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Posted at 9:51 AM ET, 03/ 8/2011

Column: Put-up-or-shut-up time on health-care reform

By Ezra Klein

It’s put-up-or-shut-up time for Republicans. They managed to make it through the health-care debate without offering serious solutions of their own, and — perhaps more impressive — through the election by promising to tell us their solutions after they’d won. But the jig is up. They need a health-care plan — and quickly.

The GOP knew this day would come. In May 2009, Republican message-maestro Frank Luntz released a polling memo warning that “if the dynamic becomes ‘President Obama is on the side of reform and Republicans are against it,’ then the battle is lost.” Repeal, Luntz argued, wouldn’t be good enough. It would have to be “repeal and replace.” And so it was.

That, however, is easier said than done.

To understand the trouble the Republicans find themselves in, you need to understand the party’s history with health-care reform. For much of the 20th century, Democrats fought for a single-payer system, and Republicans countered with calls for an employer-based system. In February 1974, President Richard Nixon made it official. “Comprehensive health insurance is an idea whose time has come in America,” he said, announcing a plan in which “every employer would be required to offer all full-time employees the Comprehensive Health Insurance Plan.”

In a moment of historically bad judgment — Ted Kennedy later called it his greatest political regret — Democrats turned him down. They thought they could still get single payer. They were wrong.

By the 1990s, they had learned from their mistake. Bill Clinton took office and, after a wrenching year of negotiations, announced legislation similar to Nixon's.

”Under this health-care security plan,” Clinton said, “every employer and every individual will be asked to contribute something to health care.”

But Republicans again balked, calling instead for a system of “individual responsibility.” Senate Republicans quickly offered two bills — the horribly named Health Equity and Access Reform Act and the Consumer Choice Health Security Act — based on the idea that every person who has the means to buy health insurance should have to do so. We now call that concept “the individual mandate.”

Both bills attracted 20 or more co-sponsors. Neither passed, as Republicans yanked their compromise legislation the moment Democrats became desperate enough to consider it. The individual mandate, however, didn’t go away. It kicked around conservative health-care policy circles, racking up endorsements from the conservative Heritage Foundation and the libertarian magazine Reason. A year later, the mandate showed up in a law that then-Gov. Mitt Romney signed in Massachusetts. And then it was in the bipartisan proposal that Utah Republican Bob Bennett and Oregon Democrat Ron Wyden introduced in the Senate. And next, it was the centerpiece of the Democrats’ health-care reform push. Consensus, it seemed, was at hand.

Or not. Republicans turned on the individual mandate again. Senators who’d had their names on a bill that included an individual mandate — Orrin Hatch, Chuck Grassley, Bob Bennett, Mike Crapo, Bob Corker, Lamar Alexander, Olympia Snowe and Kit Bond, to name a few — voted to object, calling the policy “unconstitutional.” Romney had to explain away his signature accomplishment as governor of Massachusetts. And Republicans found themselves without a fallback.

The party’s current mood on health-care policy is perhaps best expressed by the efforts that Michael Cannon, an influential health-care wonk at the libertarian Cato Institute, has made to enlist members in his “anti-universal coverage club.”

Enter Wyden-Brown, an Affordable Care Act amendment that the White House has made a big show of endorsing: It says that any state that can produce a credible plan to cover as many people, with as comprehensive insurance, at as low a cost as the Affordable Care Act can wriggle out of all the law’s mandates but still receive all the law’s money. Vermont’s governor, for one, is stoked: He wants to try a single-payer proposal.

Most conservatives have been actively hostile. They make some fair technical points. The law envisions the secretary of Health and Human Services handing out the waivers, while the Heritage Foundation’s Stuart Butler would prefer to see a bipartisan commission in charge. But most take aim at the proposal’s basic goals: that care has to be as universal, as good and as cheap.

Cannon, for instance, frets that there’s no conservative policy that “would cover as many people as a law that forces them to buy coverage under penalty of law.” Butler worries that it “locks the states into guaranteeing a generous and costly level of benefits.”

But as the New Republic’s Jonathan Cohn points out, under the Affordable Care Act, a family of four could shell out $12,500 out of pocket for medical costs. How much stingier should the insurance be?

And Cannon is right that conservatives don’t have solutions to provide coverage as universal as what the Affordable Care Act would. But whose fault is that?

Conservatives once offered solutions competitive with what the Democrats were proposing, but over the past 30 years, they’ve abandoned each and every one of them to stymie Democratic presidents. Confronted with a challenge to provide broader access to better health care at a lower cost, they’re reduced to complaining that those aren’t the right goals for health-care reform. But we’ve yet to see how “less comprehensive insurance for fewer people” would play in Peoria. My hunch is it wouldn’t play very well.

For decades, Republicans have chosen stopping Democratic presidents over reforming the American health-care system. Now that reform has passed, the solution for members of the GOP is to press the rewind button. They’re about to find out that it’s not enough.

On that much, Luntz and I agree: If the public comes to see the GOP as opposed to reform, “the battle is lost” — at least if you believe “the battle” is to beat the Democrats rather than provide quality health insurance to every American.

By Ezra Klein  | March 8, 2011; 9:51 AM ET
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Next: Vilsack: ‘I took it as a slam on rural America’


It'd be a smart move now for Democrats to get a few Republicans on board with moderate environmental and energy reform proposals, however limited. Having some Republicans backing moderate health care reform positions really helped, even when those same Republicans later abandoned their positions. Democrats repeating "Republicans used to support such and such" really revealed the narrative.

Posted by: Chris48 | March 8, 2011 10:42 AM | Report abuse

It will always be hard to have reform in a system that includes CEO pay of $205,000,000 per year (United HealthCare Bill McGuire for one) - huge resources siphoned off for non-medical use - The money is in the system to provide superb care to each of us, it just doesn't work out that way - Single payer national plan is the only way to control cost and access -

Posted by: winchestereast | March 8, 2011 11:07 AM | Report abuse

It is nice to see Ezra finally write about how Ted Kennedy, "the lion of the senate", was responsible for derailing universal health care in the seventies. Now if he would only level the same accusations at Senator Kennedy as he did at Senator Lieberman, that he was responsible for millions of deaths because of his political maneuverings, then I will know that Ezra is not just a shrill for the liberal left.

Posted by: cummije5 | March 8, 2011 11:11 AM | Report abuse

i think it might be hard for people from cities to get a sense of what rural american farming is, now.
when driving through the central valley in is hardly a rockwellian image of small family farms, with grange meetings.
it looks like american industrialized farming has nothing to do with "nature."
this may seem like a small thing, but in the minds of many people, i dont think it is.
i may be mistaken about this...but it seems like heavy, highly industrialized farming.
i think they bring in huge trucks to transport bees from other places, to even pollinate the immensity of the crops there.
and going across the united states, looking out through train windows through miles and miles of corn or sunflowers...i kept wondering if it was all genetically modified and mystified...and if monarch butterflies fell in the fields, because they got sick on the corn.
i think the average person, (i might be wrong about this) doesnt think of "rural america," like "little house on the prairie," in a laura ingalls wilder book.... of hale and hearty folk, with pies on the window sill in the summertime.
.they think of archer daniels, and monsanto, and colony collapse disorder....and kellogg's cereals...and the industrial abuse of chickens and pigs....
i think many people distrust agriculture in america.
they wonder about the corporate control....the abuses, and what is systemically in the crops we eat.
going up through the central of the horrors of the trip, is an area that extends for more than a mile, of cows that seem to be waiting by thousands, to be slaughtered. it feels like a concentration camp for cows.
and i think this is a lot of the impression now, that people have of farming and rural america.
not an apple orchard with a white frame house.
but miles and miles of sophisticated and soulless fields, with super-resistant crops that could be hazardous to your health, and the agricultural industry and lobbies have been ABLE TO AVOID LABELLING IF THEY ARE GENETICALLY MODIFIED.
i may be wrong, but i think the average person, who doesnt live in these rural areas, wonders about the agricultural lobbies, the methods of growing things, what kind of seeds they are using, how it all affects our health, what is the role of migrant workers, and many other questions, that make people uneasy...
i may be wrong, but i think that many people wonder about all of this, and the image of the individual farmer, in dungarees, laboring in a field, has been replaced by the website for monsanto and food companies that have slathered us in high seems like we know little about our food....
and this is what has replaced the image of "rural america."
just my opinion, of course.

Posted by: jkaren | March 8, 2011 11:19 AM | Report abuse

sorry, above comment was meant to be posted in comments for the interview with secretary vilsack.
thank you.

Posted by: jkaren | March 8, 2011 11:25 AM | Report abuse

@Chris48 - Would be great, but not holding my breath. Those guys are busy trying to gut the EPA, at the behest of some fairly large industry lobbies: oil & gas, utilities, coal fired pizzerias, etc.

As a recruiter in the space, we saw $1b in new venture money flow into Cleantech just in Jan alone, however, after all of the budget nonsense and Republicans moving aggressively to strip EPA of funding to regulate Greenhouse Gas Emissions, new investment has fallen off a cliff. I'm honestly starting to believe congress is a great place to rehabilitate republican head-injury patients.

Posted by: cleantekki | March 8, 2011 11:25 AM | Report abuse

I simultaneously laugh and shake my head at the foolishness of liberals like Ezra every time I hear one of them talk about Romey's health plan for Massachusetts and imply it's hypocritical to support something at a STATE level that you may not support at a FEDERAL level.

It just illustrates that to a progressive there is only one State, not 50 (or 57 if you are our current President).

Which, of course, puts progressives at extreme odds with the guys who wrote the know, that old piece of paper that pretty clearly and firmly established the limits of what the FEDERAL government can and cannot do, which does not equal the same limits of what individual STATES can and cannot do.

Posted by: dbw1 | March 8, 2011 11:26 AM | Report abuse

@ winchestereast: We've got it good in FL - Our Governor ran Columbia HCA when they were busy defrauding medicare; on his watch they paid the highest corporate fine in history - 1.7B. (BTW - he ran for Gov saying that he'd run the state like a business -God help us). Now that he's governor he's all for privatizing medicaid. Honestly didn't see that one coming . . . not!

Posted by: cleantekki | March 8, 2011 11:30 AM | Report abuse

Using similar logic regarding Ted Kennedy and healthcare. Shouldn't President Obama negotiate a much more conservative plan for energy independence with Republicans. I personally think so. And with energy prices front and center in the papers and public sphere, this current crisis may be a good time to utilize a shock doctrine of sorts to move towards energy policy changes. Progressives won't get everything we want, but if we can get a template in place, then incremental change can occur now and in the future.

Posted by: rfjohnson77 | March 8, 2011 11:40 AM | Report abuse

As long as healthcare and its insurance remains a for-profit entity, we will have ethical problems. There needs to be strict regulation on all levels in order to weed out the corruption already in place. Its simply trading people's health and life for profit which is morally bankrupt.

Posted by: EducatingTheFools | March 8, 2011 11:48 AM | Report abuse

As to the "individual mandate" supposedly being unconstitutional:

Don't any of these Republicans live in states where anyone who drives a car is required to have liability insurance? Why aren't they railing against that?? I can appreciate the analogy is not exact, but it seems it should get the Tea Partiers at least as upset, if indeed all they cared about was individual liberties.

Posted by: bcoole | March 8, 2011 11:50 AM | Report abuse

dbw1, it's always been about federalism-of-convenience, i.e., when you don't like a federal proposal, you say "let the states decide," but when you do: "this is a role for the federal government." Kind of like it being "judicial activism" when you preferred the status quo.

Given that the population for better or worse is largely dependent on employer-provided health insurance benefits and firms are largely interstate concerns, to a certain extent it makes more sense for these benefits to be administered and provided on a national as opposed to state-to-state level.

Posted by: arm3 | March 8, 2011 11:51 AM | Report abuse

Why is it put up or shut up time?

The republicans are happy, they just kicked ass in 2010, likely to do the same in 2012. I would assume (from a political standpoint) that they are just fine blasting Obamacare.

Posted by: marteen | March 8, 2011 11:51 AM | Report abuse

The road to single payer runs through state-level experiments. The Republicans know this and that's why they are opposed to Wyden-Brown.

Posted by: willows1 | March 8, 2011 12:22 PM | Report abuse

"one of the horrors of the trip, is an area that extends for more than a mile, of cows that seem to be waiting by thousands, to be slaughtered. it feels like a concentration camp for cows."

You're talking about Harris Ranch, which the locals refer to as "Cowschwitz".

Posted by: Nylund154 | March 8, 2011 1:20 PM | Report abuse

"Its simply trading people's health and life for profit which is morally bankrupt."

Let us start by forcing doctors to work for free. After all, they profit off of sick people, and that's just wrong!

Posted by: justin84 | March 8, 2011 2:20 PM | Report abuse

"Let us start by forcing doctors to work for free. After all, they profit off of sick people, and that's just wrong!"

I think the quote (not sure where from) has more to do with acts of negligence or recklessness causing harm that is morally bankrupt. See: Ford Pinto.

No one is asking for doctors not to be paid, or even paid well. Costs probably need to be reevaluated, however. The market certainly is distorted.

Posted by: arm3 | March 8, 2011 3:52 PM | Report abuse

"I think the quote (not sure where from) has more to do with acts of negligence or recklessness causing harm that is morally bankrupt. See: Ford Pinto."

If we are only talking about negligence or recklessness, then I don't see the problem - there is already a court system.

"No one is asking for doctors not to be paid, or even paid well."

That's not the point. People complain all the time about various negative effects of the profit motive in the health care sector. Excess salaries paid to practioners are significantly greater than the total profit which flows through to all health care companies. Some doctors make hundreds of thousands per year - they could easily live on $50,000/yr, especially once the loans are paid off.

Therefore, those who complain about profit in health care should be consistent and oppose high salaries for doctors, as they are profiting from the misery of sick people.

Posted by: justin84 | March 8, 2011 4:29 PM | Report abuse

I always wonder about Ted Kennedy's "historic mistake." During the 1990s, Bob Haldeman's diary or journal was published. If I am not mistaken, it indicated that Nixon only offered his comprehensive health insurance plan because he believed that it would never pass. Essentailly, it was a political tactic only, not a serious policy proposal.

Posted by: farrell_bill | March 8, 2011 4:44 PM | Report abuse

Wrong again, wunderkind. It will soon be put put up or shut up time for the Empty Suit Known as Barack Hussein Obama. We The People have noticed the largest monthly deficit evah.

"Because the Only Good Progressive is a Failed Progressive"

Posted by: joefigliola1 | March 8, 2011 8:19 PM | Report abuse

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Posted by: autoprt | March 9, 2011 2:38 AM | Report abuse

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