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Hard Truths And Half Truths On Health Care

Hillary Clinton and John Edwards haven't had much trouble convincing experts that their health care plans will reach more people -- and come closer to truly universal coverage -- than Barack Obama's. That's because Clinton and Edwards would require everybody to obtain health insurance and Obama wouldn't.

(If you've been sleeping under a rock and haven't heard this debate, read here and here.)

But Clinton and Edwards haven't had such an easy time convincing voters about this, because – quite frankly – it's not that easy a proposition to defend. Nobody likes being forced to do anything.

Tonight, though, I thought both Clinton and Edwards framed the argument perfectly. For Clinton, it was all about asking for “shared responsibility” and putting down a political marker for universal coverage. She started with this statement:

I am adamantly in favor of universal health care.  And that means everybody is covered.  And we will have a system to make it affordable, but it will be required, as part of shared responsibility, under a new way of making sure that we don't leave anybody out and provide quality, affordable health care for everyone. 
...if you don't start out trying to get universal health care, we know -- and our members of Congress know -- you'll never get there. If a Democrat doesn't stand for universal health care that includes every single American, you can see the consequences of what that will mean.  I think it is imperative that we have plans, as both John and I do, that from the very beginning say, "You know what? Everybody has got to be covered....
I think that the whole idea of universal health care is such a core Democratic principle that I am willing to go to the mat for it. I've been there before.  I will be there again.  I am not giving in; I am not giving up; and I'm not going to start out leaving 15 million Americans out of health care.

It was Edwards, though, who had the best argument of all. When Obama said, as he has frequently, he doesn't want to force people to buy health insurance, Edwards asked whether he would make the same sort of argument about Social Security:

The problem with this argument is you can make exactly the same argument about Social Security. ... I mean, you think about the analogy.  What George Bush says is he wants people to be able to get out of the Social Security system, choose, elect to get out of the Social Security system.  Well, that's exactly what this argument is. ... This argument is you shouldn't have to have health care.  If you choose not to have health care, you shouldn't have to have it. And that is a threshold question.  It is a judgment.  It's a fair policy debate. 
You know, if you look at the recent article about Senator Obama's work on health care reform in the Illinois legislature, it's a very interesting piece about how he basically did the bidding of the insurance companies during that effort.

During the debate, the Clinton campaign circulated this Boston Globe article as proof of the charge. The article examines something called the “Health Care Justice Act,” which Obama co-sponsored and which passed during his final year in the Illinois state Seante.  And, as that article establishes, Obama held discussions with representatives of the insurance industry and made some changes on their behalf.

But the Globe piece tells only a small portion of the story. I looked into this episode (along with some of Obama's other health care reform efforts) as part of an article that's in our current print edition. The full text is available to subscribers only, but I can give a few relevant paragraphs here:

From 1997 to 2004, as a member of the Illinois Senate, Obama advocated several proposals to make medical care more accessible--culminating, three years ago, in a bill designed to force the creation of a universal coverage system for Illinois. And, while none of these efforts come even close in scale to what he's promised to try in Washington, they do provide a window into the governing style he would pursue there.

Time after time, Obama brought adversaries into the process early, heard out their concerns, then fashioned compromises many of them ultimately supported. In other words, he used the very strategy he's been describing on the campaign trail--the one giving people like me such angst. And yet, if you talk to liberals in Springfield, the ones who've spent decades fighting for universal health care, you don't hear a lot of disappointment with him. As far as they are concerned, Obama's signature inclusiveness was always a means to an end--a way to push the limits of reform rather than accept them. And, they say, it worked.

In 2002, when Democrats won back control of the Senate, Obama became chairman of the Health and Human Services Committee. And it was from that perch that he adopted his other noteworthy health care cause, a measure called the Health Care Justice Act. The brainchild of grassroots activists tired of fighting losing battles to create a single-payer system for Illinois, the act, as originally proposed, would have created a task force, empowered it to develop a universal coverage plan, and then forced the legislature to vote on that plan. Predictably, it aroused the ire of insurers and other business interests, who, by all accounts, lobbied to derail the effort. "They--the insurers--pushed [Obama] really hard," says Jim Duffett, executive director of the Campaign for Better Health Care, the group championing the plan. "They also tried to use other people to push him really hard."

Publicly, Obama used hearings to rally voter support for universal coverage. Inside the statehouse, he pursued a two-track strategy. He made common cause with doctors and hospitals, two groups that had become more sympathetic to universal coverage because of the financial burdens charity care placed on them. This gave cover to moderates who wanted to support the bill, while increasing pressure on the insurers to fall in line. At the same time, Obama carried on discussions with the insurance and business lobbyists directly, eventually granting them two key concessions: He altered the makeup of the task force to make it more industryfriendly and dropped the provision requiring a vote from the next year's General Assembly. "We had significant concerns and looked to Senator Obama, who is an extremely bright and accessible individual," Phil Lackman, who represents the Professional Independent Insurance Agents of Illinois, told me. "My experience is that he is willing to listen to anybody willing to talk to him."

It's those kinds of statements that lead to stories, like one that The Boston Globe published in the fall, noting that "Obama's own experience in lawmaking involved dealings with the kinds of lobbyists and special interests he now demonizes on the campaign trail." But, whatever the contrast with Obama's campaign rhetoric, reformers in Springfield say the concessions worked out just fine. As it turned out, binding a future Assembly to vote on a measure was probably unconstitutional anyway. And the presence of insurance representatives on the task force may have actually bestowed it with additional legitimacy. Although those members would end up filing a dissent to the task force's final report--which was issued after Obama had moved on to the U.S. Senate--press attention focused on the majority recommendation. And that recommendation was just what many advocates hoped (and opponents feared) it would be: a comprehensive plan for universal coverage, financed and overseen by the state government. "He didn't back down," says Duffett. "There was no mandate [on the next Assembly to vote], but that was a constitutional issue. ... We got everything else we wanted."

Duffett's quote is important because he is among the state's most prominent and committed advocates on behalf of universal health care. (For the wonks out there, he's the Illinois equivalent of Ron Pollack.)  If Obama were in the pocket of health care lobbyists, he'd be the first guy to complain. But Duffett has only good things to say about Obama. Very good things, as a matter of fact. 

--Jonathan Cohn