Obama and Health Care “Reform”

2009 September 18
by HiFi

imagesTwo days ago senator Max Baucus revealed the Senate Finance committee’s health care bill. Baucus had delayed this bill for months in an attempt to get what he had promised as moderate Republican support. Baucus, who is heavily funded by the health care industry, has strong links with industry lobbyists, many of whom are former staffers in his office. His attempt to get Republican support for a centrist bill have collapsed in his face. In the end, Baucus’ plan has failed to build consensus among the political elites.

This is significant because Obama embraced a strategy that hoped to avoid the mistakes of the Clinton administration’s health care disaster by hitching his ride to Baucus and the finance committee to come up with a centrist plan. This contradicted his earlier positions as both a Senator, when he backed a universal single-payer system, and as a presidential candidate, when he retreated to a commitment to a public option. As support for Obama fades quickly there is no better contrast between the hopes of millions of people who were key to his election victory and the realities his actual politics expose about bourgeois democracy.

But Obama also has a problem with the House Democrats who, along with liberal talking heads, columnists and the “netroots”, pushed back against him at the end of August after he said he was willing to drop support for a public option. House Democrats and the liberal section of the Senate have staked out their own position around the Senate Health, Education, Labor and Pensions (HELP) Committee’s bill that emerged in July. This bill is similar to one in the House.

The main difference between the two Senate bills is the public option. Where the HELP committee’s bill contains it, Baucus has purged it from the Finance committee’s plan. If the public option is apparently a source of tension between centrists and liberal wing of the Democratic Party, then what is the public option composed of?

First conceived as a program similar to Medicare, the plan intended to enroll 130 million people. This was necessary advocates pointed out, to create a large enough market share needed to bargain for reduced costs from health care providers. However, the idea of a public option has been dramatically transformed since its original inception in 2007.

The Congressional Budget Office estimates that the current public option, as represented by the HELP committee plan, will cover only 10-16 million people. The problem here is that for a public plan to be successful it would need much greater numbers to negotiate reduced prices. The HELP public option will not pay significantly less than private insurers to providers, nor will it begin with a pool of enrollees and, thanks to the intervention of the conservative American Medical Association, providers are under no obligation to participate in the plan.

An important component to all of this are the big unions. Obama knows they are important in getting the vote our for him in the next elections and he has addressed union audiences twice in recent weeks on health care. Most unions have either endorsed a single-payer, universal health care policy, or the so-called public option. But Obama froze out groups advocating universal health care shortly after he took power when the initial round of negotiations with insurance companies resulted in a commitment to individual mandates to buy insurance, following roughly the Massachusetts model. The Obama administration was successful in preventing industry opposition to the idea of new health care policy by promising to coerce tens of millions of new customers to their doors.

Health Care for America Now, a coalition which includes AFSCME and the SEIU, have been the most active promoters of the watered down public option as, they claim, a chance for a great “progressive” victory. While some progressives argue, improbably, that this is only the first step towards universal coverage, the union bureaucracy are likely seeing a more opportunist victory here. They need what can be spun as a “win” from Obama to justify their unquestioned backing of him. They need to put more tape and glue on their cracking legitimacy. Therefore liberal Democrats and the political forces representative of Health Care for America Now making a fuss over the gutted public option are looking for a way out of where their politics and interests have led them: in complete contradiction of their rhetoric.

With this elaborate public relations dance, Obama is trying to help them and himself out. As the NYTimes reported, the goal for Obama’s speech last week in the Senate was to set the agenda for scaling back Congressional plans for health care reform and refocus on cutting costs for the government and corporations. The center of Obama’s speech was its “deficit neutrality” and its message about the public option, which was, essentially, to bury it. Obama signaled that he expected less than 5% of people to be signed up for the public option, far less than the HELP version, and a friendly amendment to the Baucus plan. Such a public option, if enacted, would offer minimum coverage with relatively steep fees along the lines of a supplement to medicaid or medicaid-like plan. Even given this, it has to be remembered that medicare and medicaid itself are deeply flawed programs.

So what are the core elements of “Obamacare” as it looks now? While the numbers and details around the edges are rough, the alignment of political forces and the ideology Obama represents make the fundamentals seem certain. Individual mandates are the central part of the “reform”. This means that the uninsured must buy insurance. Since this will be financially difficult for working people there will be subsidies in the form of tax credits. However, these subsidies are not substantial enough to cover the premiums that would be mandated. For example, these mandates will cost somewhere between 10-13% of yearly income for a family of three making approximately 63,000 dollars. This does not include deductibles and co-pays.

In order to partially pay for this plan–roughly 900 billion over ten years–there will be 500 billion in projected cuts to medicare and medicaid that will limit health coverage for the insured. It will further cover costs by imposing fees on employer sponsored health policies that go over a certain limit. These fees will be substantially less than the penalties inflicted on working people who can’t afford mandated insurance. The purpose of this component of any plan is to give political cover to employers to contract cheaper health plans for workers–especially union workers who have won greater benefits. Therefore employers are being incentivized to either further reduce benefits or dump people on “insurance exchanges” from where the existing and newly uninsured will have to buy insurance from.

So why is this consensus over health care “reform” among capitalists and the political elite coming together now?

They recognize they have their own crisis of healthcare. Obama’s relentless focus on cutting costs are meant to pass on the effects of health care inflation–rising approximately four times faster than wages–to workers. Health benefits are eating into corporate profits. Just as wages must continue to fall in the U.S., so must benefits and pensions in order for American capitalists to stay profitable within global capitalism. Yet this is only an expression of a much deeper phenomenon that goes to the heart of the current economic crisis. Capitalists must find ways to compensate for the falling of profit rates on a global scale. This is the reason for the attack on education, health care, unions, pensions etc. the last 30 years. In order to increase the rate of exploitation they must force workers to carry more of the burden of social reproduction. It is for this reason that during the restructuring of GM and Chrysler the government, with UAW approval, forced cuts in benefits and increased premiums and co-pays for autoworkers.

Therefore Obama embraced the mantra of “entitlement reform” early on in his administration by holding a “Fiscal Responsibility Summit”. Many of the players at the summit are part of broader effort to loot Social Security and Medicare. Part of “entitlement reform”, then, is looting Medicare and government coffers in massive giveaways to the insurance companies. This is part of the general pattern of the capitalists taking advantage of the crisis to deepen their attacks, the bank bail out being the most obvious.

However, there are around 60-70 million uninsured and under-insured in the United States. Not only do tens of thousands of people die every year in the U.S. for a lack of health coverage, but the U.S. spends more on health care than any other comparable country in the world, most of whom have some form of universal health care. Obama now represents a wing of the political elite who understand that this situation, which will only grow worse as more employers offer no health care at all, will threaten the legitimacy of the their own power. Therefore they are attempting to rationalize the system by realigning the framework of understanding the social need for health care within neo-liberal social ideology. The realities of a worsening health care system must be reconciled with the need for “change”.

In the latest example of newspeak, the Right have called Obamacare “socialism” and the official media as “progressive”. It is a surreal moment. The reality is very different. Obama’s reform will be remembered similar to Bill Clinton’s “welfare reform”. As part of the same process that “health care reform” can be thought of, welfare was turned into “workfare”–cheap labor for the state and corporations.

  • http://democracyandhiphop.blogspot.com/ Krisna

    Excellent piece, mlove. That clears up a lot of confusion over the different conceptions of the proposed health care reforms. Also, it shows what the real impetus is from the top to change how health care is managed and the historical context for why health care and other institutions that have benefited working people (however minimally) are being decimated: to ebb the falling rate of profit. This is a reality that can be quite confusing when seen in terms of skyrocketing profits and the largest redistribution of wealth in history. But when considering where actual value is created, in the production and reproduction of commodities, we see that the induction of more and more labor-saving technology into the process of production has placed a significant damper on the capitalists’ ability to make a profit. No wonder they are gutting social services and carrying out such widespread austerity measures at a breakneck pace.

    One thing worth highlighting in this piece is the polarization within the Democratic Party. Often the Democrats are painted by various sections of the Left as somewhat homogeneous. Employing this logic, having a simple majority of Democrats in the House and Senate should mean victory on each of the major policy proposals. But the failure of EFCA and now Obama’s turn to Baucus’ Finance Committee plan (and a litany of other concessions) reveal how pronounced the rift is between centrists and liberals and this in particular has had the effect of alienating the liberal wing. My question is, what are the implications for such polarization among the Democrats? Perhaps, “polarization” is too strong, but what are the short and long term consequences of the differences? Immediately I can say that we should be sober about what we think is possible even by bourgeois standards. Unless there is a dramatic increase in illegal activity among the working class (strikes, marches, boycotts, and barricades), we shouldn’t expect to see much consensus on questions of universal health care.

    Word.

  • CG

    Thanks a lot for sharing this piece, mlove. I think the issue of health care is a hard one for the left to take up; in particular, this is because the notion of health has been so successfully enclosed in a capitalist system of paying for medications, treatments, and visits, that we cannot conceive of a “public option” for health care that is not synonymous with a medicaid-like system. It is this inability to see paying for medical care, to issues of access over HEALTH CARE , I think, that have at least in part allowed the Obama administration to so successfully re-place the burden of health and illness onto poor, working, and non-working folks.

    What scares me, though, is that someimes the “most left” option is to fight for “universal health care”, i.e., a medicaid model. What many might not know, is that medicaid itself has been scaled back significantly in the last several years; many people receiving public benefits are forced onto “medicaid managed care”, which means that you have to find an HMO, which most likely will not cover as many things as medicaid. In the meantime, what exactly is medicaid covering? For poor, ill, and disabled folks, at least, it covers doctors visits and meds that control people to make them easier to manage (for example in homeless shelters or transitional housing). State control over medical benefits serves a similar purpose to state control over public schools or over housing; to create a systematic and hegemonic means of control, that can lead to alienation from things like knowledge, housing, or health; that can then be turned into commodities for purchase.

    I think that a way to move forward from these recent developments, which I think mlove points to as being continuations/new manifestations of other state-led initiatives to distance people from their labor and bodies, is to try to think about what a reclamation of health could look like? During organized labor movements throughout history, long general strikes have been maintained by having people in caring roles that had been deskilled and devalued, providing care for free to other strikers. This often included doctors. What would it look like if, instead of working to keep people ill in order to continue to raise capital (whether from medicaid or private insurance companis–it should be noted that providers like medicaid more because it often allows for charging of unnecessary or un-completed procedures and medicines that private companies refuse to cover–i.e., doctors and pharmacists can eek out more capital from the state at the expense of people’s health), folks engaged in free provision of care, or a re-skilling of health work? This would have to work in conjunction with labor movements to create emotionally and physically safe workplaces, and against social security and public housing programs that discipline non-hetero-standard family formations (such as TANF, workfare, etc). It would also mean a process of de-pathologization of poverty; and an active effort to sustain the health and vitality of folks who are working or unemployed…

  • http://www.democracyandhiphop.com Lauren

    CG, can you expand on the relationship between this statement: “process of de-pathologization of poverty” and your larger point about rethinking health care?

    What you raise brings to mind two interrelated questions: what might health care look like in a new society (i.e. a direct democratic or self-managing society) and what a transitional program for health care might look like. By the latter I mean how can health care be organized around and fought for in communities today, under a capitalist system, in ways that build the power and confidence (and health!) of working class folks and contribute towards a more generalized confrontation with the capitalist class (in the form of movements or revolutions). I’ll focus on the latter here as it relates more directly to the examples you raise. It’s helpful to look at how some movements have historically taken up health issues, although that’s an area I’m not real familiar with.

    Organizing around health care often seems to intersect and overlap with struggles focused on other issues – i.e. ecological destruction, reproductive freedom, or access to health resources (health food stores & grocers; free healthy food programs like the Black Panthers’ Free Breakfast programs). Communities have organized for access to clean natural resources and to defend against pollution by factories and militaries. Students could organize around the food provided in their school cafeterias & dorms, demanding healthier food and linking that to struggles among cafeteria workers.

    But that gets us to an important point CG raises: rethinking health in relation to labor. Health care isn’t just an issue of dispensation; it’s an issue of control. How can health care workers (nurses, orderlies, CNAs, etc.) organize for control over how their hospital offers medical care? For instance, hospital workers organizing with the community to fire the hospital board – usually wealthy businesspeople with little to no experience in medicine and whose primary interest is profit – and democratically elect a board made of workers and community members. How can hospital workers make connections to and organize with home care workers and workers at private facilities (i.e. retirement homes) so that the latter aren’t used by capitalists as a tool for undermining the quality and quantity of care provided by all? This is an issue I’ve seen come up in Cali and I’m sure it’s relevant elsewhere.

    I think the struggle to rethink health care has to also be about breaking down the barrier of it being looked at as “skilled labor” and specialized knowledge. Break down the tightly controlled boundaries of elite medical schools as the so-called keepers of such knowledge and skills. This could take the form of demanding open admissions at medical schools on campuses where we might be organizing. It would also mean having our own working class schools, so to speak, that could replicate that knowledge among larger numbers of people in organizations and within new movements.

    An inspiring example of the latter is the Jane Collective, an underground organization in Chicago in the late 1960s and early 1970s that offered safe and affordable abortions before Roe v. Wade made them legal. At first the Collective had friendly doctors come in to perform the abortions, then eventually they had doctors train women in the group on how to perform them. Many of these women had no medical background, but with collective study and training by someone who was an “expert” they were able to do the work themselves and meet the growing demand for abortions.

  • CG

    Lauren,
    Thanks for your response, your analysis and examples are really helpful in thinking through these issues, and moving them forward.

    A challenge I have come up against in our labor struggles at UW, and in thinking through and articulating critiques of health care, is that the struggles by working folks are in one way inherently different from struggles by “ill” poor and non-working folks; that is that “ill”/non-working/poor folks are always already being managed by a variety of bureaucracies; either directly run by the state (such as in public nursing homes or city-run shelters), or by private companies and/or non-profits receiving state benefits (such as with social workers, who are paid by social security and medicaid). On top of dealing with this intense micro-managing of their BODIES, these folks are also facing pain, distress, and often times lack of housing or in-appropriate housing.

    Patholigization, then, is the process of making poverty bodily; of locating poverty within the bodies of poor folks, instead of in the broader capitalist system that produces poverty. This bodily poverty then needs to be TREATED; however, the treatment that people receive is tied to ill-health diagnoses (for example, veterans can only receive benefits with a disability diagnosis; medicaid is either an age/income or disability/income benefit). The tie to a rethinking of health care more broadly is that “public” or state health care is not now about actually keeping people healthy; instead, it is about controlling folks who are poor and/or ill, and instead of providing TRUE remedies (appropriate housing, the end to a capitalist system, non-toxic and non-corporate drugs), people are given Haldol, Insulin, and a shit-ton of forms that can only be filled out with the help of a certified Social Worker.

    So, your point about control over the means of making people healthy/caring is so incredibly key! Your points about open access, mutual education, etc are a HUGE step in de-patholigization…if poor folks are providing high levels of care, then the separation between illness and health decreases. Organizing health care workers so that they can simultaneously maintain their own (and their families’/communities’) health and well-being, and provide better care is then incredibly important in linking struggles over health, feminization of work, and labor.

    In addition, I believe a concurrent struggle needs to be the support of the organization of folks suffering ill-health to DEMAND not just more drugs, not just payment for surgeries, but an end to state and economic structures that make them and keep them ill in the first place; folks suffering from ill-health can fight for care-takers who are not exploited, who are able to care in full capacity, but also for care work to be able to happen outside of state and private institutions. A true re-valuing of health and care would also mean support both for folks performing care work in households and/or in communities, and folks receiving care in these settings. This means fundamentally challenging the notion that we are always only either ILL or HEALTHY and either cared for or caring. I think that this idea is actually really echoed by the example of the Jane Collective: when health and care can be understood as basic rights, not just to be healthy and care for, but to PROVIDE health and care, and when these can be understood as not just oppositional binaries,the demands for fair labor treatment, access, and gender equality will be closer to being answered.