Abstract:
On September 9, 2009, President Barack Obama addressed a rare joint session of Congress in order to push the vote on the health care reform. During the Presidential campaign of 2008, Obama had closely linked his candidacy to the issue of health care reform, and his first few months in office have displayed the same focus. The President is personally involved in the reform of the system, and his convictions are one of the most important factors; pushing the debate all summer long. Opposition to reform abounds, from political concerns to ideology. The lack of one vote could potentially become the deciding factor between success and failure; especially if the short vote was that of the esteemed Senator from Massachusetts, Ted Kennedy. In any case, Barack Obama still has a chance of success; and it is fundamental to consider the nature of his plan, apart from the position of the debates. Currently, the game is still open.
- Joint session of Congress at the United States Capitol in Washington, D.C., September 9, 2009. Official White House Photo by Lawrence Jackson.
Introduction:
The US health care system is a double face reality. There is no question that the USA is the leader in research and development for health care treatments and the use of innovative technology in the fight against many diseases. On the other hand, there is the question of lack of efficiency in the supplying of many services, the difficulty of the process for seeking treatments due to bureaucracy of the insurance system and, finally, a great waste of money; which leads the entire system to a serious economic risk of sustainability. The result is more than twenty years of domestic debate and ideological conflict between, generally, Republicans and Democrats. Past democratic administrations tried to pursue reform, but never seemed to garner the votes needed in Congress, support of public opinion, or power of the lobbies. The failure of President Clinton proposal, strongly advocated by the current Secretary of State Hillary Clinton (“Hillarycare” as named by her detractors) is a recurrent emblem and a concrete fear. Despite a Democratic-controlled Congress, the plan did not receive enough support for a floor vote in either the House or the Senate; and proposal was abandoned. Administrations pursuing this kind of reform have the tendency to pay a high price come election time.
Almost a year into his election, President Barack Obama is trying to pursue his health care reform and some factors need to be examined in order to have a clearer idea of what can happen during the coming months. First of all, it seems President Obama is using a different strategy; an approach combining his strong determination along with cautious mediation with all reform opponents. On September 9, 2009 the President spoke to a joint session of House of Representatives and Senate to push the necessity of this reform: it is fundamental to consider the rarity of a joint session of this nature; apart from the State of the Union and Inaugural Address, the last time both Houses came together for a joint session was in September 2001, when President George Bush spoke in the aftermath of 9/11 regarding the War on Terror. Obama attempted to clarify the details of his plan, to reduce fears and concerns reform-opposers have tried to instigate, for example, touching Americans’ sentiments of using government funds for abortions. Secondly Obama spoke directly to all Americans, having clear in his mind the role public opinion can play. Finally, he needs to strengthen and unite the Democrats, even considering a bipartisan reform, which currently is really difficult to consider. On the other side, most Republicans still remain fiercely opposed to the reform plan, and a small moderate wing of the GOP remains unconvinced.
Barack Obama decided to link this plan to his presidency, and his convictions are sustained by his determination. The President is cognisant of the immense interests at stake; therefore the use of mediation on all sides, political, insurance, and lobbies is pursued constantly. Focusing on these factors, we should be able to analyze the pillars of the Obamacare’s (currently used more as a “personification” of a reform than a disparaging word) opportunity of success. In spite of the many changes and proposals put forward in the coming months, it seems possible to consider the game still open.
- President Barack Obama delivers a health care address to a joint session of Congress at the U.S. Capitol in Washington, D.C., September 9, 2009. Official White House Photo by Pete Souza.
US healthcare system: concerns pushing for the reform.
From more than twenty years, there has been constant debate in the US domestic affairs about the health care system: stronger at times during the reform-plan campaigns but always present in the political and social arenas. Despite the contrasting ideas of Republicans and Democrats, the system as a whole needs to be reformed; hot issues must be addressed and proper allocation of funds is a necessity. This economic concern must be considered because the expenditures for the current system are too high, quite untenable with the growing deficit, especially considering the present economic crisis and its future consequences. In addition, the health care costs are supposed to be certainly untenable in ten years, without any changes. Central to the problem is the rising trend of expenditure without quality and with increasing doubts on the efficiency and effectiveness of the system. Both Republicans and Democrats cannot deny that escalation of overall costs will be a cumbersome problem.
During his campaign, Barack Obama urged the need for health care reform, and as President, he appears to be holding on to his promise. We can consider two different perspectives. In the long term, the purpose is to implement a European style reform for the US health care plan; in the short term, President Obama wants to see the beginning of partial changes within the system. Obama knows the political obstacles he faces, those which lie in the Republicans’ opposition, in the Democrats’ fear of the Hillarycare’s ghost and in their lukewarm approval of the plan. Such a political situation must consider the upcoming mid-term election of November 2, 2010 (adding the State Gubernatorial elections in the same date). Other key issues that will need to be taken into consideration are public opinion support and the nation’s recovery from the economic crisis.
Building the appropriate background: steps and obstacles.
In these two past months, press, think tanks and analysts alike have all made recommendations on the health care reform plan, forecasting social and economic outcome carried out by a reform of the whole system. To understand this clearer, it is fundamental to take a step back to consider only the real and initial target of President Obama, and the strategy pursued from the beginning. Following this method, Barack Obama focused his attention to give the reform a concrete start; he is not pursuing a complete revision of the entire system and to pass it compulsorily by the end of this year. Secondly, the White House clearly stated the obligatory guidelines, as pillars of the plan, but President Obama is conscious of the need for debate on some other proposals. Those mandatory principles are the basis from which it is not possible to move away from, even prospecting a hard fight with Republicans and lobbies. On the other side, the roundtables which brought about a difficult shared-as-possible deal will go on until the vote in Congress. Especially to find an extremis deal with the moderate GOPs. So the guidelines are the mirror of Obama’s convictions and his determination. On the other hand, Democrats try to avoid a complete confrontation and mediation is fundamental to act in the narrow margins for a consensus. The social background is heavily affected by American public opinion, which remains doubtful. Even if we have to underline that the ideological concerns more than the concrete needs play a big role on the Americans sentiments and doubts on the plan.
The perspective to gradually change the system remains in the horizon, and the process of involving opponents of reform through constructive mediation does not appear to be an easy task. For example, to postpone the debate after summer can be considered a failure, but it gave more time to the committees to find more common points. On the other side, it seems the campaign for the mid-term and gubernatorial elections of 2010 has already started. Many Democratic Senators are worried about a negative reflex that can compromise their campaigns, and of course the Republicans will be quick to exploit this issue for their purposes too. Knowing the public’s doubts on ideological change, they will push to link Obama’s plan with a Socialistic policy. President Obama is conscious about the importance of the first electoral test just in the middle of his administration, and for this purpose, he personally went locally to explain his plan and to present his platforms through town-hall style meetings. The possibility of a vote before the end of 2009 remains a possibility, and the Democratic political majority will definitely be put to the test before mid-term elections.
The interests at stake and key changing points.
At this point, it is appropriate to detail the guidelines of the reform, summarizing the position of health and insurance lobbies, and public opinion sentiments:
Medicare social insurance (the governmental program providing health insurance coverage to people who are aged sixty-five and over) and Medicaid (the governmental program for eligible individuals and families with low incomes and resources) will be expanded.
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More than forty-seven Americans (46,3 millions for a share more than 6% of US population) are without heath care insurance; one of the reform targets is to reduce this quota. The plan considers a feasible path to increase the taxations on the ultra-rich, preserving a further direct taxation over middle-class, already seriously hit by the economic crisis. Secondly, there is the need to cut all the unnecessary costs due to the redundancy of prescriptions and exams, for example because twice done or too easy granted for a narrow high level policyholders.
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The plan does not count a general cut of all health costs. The reform provides the detailed cutting of the unnecessary expenditure with a different allocation of those funds, in order to cover the gap in the lack of efficiency. Credit crunch, economic crisis and rising unemployment do not permit Obama to increase the US deficit. For this reason, the costs cutting will be relatively contained: Obama’s reform considers almost $100-200 billion of expenditure less than the current system balance, considering the period 2010-2019. The real target of the reform is to counteract the system inefficiency and waste of funds with a better allocation for the state money.
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The strongest health lobbies seem to seriously consider dialogue options, rather than focusing only on a direct fight against the plan. This does not mean that there is a consensus or a positive approach: the process is extremely difficult. Nevertheless, it is a completely different sign from the past. In addition, if there is a “tendency” to dialogue by lobbies, we can prospect the lobbies are both the stronger opponents and the ones that believe the Obama Government will be able to change something in the system. Obama’s health care reform seems to balance the direct intervention of the State in the system, following the logic of market and competition. President Obama wants the State to enter in the health care insurance market, but to remain just a “small fish”, covering a small market share. With this strategy, the State will propose a health care insurance with only basic and limited services, in order to be a feasible alternative for those Americans who can not sustain private insurance costs or who run a financial deficit risk in case of a disease of just only one family member. The entrance of the State in the insurance market would push the other health insurance companies to lower their prices or work on the efficiency of their services, following the rule of market competition. The strategy follows the rule of demand-offer, with a precise market product, preserving the life of the sector.
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Big companies and employers’ lobbies strongly oppose the reform, because it obliges them to provide health insurance coverage for their employees, and to pay the costs. In this case, it seems possible that the plan will not change the current situation all that much, in order to open a dialogue between the parts. Barack Obama is in favour of proposing fines in the case employers will not respect this coverage. Nevertheless, the President does not want to push too much on this issue. In fact, before summer some companies declared their availability to dialogue on the reform. For example, Wal-Mart could be the first important interlocutor sitting at that table.
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It is undoubtedly true health care reform was one of the pillars of Obama’s presidential campaign, and one of the most important issues of his constituency; on the other hand, American public opinion has different priorities and it is not at all persuaded. The economic crisis hit American society and currently, the major fear is about rising unemployment, which is close to 10%. Moreover, Americans are conscious of the untenability of their health system but do not want to be obliged to change their private and individual choices. The idea of a socialized health system – and especially the direct reference to the word “Socialism” – scares them. Ideologically, this reform is considered as an inappropriate intervention of the State. Following the Gallup polls, there is a constant trend in the Americans idea during the last month. On the other hand, the President’s charisma during the September 9 address to Congress has strengthened the personal appeal Obama has with Americans. A CNN poll, done right after the speech, shows that 67% of Americans would support a reform for the system, instead of the previous 53%.
- Gallup Poll August-September 2009
Public opinion sentiments against the reform were demonstrated on September 12, 2009 during the so called “Taxpayer March on Washington”. Even the claim was to expose a clearly general sentiment of all the Americans against health care reform; there are some points to detail. First of all, the protesters generally belonged to the more conservative right wing of the country. Despite the focus on the health care reform they opposed Democratic policies: health care reform, economic guidelines, climate-change bills and coal workers protesters about energetic policies. As many said: it was not about health care, but about Obama’s plans, perceived as a freedom constrictions. In fact, Washington Post-ABC News poll published on September 14, 2009 show 46% favoring the proposed changes and 48% against them.
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In conclusion, the fundamental premise for every concretely feasible reform should be the real possibility for the single person to have the freedom of choice: to go on with his own health policy or to prefer the state system. This freedom of choice will be one of the most important pillars to pass the reform.
The “Edward Kennedy factor”.
The death of Senator Edward – Ted – Kennedy (August, 25 2009) could pose a large obstacle for the approval of the plan. Ideologically, Democrats and Barack Obama have lost one of the preeminent voice of all democratic senators and surely the strongest defender of the necessity of this reform. But practically there are two fundamental strengths the Senator could have lent to this reform.
- Senator Edward – Ted – Kennedy: US Senate Official Picture
Ted Kennedy’s authority and his political devotion to the cause of the health reform were acknowledged even by a good number of Republicans, he could have been the bridge with more moderate republican wing. Secondly, there is the issue of the numbers for the approval. Democratic majority (US Senate) is done by sixty seats – fifty-seven not considering the lack of Ted Kennedy and two independents both caucused with Democrats – against Republicans’ forty. Currently, the need of a strong majority is due to face the opposition filibustering (always having in mind the next year mid-term election with one third Senate seats changing). Ted Kennedy was really, and publicly, worried about the possible lack of his vote. In fact, he suggested Massachusetts Governor Deval L. Patrick to promote a variation of the current law for the election of senators in the State, in case of vacancy. In Massachusetts, the current law arranges special election after a period of 145/160 days from the vacancy, without any temporary filling for the seat. The US Constitution declares that “the legislature of any State may empower the executive thereof to make temporary appointments until the people fill the vacancies by election as the legislature may direct”, so there is the constitutional margin to act. If Governor Patrick approves Kennedy’s suggestion, Massachusetts’s legislator has not declared in favour of it, yet.
The possibility of an interim appointment for the seat is diminishing; in the meantime some contenders are declaring their interests for the special elections. Currently, it is difficult to forecast a temporary nominee for Ted Kennedy’s seat, at least without making the political fight more and more difficult. It is possible that only one Senator will represent Massachusetts until January 2010, leaving Obama without a heavy pro-reform vote.
Concluding: Barack Obama has the chance to reform the system, but it is not easy.
There are a great number of obstacles to pass a health care reform in the United States, and all those obstacles are difficult to overcome. There are political, social and ideological concerns. Republicans and Democrats have strikingly different opinions and it is seems impossible to consider a real bilateral agreement; moreover, at the stake for next year’s elections. Public opinion is divided. The effects of the economic crisis scare the American families and the Administration has a narrow margin for the use of the funds.
Despite of all these concerns, it is possible to prospect the start of the health care reform before the end of 2009. The Obama Administration is conscious on the costs of the reform, and improvement of the system’s efficiency is considered as a critical economic target. Every single choice will be taken considering the allocation of the funds, and unnecessary wastes to such funds will not be permitted.
The President’s convictions, personal involvements and mediation will be used with every actor – from lobbies to political representatives – in order to start changing the system. Undoubtedly, the US government will not be the major supplier for health care insurance on the short term; Barack Obama is not pursuing this path.
The real strategy is to enter in the private insurance market, to propose a specific product to a definite group of persons. Following the market reason and the competition rule, we can suppose that the Government will offer a product that is economically feasible for anyone, with good quality though extremely limited. We can continue the market example and call it entry level health guarantee. The reason of a possible success lies in this innovative market strategy, different from any other reforms of the past. Despite the new features of this reform plan, another obstruction remains trying to convince the American public that this market participation will not result in what they fear – Socialism.
Marco Pedrazzini – Maria Corissa Artadi.
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