squeezed a lot harder than the insurance companies. Oh, and any chance you can get space to publish an outline of "gold", "silver", and "bronze" insurance levels and how they compare with what's being called "cadillac" coverage for purposes of taxing benefits? It would be very sadly ironic if we used taxes to help people buy insurance that will only be "affordable" if it isn't very good.

Posted by: sandrine1 | December 21, 2009 11:19 AM | Report abuse

Ezra - thanks for recognizing the frustrations and disappointment of progressives about the lost of the public option/medicare extension and "conservaDems" veering this legislation more and to the right. You understood and said here's why this legislation should still be supported. You then went on to give details which you know progressives love. ha ha. Gibbs and Axelrod didn't get that memo and started off attacking Dean and thereby others who felt similarly. It's part of a pattern I see from the President and his staff attitude towards progressives in and out of office. I'm sure Obama and his staff aren't always happy with centrists and conservatives but they don't telegraph their feelings as much. Instead they tend to bend over backwards to convey they are listening to these groups. No one likes being taken for granted. That said, Feingold and Webb need to man up, hiding behind the president for their vote on this bill. Although I agree Obama could have provided more leadership in bringing people back to the reason for reform, he was gone. It's a pattern I noticed, near the end of the presidential campaign. He bought into not fighting his opponents that he forgot supporters needed to see him fighting/passionate on their behalf, especially in this high stress/anxiety fill times.

That said, some people do seem to forget that the president decided to go for this major legislation in his first year, a few months into office at a time of a severe economic crisis. Congress could not have gone ahead without his supporting the effort at this time. The bottom line is that more Americans will have access to healthcare. It's why this South Carolina waitress voted for him http://www.youtube.com/watch?v=F8FdVo0IT2w&feature=player_embedded

Posted by: wshudley | December 21, 2009 11:55 AM | Report abuse

In your older post on you wrote:

“costs aren't rising because insurance is expensive. They're rising because health care is expensive.”

NONSENSE!

Just a cursory review of other countries makes clear that REAL outcomes, longer life, better infant mortality, is being met elsewhere at significantly lower tradeoff.

As NM Senator Bingaman has stated: “Many countries achieve higher life expectancy rates with significantly lower spending.”


Why? Because NONE of these countries allow private health insurance (although some like Switzerland or Germany may APPEAR to have insurance markets, on closer inspection they are NOT- they are merely alternative private health care delivery plans).

While there are other issues,PRIVATE INSURANCE is the main factor explaining our higher real costs.

We have a huge industry- that once we accept the premise of universal health care and a single actuarial pool that treats all members equally - that is merely skimming (rent seeking) for providing a phantom function (assessing a risk that is non-meaningful).

The industry simply adds little value. There is widespread agreement that this inflated administrative nonsense is the primary waste in the system, inflating costs by roughly one half to one third, and why Americans pay so much more for health care, with worse outcomes compared to other nations. We are talking about WASTE, in terms of phantom services, approaching one trillion dollars/year.

Secondly, while it is true that in a real universal care system, all folks must be included, it is NOT true that mandates are the only way of addressing this. The alternative is to fund these out of GENERAL revenues, the way our wars and the military are funded. The difference is mandates are a backdoor method of keeping an obsolete industry viable, and allows gaming of the system in a way general funding does not.

In sum, Obama, while not willing to consider a single payer directly, did campaign on:
1) offering Americans a REAL CHOICE on whether they wished to opt into a public insurance option and
2) assurances that they would not be FORCED into supporting an industry they felt was at the crux of the problem.

Obama broke his word on BOTH key issues.

Posted by: erichwwk1 | December 21, 2009 11:55 AM | Report abuse

Other than that, Mrs. Lincoln, how did you enjoy the play?
No public option.
Mandates.
No drug reimportation.
You're kidding, right Ezra?
Please, please, stop accepting emails from Rahm and learn to think for yourself.

Posted by: kmblue | December 21, 2009 1:18 PM | Report abuse

Ezra,
The major message of the Obama campaign was what? Change.

The major vehicle by which Obama achieved his success was what? A popular mobilization of contributors and voters.

Technically he is "change" relative to Bush but that wasn't difficult at all, given that Bush will rank somewhere in the bottom quintile of Presidents.

Obama also rapidly moved to distance himself from the movement and the ordinary people that scraped together money to elect him. He has been largely an establishment President.

So, while yes the reform bill that he got has a resemblance to the policy proposals that he endorsed as a candidate but the spirit of "Change" is not in it, as I think you often acknowledge.

Posted by: michaelterra | December 21, 2009 3:50 PM | Report abuse

ericchwwk1: Health care is more expensive here because public health insurance is a more effective way of lowering health care costs than private health care (they can negotiate prices better, and so forth). But health care IS the problem.

Posted by: usergoogol | December 21, 2009 5:17 PM | Report abuse

Lobbyist written health insurance windfall was a campaign promise? I must have missed that.

Let's use the Obama method in the next election.

Let's openly say we are for him and then pull the rug from under him.

It works both ways.

Posted by: Rubiconski | December 21, 2009 9:18 PM | Report abuse

If Obama had run on the following would he have been elected?

1) I will cut Medicare by $500 billion dollars to fund my half of my health care reform.

2) The other half of my reform ($500 billion) will be paid for by raising the payroll tax, creating a new tax on middle class health benefits, requiring middle class seniors to pay more for Medicare benefits, reducing access to Flexible Savings Accounts, and making it harder for middle class families to deduct "out of pocket" medical expenses on their tax returns.

I wonder?

Posted by: cautious | December 22, 2009 2:43 AM | Report abuse

Mr. Klein, you are completely and utterly delusional. Except for the main points of his program, Obama got the program he campaigned on? That is absurd and silly on the face of it. This is a failure stacked on a number of failures where Obama went directly against what he promised on a number of topics: civil rights, privacy, Patriot Act, wars, justice, accountability. This constitutes a pattern.
Klein's apologia for Obama and the horrible Senate is another pattern: the pattern of self-destructive, foolish adoration for failures that seem "reasonable" or "Bi-partisan" but are widely seen by the people as simple failures. Failures of policy, judgment, character, and honesty.
Klein, Silver, and Krugman are hyping the "candy" we're going to get with the spinach of the Senate's miscarriage long before the actual candy is in our hands. It's the wisp of a promise of candy from people with chocolate on their faces. I don't want the hint of a promise of candy in the future; I want what I was promised a year ago from the man I funded and supported, who did little in public to push for the two key provisions that would have made change possible in the health care and insurance part of the economy.
Obama had no problem going LBJ on Congress to get funding to keep murdering people overseas-why can't he strongarm congress to help his fellow Americans?

Posted by: sparkplug1 | December 22, 2009 3:03 AM | Report abuse

Maybe you need alzheimers medication. The Senate bill contains a tax increase on the middle class. It fails to hold fat cats and corporations accountable. It includes mandates. These are all campaign promises that this bill violates. I am really sick of bad journalism and propaganda.

Posted by: dkoakland | December 22, 2009 5:48 AM | Report abuse

Matt Welch at reason.com does to Ezra Klein's defense of Obama what Obama did to his own campaign promises on health care - chews 'em up and spits 'em out.

http://reason.com/blog/2009/12/22/can-obama-open-his-mouth-witho

Posted by: seanfitz2004 | December 23, 2009 7:12 PM | Report abuse

This is "change" you can believe in? -- Harry Reid playing backroom porker with Landrieu and Nelson to see whose snout goes deepest into the trough and then having the gold-plated chutzpah to defend the practice by criticizing senators who did not do the same as well. Change? Lyndon Johnson and Daley Pere would blush at the sheer gall of it.

Posted by: seanfitz2004 | December 23, 2009 7:17 PM | Report abuse

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