Part One
THE STAKES

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1 | THE GREAT DIVIDE
Of all the stories from the summer of 2009, when town hall meetings across the country erupted in fiery protests against health care reform, there was one story that quickly made the rounds among Democrats on Capitol Hill. It was the perfect illustration of just how deeply some people's distrust of government had affected their views of the health care debate.
It took place on Monday, August 3, right at the beginning of the month-long August recess that Congress traditionally takes. Gene Green, a moderate House Democrat, was facing a rowdy crowd of constituents in his hometown of Houston, Texas. Already, they were unhappy with his recent vote for the House climate-change bill. Now, they let him know they were equally unhappy with what they'd heard about the health care reform bill.
One man in the audience shouted out to the rest of the crowd, "How many people, by a show of hands, oppose any form of socialized or government-run health care?"
Almost everyone in the room raised their hands. There was lots of cheering, whooping, and hollering. Someone yelled out, "Yes, sir!"
So Green turned the question on its head. "How many of you have Medicare?" he asked. Medicare, of course, is the government-run health care program that pays for medical care for 45 million people, including 37 million seniors and 7 million people with disabilities. It is the program that provides the crucial safety net for our nation's elderly, regardless of whether they are rich or poor, sick or healthy. About half of the people in their crowd raised their hands.1
The discussion quickly moved on, so it's not clear how many of those people understood the irony. Green didn't ask the natural follow-up: "Are you aware that Medicare is a government-run program?" Instead, he let a man in the audience raise his concerns about how Medicare is working in practice—with doctors refusing to accept Medicare patients because the federal government is cutting their payments. That's a valid concern, and it deserved to be dealt with on its own. But it's one thing to address problems in the Medicare system. It's another to oppose, on its face, any kind of health care safety net that involves the government in any way.
Should we get rid of Medicare and let senior citizens fend for themselves? Should we eliminate the Medicaid program for the poor and people with disabilities? What about the State Children's Health Insurance Program, which helps low-income families get health coverage for their kids? Some people might, in fact, be happy to end all of those programs on principle. But it wouldn't be a widely held view.
And yet, that moment in Gene Green's town hall meeting went a long way toward explaining the forces that have kept health care reform out of reach for nearly a century. Why has it been so difficult for the United States to do what the rest of the world's industrialized nations have already done—build a complete health care safety net that protects everyone in his or her greatest time of need? Some nations have done it through a government system, others have done it through the private sector, but our nation has always stood out for its inability to help the millions of Americans who fall through the cracks.
There are plenty of reasons for that, and to some extent they reinforce each other. The issues in the health care debate are complex and often poorly explained; people want to preserve what they have, even if what they have is less secure than they might think; and the nation has become so politically polarized that different groups of Americans see the same reality in different ways. But it's hard to miss the one factor that truly drives the intensity of the opposition. Health care has become a symbol of the deep divide in Americans' feelings about the role government should play in solving our social problems.
Even for the majority of us who are fortunate enough to have health coverage, what we have is so fragile that one bad turn of events can end in disaster. Six out of ten personal bankruptcies in the United States are directly related to people's medical bills—and of that group, three out of four piled up unaffordable debts even though they had health insurance.2 Medical crises have caused as many as half of all home foreclosures.3 And more than a third of all Americans who tried to buy health insurance on their own couldn't get the coverage they needed because they had preexisting conditions.4 But for many Americans, the distrust of government runs so deep that they'll resist anything that might expand the government's role in solving the problems.
There is a bit of a disconnect here, because many Americans seem to believe that our medical care is run completely by the private sector. That just isn't the case. What we actually have is a public-private hybrid. As of 2007, public programs such as Medicare, Medicaid, and the State Children's Health Insurance Program accounted for about 46 percent of all national health care spending. That leaves a little more than half to private spending, mostly insurance coverage and some out-of-pocket costs.5 What we are really arguing about, then, is what the proper mix should be. Should it be closer to half and half? Mostly private spending? Mostly public spending? Other countries have had this same argument, as we will see later, and it is usually an ongoing debate, never completely resolved. We can continue to debate the question, too. But it should not stop us from fixing what we have so it does not continue to let millions of Americans fall through the cracks.
Many of my former Republican colleagues, I'm sorry to say, have fed Americans' distrust of government with speeches and public comments that greatly exaggerated the role Washington would play in a reformed health care sector. House Minority Leader John Boehner of Ohio regularly warned that the bills in Congress would lead to "a big, government-run health care system."6 Senator Jim DeMint of South Carolina—the same senator who predicted that health care would be Obama's "Waterloo" and that a defeat would "break him"—predicted that health care reform would "eventually crowd out quality private insurance and force Americans into a government-run health care system."7 Even Senator Orrin Hatch of Utah, who worked closely with lawmakers from both parties to create the State Children's Health Insurance Program in the 1990s, argued that Democrats were really trying to create a single-payer health care system like Canada's. "If they can't do it automatically, they'll do it in increments," Hatch said, and "that means we're going to have a one-size-fits-all government-run health care program right out of Washington."8
I never have understood why so many Republicans make this argument. It is basically an admission that Americans might like a public option if they got to try it—because if they didn't, how could it ever lead to a single-payer system? The larger point, however, is that the critics of the public option misread how Americans truly feel about government-run health care. When they actually experience it, they are fine with it. Medicare is so popular with seniors that they resist anything they think will threaten it. The economically disadvantaged may not love Medicaid, but they understand its vital role in their lives. The Department of Veterans Affairs health care system is more popular with veterans than private insurance is with other Americans.9 And TRICARE, the health care program for the armed forces, keeps topping the customer satisfaction lists in surveys that include all of the major private insurers.10
Still, the fear of government-run health care has been easily exploited by opponents of reform for decades. There's nothing new about the charges of "socialized medicine." It's the label the powerful American Medical Association (AMA) used to use as a weapon against the earliest national health care efforts. In 1934, the committee that drafted Franklin D. Roosevelt's original Social Security bill threw in one line about the need to study national health insurance and make recommendations to Congress. Lawmakers received so many angry telegrams in protest that the House Ways and Means Committee removed the line from the bill.11 That year, the AMA blasted a more specialized group, the American College of Surgeons, for endorsing national health insurance, condemning "this apparent attempt to dominate and control the nature of medical practice."12 When Harry Truman asked Congress to pass national health insurance in 1949, the AMA's charges of "socialized medicine" helped unseat some of the plan's strongest supporters in the Senate.13
It was only after the Lyndon B. Johnson's landslide election in 1964, which gave him strong Democratic majorities in Congress, that the political environment was right to create Medicare and Medicaid—a more incremental strategy that provided special protections for the elderly and the poor. But every attempt since then to expand those protections to all Americans has bogged down, largely because of the fear that a bigger government role in health care would take away the freedom most people have to obtain the health care they think they need. When our efforts to pass Bill Clinton's health care plan failed in 1994, it was partly because it was too complicated for most people to understand. But it also failed because that complexity allowed its opponents to portray the plan as a threat to their ability to choose their health plans and their doctors.
This time, many of the old foes of health care reform had turned to supporters, thanks to the growing recognition that skyrocketing costs and serious gaps in people's coverage had made it impossible to defend what was happening. Even the AMA became an ally of the reformers, at least in principle. In June 2009, J. James Rohack, the association's president at the time, declared "our dedication to provide affordable, quality health insurance coverage not just for some, but for everyone."14
But the old skepticism of government had not completely disappeared. Instead, the distance between the ideological camps seemed greater than ever.
As Barack Obama began his presidency, Democrats became more hopeful about the role of government, and Republicans became more deeply pessimistic—a direct reflection of voters' happiness with who was in the White House. In May 2009, four months after Obama took office, the Pew Research Center for the People and the Press found that 74 percent of Republicans agreed with the statement, "When something is run by the government, it is usually inefficient and wasteful"—a view shared by only 42 percent of Democrats. Two years earlier, there had been almost no gap between Republicans and Democrats, largely because Republicans were happier and Democrats were unhappier during George W. Bush's presidency.15
How deep is the public's distrust of the government's ability to solve problems? Andrew Kohut, the president of the Pew center, concluded that Medicare would face just as much opposition as the current health care reform effort if it were proposed today.16 In January 1965, as the momentum to create Medicare reached its peak, Gallup found that more than six out of ten Americans supported the idea. But in the May 2009 survey, as Congress prepared to start its work on the health care reform bills, the Pew center found outright confusion and hostility toward government. The vast majority of Americans, 86 percent, said the government "needs to do more to make health care affordable and accessible." Yet 46 percent were also "concerned that the government is becoming too involved in health care"—meaning a substantial number of Americans held conflicting views about what Obama and Congress were about to take on.17
It was also clear, though, that the distrust was lopsided, and that Democrats and Republicans had almost nothing in common in their views of the health care debate. Sixty-eight percent of Republicans thought the government was "becoming too involved in health care"—a view shared by only 29 percent of Democrats and 44 percent of independents. Still, it was sobering that the numbers were that high among independents, and that so many Democrats were so skeptical. Democrats have a lot of disagreements, and we have learned over the years that government can't solve all of our problems. But if there is any single core value we have always shared, it is the view that government is still the best forum we have to help each other in times of crisis. And when millions of Americans struggle to meet their basic health care needs, they are dealing with one of the most urgent crises anyone can face.
The great divide in our society, which keeps us bickering endlessly about the role of government in our health care, largely exists for people who have no direct experience with its shortcomings. For those who have been affected personally by those shortcomings, the divide disappears. Even Republicans who are deeply skeptical of government's ability to solve problems sometimes change their minds about health care when they have a direct experience with the failings of the private side.
Barry Keene, a Republican mechanical engineer and private consultant in Lafayette, Colorado, believes government handles a lot of things badly—but he no longer thinks health care is one of them. When his wife fell off a step stool in 2005 and broke her leg, the couple ended up more than $50,000 in debt, thanks to a health insurance policy that did not protect them from "balance billing"—where the providers charge more than the insurance company has agreed to pay, collect whatever they can from insurance, and then send the patient a bill for the rest. What truly astounded Keene, however, was what happened when his wife called the hospital about its $42,000 share of their bill. Within five minutes, she had negotiated a 50 percent discount—over the phone. "That captured my attention," Keene recalls. "To be able to negotiate a fifty percent reduction in five minutes, that just doesn't happen in my world. What is the real cost? And who pays the list price? And what do the insurance companies really pay?" Keene is now a vocal supporter of single-payer health care and an advocate of greater transparency in our medical care.18
For decades, it has been easy to convince Americans that health care reform will lead us down the path toward greater government control over our lives and interference in our most personal medical decisions. That was the troubled political environment that greeted the Obama administration as it set out to break the health care deadlock. But if Obama and Congress could overcome those odds, they would transform the landscape of our national debates over health care. The great divide would no longer prevent us from solving our most urgent national problems. And Obama's place in history would be set.