From protest to coalition politics: Fighting for health reform

Written by: Harold P on Apr 20, 2009 10:26 AM EDT

In 1965, civil rights leader and thinker Bayard Rustin wrote a classic essay, "From protest to politics," that described the disorienting change brought about by the movement's own classic victories. (For youngsters, 1964-65 was the brief but glorious political season that brought us Medicare, Medicaid, the Civil Rights Act, the Voting Rights Act, and more. Things burned out quickly. Yet before it was over, Lyndon Johnson, Martin Luther King, Wilber Mills, and millions of nameless other people made America a better place.)

At the peak of these successes, Rustin and some others could see that the easy victories had been won, and that far tougher battles lay ahead. They could not foresee agonies to come: the Tet offensive, the assassinations, the election of Richard Nixon. Yet Rustin could see far enough to know that gaining the right to vote was easier than gaining the right to a decent job, that stupid and backward legal segregation was easier to overturn than the excesses of a high-tech economy that so readily mistreats low-income workers.

Rustin could see two other things: One profoundly radical, one easily misinterpreted as conservative. The radical part was to foresee—or at least hope to see—the transformation of the civil rights cause from a protest movement over specific Jim Crow indignities into a much larger social movement concerned with attacking larger obstacles that remain today deeply-rooted in American economic and political life. Rustin notes current estimates that a successful war on poverty would require the then-unimaginable sum of $100 billion. Adjusted for inflation, that's $675 billion in today's dollars, a sum ironically close to that provided in TARP funds in the financial bailout. Rustin asked: "Where … are the forces now in motion to compel such a commitment?" 

He realized that mobilizing resources on this scale requires more than a vanguard of nonviolent protesters putting their bodies on the line at segregated lunch counters. It requires a truly mass movement that could mobilize millions of Americans who were not part of the civil rights movement but who had much to gain from progressive economic and social policies. Such a movement could force, or at least empower, sympathetic but cautious politicians in Congress and the White House to support concrete progressive legislation. Rustin envisioned some familiar measures: aid for urban schools, job training, fairer tax policies. Some things would be different today. The list would more for the environment and urban transport, maybe fewer WPA-style physical investments. 

Unavoidably, serious healthcare reform would occupy a central place. If any one of several serious Democratic proposals for universal coverage were enacted into law, this would be one of the most progressive pieces of social policy legislation in generations. It would help millions of Americans who are not low-income, but who remain vulnerable due to health problems and the vagaries of private coverage. It would serve the interests of millions of other people, too, including literally millions of healthcare professionals who cannot now care for their patients the way they were trained to do. 

But don't kid yourself. Those very reforms threaten deeply-entrenched interests who go beyond the standard-issue bad guys in this debate. Serious reforms will ultimately require heavy lifting to control escalating costs. We can do some of that through innovations such as pay-for-performance, improved electronic medical records, and comparative effectiveness research. Serious cost-containment will require hard bargaining with medical providers, pharmaceutical companies, and others who don't want this to happen. 

A strong public plan--such as the ones proposed by Jacob Hacker and earlier by our own Helen Halpin--puts us in position to accomplish this goal. Weaker versions, such as the one proposed by Len Nichols and John Bertko are less satisfying, but create valuable infrastructure that can be improved and strengthened. (We've had a lively discussion of this over at the New Republic’s the Treatment section- Check it out here)

The public plan is one of two key proposals--the other being the establishment of a strong National Insurance Exchange--that will determine whether the 2009 health reform is a true milestone or another extremely useful but ultimately modest incremental reform. The public plan is also a key dividing line between progressives and moderates within the broad coalition that favors reform. I don’t know whether the public plan will survive. Its supporters are locked in a Senate knife fight. 

This brings me to Rustin's second insight. Reformers need allies, and they must be committed and smart practitioners of coalition politics. Rustin excoriated moderates who refused to support genuine reforms. He also chastised reformers who adopt a militant posture, yet who fail to be effective allies or who fail to step up for allies when they are most needed. 

I won't be subtle here. I count myself among those who aspire to some version of a single-payer (or near-single-payer) health system. From many perspectives, including my own discipline of public health, Medicare for all would be vastly better than our current financing system. Some single-payer supporters are sitting on their hands, because they believe President Obama's proposed reforms are too limited. 

I understand and share the fear that this year's bill will have gaps and shortcomings that will need expansion and repair. Reforming and improving one-sixth of the U.S. economy is process, not something that will happen in a single bill. Once this bill is passed, many of us will become sympathetic critics, pushing the administration to move harder and faster to build on these reforms. 

That's for next year. Right now is the time for practical politics. President Obama is pursuing the right overall strategy to ensure that we achieve an ambitious, if imperfect health reform. He needs help. The more allies he has, the more people stand up to be counted, the stronger this bill will be. By any conceivable measure, including the ultimate prospect of achieving the goals exemplified by a single-payer plan, passing health reform in 2009 would be a huge victory for progressive values. A loss would be a correspondingly stinging defeat.

This is the moment when politicians on Capital Hill, and in the White House, too, are assessing the costs and benefits of fighting for particular pieces of contested legislation. They know that conservatives, insurers, and other interest groups hate the public plan. They are less certain about the political gains of really fighting for this component of candidate Obama's health plan. If a large group of progressives don't visibly and strongly value the public plan, you can guess how this thing will go.

This is also the moment when progressive elected politicians are looking around to see who they can really count on to help get the best deal done. These are the moments in which people will earn or will lose a seat at the table moving forward. 

In our very first blog posting, David Cutler noted many stakeholders in 1993-94 really wanted reform, but preferred no-reform if they could not get their preferred vision of reform. That was one reason we lost. We're in a different place now. We have a progressive President, a strong House majority, and a shaky but real Senate majority poised to do business. 

If you care about health reform, if you aspire to a single-payer plan, now is the time to do everything you can to help.

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