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The Battle to Define the New Health Care System

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Posted on Nov 1, 2009
Barack Obama
White House / Pete Souza

By E.J. Dionne, Jr.

The next health care fight has already started. It’s the battle to define the bill that President Obama will eventually sign as a victory for consumers, taxpayers and the common good.

You might say this view is premature. Legislation has yet to pass the House or the Senate, there are differences between the two bodies, and some moderates still have doubts.

But barring astoundingly self-defeating behavior by Democrats, a decent bill will get to Obama’s desk. He and his party will then own the most sweeping reform of the American social safety net since the passage of Medicare in the 1960s and, arguably, Social Security in the 1930s.

Both parties know this. That’s why much of the rhetoric you’ll hear in the coming weeks will not really be about whether to pass a bill. It will be designed to shape how the voters who will decide the 2010 elections—and, ultimately, the fate of health care reform itself—come to view the new system.

Republicans will try hard to minimize the benefits that will flow from the reform and set themselves up to claim that anything bad that happens to anyone’s health care in the next few years is Obama’s fault. It will be a bit like those New York City taxi drivers during the late 1960s and early ‘70s who despised Mayor John V. Lindsay so much that they were prepared to blame him for bad weather. 


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And since most of the changes don’t become effective until 2013, the next few years will be a time of uncertainties and unknowns. Citizens typically want to know what’s in this for them, and what they’ll get right now.

That’s why the most important document House Democrats released last week when they unveiled their bill was a list of 14 benefits that will be created immediately.

These include insurance reforms to ban lifetime limits on coverage and an end to “rescissions” under which insurers abruptly nullify patients’ policies after they file claims. One of the most popular reforms in the bill—barring insurers from denying coverage to those with pre-existing conditions—doesn’t take effect until later. So the House bill creates an interim high-risk pool to help those who need coverage in the meantime.

There are also particular benefits for Medicare recipients, including an immediate reduction in drug costs, and a very popular provision that would allow parents to keep their children on the family health plan through age 26.

Especially important are new investments in community health centers and in efforts to increase the number of primary care doctors. As millions more people get access to decent care, the system will have to provide more doctors, nurses and facilities to treat them.

“People will be excited about 2013,” said Rep. George Miller, chairman of the House Education and Labor Committee, which shares jurisdiction on the health care bill. “But there are enough benefits between now and then to keep them engaged and to keep them favorably disposed.”

The key word here is “excited,” and the central task of supporters of health care reform is to elevate the discussion to the central question at stake: Will the United States join all the other wealthy democracies in providing nearly everyone with health insurance? Or will we kick away the opportunity?

Miller focuses on how much needless anxiety a guarantee of health insurance will lift from the average family. “Right now, when you lose your job, you also lose your health care, your ability to send your kid to college, and sometimes your home,” he says. Knowing that health coverage will always be there doesn’t solve all those problems but it removes a heavy burden.

While negotiations between the two houses will be difficult, my hunch is that they could be less challenging than many are predicting.

For example, the two houses could split their differences on financing by including a scaled-back version of the Senate’s tax on high-end health plans while reducing the House’s tax on millionaires. Some of the Senate’s cost controls could be added while preserving the House’s more generous approach to coverage. And a public plan will survive because it’s an option most Americans understand and want.

Above all, the negotiators need to know that if they make the process look like a very bad day at the sausage factory, they will undermine public confidence in the outcome. From now on, they are not simply enacting a bill. They are rolling out a product.

E.J. Dionne’s e-mail address is ejdionne(at)

© 2009, Washington Post Writers Group

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By ardee, November 6, 2009 at 6:09 pm Link to this comment

Bette Grogan, November 3 at 4:22 pm #
(Unregistered commenter)

Has truthdig become a forum for right=wing nuts?  I have been visiting this site for a long time but it seems it is becoming a place for hate-filled right wingers to denigrate our president who is doing everything in his power to help us all.  I hate to stop visiting this site but I don’t come here to listen to this hate and these lies from the right.

Free speech is messy, isn’t it? One might consider being grateful that most of those you classify as right wingers put up a rather shoddy defense. Further the give and take of the few honest right wingers here seem necessary, if only as sounding boards to reaffirm ones beliefs…

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By Fraser Tothus, November 5, 2009 at 7:49 pm Link to this comment
(Unregistered commenter)

I cannot understand why business opposes having the costs of health care socialized, unless the Lords believe that the fiction that “government can’t do anything right” will be undone by the example.  It is widely understood that all the “successful” corporations depend on the fact that government works very well, indeed… for the largest incorporations ...shielding them from the “free market” with never-ending bail-outs, hand-outs, write-offs, abatements, land-giveaways, subsidies, tariffs, tax breaks and government’s (and the “liberal press”) most welcome habit of never taking labor’s side in any dispute.  Corporations could not exist without a massive dose of state socialism, and certainly wouldn’t survive in a “free market”.  They understand how predatory capitalism is, and demand big government protect them, and hold them harmless from any social liability.  Could it be that their opposition is only to ward off the threat of a good example?  Is it that the use of the peoples’ money for anything other than corporate benefit sends the wrong message, sets a bad precedent? 

It seems to me the article’s headline has very nearly hit the nail on the head: the “battle” over this issue, as with others, is not over its relative merits.  At its most basic, it is a class war, with the upper class using their wealth to fund a propaganda blitz.  The battle is over convincing the American people to accept that they are wrong to care about one another, wrong to expect any social benefit from the use of their own money.  What I find most surprising is that after decades of this barrage, after decades of repetition, the American people still are far to the Left of Congress, the Courts, and the Executive. They know they have been sold out, have seen the devastation for themselves in countless examples.  Regarding Health Care, despite all of the corporate propaganda, the American people, by a very large majority, still stubbornly cling to the notion that universal, single-payer is the best option. The do not trust insurance companies, and do not want them involved at all.  But the people’s wishes, here as elsewhere, are ignored.  The corporate press, in its advertising campaign, omits that which it would rather not have discussed, that which runs counter to the interests of its corporate owners and their source of income: corporate advertisers. It would be foolish to expect any other behavior from them. Corporate representatives, also known as politicians, dare not bite the hand that feeds them.  But the defining to which the article’s headline refers is only part of this battle wherein the ends justify the deception used to manufacture public “consent”.  This deception too, has been long understood.  As Adolph Hitler put it, “Through clever and constant application of propaganda, people can be made to see paradise as hell, and also the other way around, to consider the most wretched sort of life as paradise.”  The “battle” is between policies that favor all of us, the commonwealth, versus policies that favor the wealthiest among us, the minority.  As Michael Parenti puts it, [The ruling elites] know who their enemies are, and their enemies are the people, the people at home and the people abroad. Their enemies are anybody who wants more social justice, anybody who wants to use the surplus value of society for social needs rather than for individual class greed, that’s their enemy.”

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By DaveZx3, November 4, 2009 at 4:43 am Link to this comment

pointus, November 3 at 5:06 pm #

“You make a good point that profit margins are low, but the size of the money pool is so huge that some health insurance CEOs are pulling in as much as a BILLION DOLLARS in a single year”.

I am in absolute agreement.  But my real point is in how the pool of cash gets that big.  It is because we filter routine expenses through the system.

If some CEO could somehow siphon off .001% of the American grocery expenditures, they would make a million also. 

The point is, quit running the money through these big machines. 

Everyone should have a job that pays enough to afford normal expenses, such as routine health care, PERIOD.  It is jobs and pay scales that are the issue more so than anything else.  You should be able to earn enough money to pay your bills. 

To deny people the ability to earn adequate wages, and then invent a system to pay their bills for them, is a type of enslavement, in which you become indebted to that system.  I would rather earn my way, thank you. 

I agree that there could be some sort of national risk pool to step in on catastrophic losss such as cancer or heart attack.  There are a number of ways that could be handled without Americans needing individual insurance policies. 

Insurance policies are a waste of time when the money pool is so big, as you say.  Large corporations don’t get insurance policies to cover their Worker’s Comp risk, they absorb the risk, hire administrators, and buy one large umbrella policy in case the loss penetrates their budgeted ceiling. 

Our medical system would be like that big corporation having each individual worker get their own individual work comp policy.  The cost would become absolutely outrageous. 

I don’t know why anyone can’t see these facts.  Probably because government, in their ignorance of how insurance works, asks the fox to explain how to go about building a hen house.

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By chrisx, November 3, 2009 at 3:40 pm Link to this comment
(Unregistered commenter)

This is a different take on the “health reform” bill currently in favor in the congress.
I am more inclined to agree with Swanson than E.J, Dionne.

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By pointus, November 3, 2009 at 1:06 pm Link to this comment

You make a good point that profit margins are low, but the size of the money pool is so huge that some health insurance CEOs are pulling in as much as a BILLION DOLLARS in a single year.
Interesting debate on the whole subject of profits at

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By DaveZx3, November 3, 2009 at 12:48 pm Link to this comment

LostHills, November 3 at 2:52 am #

“this is not a decent bill, and it’s not a victory for anyone but the insurance companies”.

I am not an insurance company lackey, but I have looked into some of the facts.  Health insurance does not show real high profit margins for insurance companies.  It is so way down on the charts it is a joke.  You can get better profit margins selling air conditioners to eskimos.  But it is so lucrative to them because even getting 2% on the billions that flow through the health care system is BIG MONEY.

The issue is, as I stated earlier, insurance is not a good mechanism to pay day to day doctor bills and prescription medicine bills, etc.  These are the expenses of living.  You don’t always know when a routine medical bill is going to come, but it is like the water pump going out on your car.  The most inexpensive way to deal with it is to just pay it.

I have done the math.  Filtering the money for unexpected but routine expenses through a system that has to play with about 40 pieces of paper to collect your money and pay your bills for you is insane. 

It is a massive system where so many people have to get involved with the process that it is not a matter of someone making obscene money, as much as it is a fact of hundreds of people making fairly decent money.  Has the same effect though, it drives the cost up. 

Insurance is a semi-legitimate mechanism for catastrophic events like cancer or heart attack, but people want insurance to pay for their dental cleanings and annual eye exams.  That is absolutely insane. 

Having a public option does no good at all.  Just adds another insurance company and hundreds of thousands of more bureaucrats to the mix. If the cost goes down, it will only be incremental, as even the pulic option will have to play the same game. 

Insurance is not the way.  Do not allow it to continue to be the way we pay our health care bills.
There are many, many better ways, and if no one knows what they are, we can discuss them.

I am at the point where I don’t even want to hear the word INSURANCE and HEALTH CARE in the same sentence.  It is insane.

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By Bette Grogan, November 3, 2009 at 12:22 pm Link to this comment
(Unregistered commenter)

Has truthdig become a forum for right=wing nuts?  I have been visiting this site for a long time but it seems it is becoming a place for hate-filled right wingers to denigrate our president who is doing everything in his power to help us all.  I hate to stop visiting this site but I don’t come here to listen to this hate and these lies from the right.

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By LostHills, November 2, 2009 at 10:52 pm Link to this comment

Sorry EJ, but this is not a decent bill, and it’s not a victory for anyone but the
insurance companies.
Note to Robert Scheer: Please stop wasting our time with this shillery. It demeans
your site.

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By rollzone, November 2, 2009 at 6:03 pm Link to this comment

hello. it is my opinion that this opposition sounding board is another means to construct a publicly acceptable piece of legislation: to gouge more taxes. 1 in 18 people do not have medical coverage, so 17 of 18 working people (after he is out of office) will have $175 a week deducted from their pay; under the guise of health care. those nonsensical figures are facts, and do not compute to a government money grab for health care, alone. only 4 people a month paying $175, would provide coverage for the 1 in 18 without. this is the largest government money grab from the public, since homeland security. it is his effort, to live high on the public trough; and has token sugar coating for health care. there will be no tort reform. health administrations will continue to cruelly gouge infirm patients. those 1 in 18 already get catastrophic care, none are turned away. an option is not an option if you are fined (taxed) for not opting in. healthy people do not need insurance. they need to pay for visits and routine tests, and stop enriching the ‘protection’ companies: from nervous fears. insurance companies would then option catastrophic care packages; over state lines: in interstate competition. the way politics satisfies itself (once you are one of the club, that’s all that counts) is by revenuing new taxes. we are over taxed beyond ‘c’ average small business survivability. you can not have been a ‘c’ student and be successful today with a small business. you need to be way above average to survive, and that is cruelly despoiling many earnest, hard working, skilled shop owners in favor of giant corporate greed. that greed runs the country, and it does not belong in politics. that is an elitist- i am more deserving than you- attitude that does not belong in a democracy. even if the war machine is the number 1 revenue source for the government, individuals with the skills and the ambitions should be able to compete against conglomerates for contracts. the playing fields are no longer fair, and this is another nail in the coffin of mom and pop; and they are the parents of this country. if the top 20% income earners of the population want to pay for this new tax, this would be redistribution of the wealth- but the majority of cost will fall on the 80% of working Americans that can not afford a new tax. their job is to tax us, find a way to tax us, and never remove any old tax, and keep on taxing. taxes ought to be cut to 4% flat tax, now that the government gets 2/3 of its income from interest on investments. sign no new tax bill.

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By VillageElder, November 2, 2009 at 4:42 pm Link to this comment

I find it hard to believe that this sham health care reform is “change we can believe in.”  By eliminating single payer and making the “public option” apply only to those in work house/ poor house the positive social and economic gains that would accrue if we had MediCare for Everybody are lost.

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By tropicgirl, November 2, 2009 at 4:34 pm Link to this comment
(Unregistered commenter)

apparently you did not realize that Obama and his shills NEVER WANTED A PUBLIC
that have been undermining from the beginning.

Sadley, they don’t really want change either.

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By dihey, November 2, 2009 at 4:06 pm Link to this comment

Pointus: apparently you were not yet aware of the fact that E.J. Dionne is a shill for the Democrats/Obama.

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By pointus, November 2, 2009 at 1:52 pm Link to this comment

Why does Truthdig print such drivel? A decent bill?

The current abominations weaving their way through our thoroughly corrupted congress are nothing more than a huge “bj for the health insurance industry,” as Bill Maher aptly described the Democrats’ health “reform.” Mandates forcing us all to buy crappy private insurance (which will continue to bleed us with obscene deductibles & co-pays), and if we’re too broke to buy it, the gov’t will slap heavy fines on us or even throw us in jail.

Single-payer, national health care is the only thing which would even come close to being “decent.”
If we had anything approaching real democracy in this country, instead of a greed-driven corporate kleptocracy, it would be a crime for corporations to lobby our elected leaders, and we would have a national single-payer health care system.
And we wouldn’t be in all these stupid fucking wars.

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By Mary Ann McNeely, November 2, 2009 at 11:34 am Link to this comment

But barring astoundingly self-defeating behavior by Democrats, a decent bill will get to Obama’s desk.

HA!!  LOL!!  That’ll be the day!

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By Hulk2008, November 2, 2009 at 11:11 am Link to this comment

No matter what passes it will be too little and too late for “reform”.  Americans automatically distrust anything that is complex or not immediately intuitive.

I was once asked to publish a detailed list of specific rules for building accurate, reliable software - and management demanded that it fit on 1 piece of paper.  30 years later I am still searching for a print font that can make the words small enough or a piece of paper large enough to fit that single page.

John Stossel and other conservatives say the free market will provide the most effective health care system, just like inexpensive vegetables and TVs.  Unfortunately, so far, 1. the free market has failed to do that. 2. Cures become “trade secrets”.  3. the measure of adequate care is set at the highest possible premium level. 4. NO patient has sufficient information to make a cost-effective decision about care (especially when unconscious and lacking a medical degree) 5. Medical science has yet to allow a patient to pre-define their own DNA and their own pre-existing conditions.

John Stossel is really the reincarnation of Henny Youngman posing as a “journalist”  - toss enough one-liners and eventually somebody laughs.

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By tropicgirl, November 2, 2009 at 10:39 am Link to this comment
(Unregistered commenter)

E.J., once again you are lullabying yourself into a stupor.

Obama is damned if he gets it and damned if he doesn’t.

If he doesn’t, then his strategy and policies are in the toilet for sure.

If he does, this will be the singlest, strongest, loudest rallying point for people,
from the elderly who will be short of Medicare funds, to the young people who
refuse (yes they will refuse) mandates. The unions, the single payer doctors
and so on will have a single, united cause against this current government with
very strange ideas.

What happens on the Capitol steps Thursday will be the beginning of the revolt
against the implementation of this hog. (on both sides, for sure).

It was a bad policy to go against the base after supporting single payer and,
the pathetic compromise, public option. It was a bad policy to trust bribed
politicians to write it. It was a bad policy to mislead people about death panels
and taxes. Its a bad policy to pay billions in wars to corrupt countries that do
not want us there, and deny healthcare for all.

Obama will get what he deserves, I feel, either way. He is tone deaf.

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By Wheelie, November 2, 2009 at 10:38 am Link to this comment
(Unregistered commenter)

Yes, certainly all eyes will be on the house/senate negotiators and their final bill. It is an absolute tragedy, though, that the thing Democrats are best at is self-defeating behavior. To limit the threat of auto-asphyxiation it is best not to hold your breath for a positive outcome.

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By DaveZx3, November 2, 2009 at 9:18 am Link to this comment

These types of events can be actarily (sp)

Sorry, I didn’t mean to spell it that badly.  I thought I at least put the “u” in there. 

Actuarily studied:  Studied by an actuary.

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By DaveZx3, November 2, 2009 at 9:12 am Link to this comment

ChaoticGood, November 2 at 4:06 am #

ChaoticGood is right on.  The incentives are bass ackwards in the medical industry. 

Also, I would add, in the efforts of reform, quit focusing on insurance as a paying mechanism for health.  Insurance is something designed for an event which is not supposed to occur, a sharing of risk for something which is very infrequent and improbable in the life of the policyholder, or at least would only happen once, like death.  But automobile accidents and house fires are best examples.  These types of events can be actarily (sp) studied and premiums developed based on intensity and frequency. 

To use insurance as a paying mechanism for health care is about as ignorant as using insurance to protect you against your gas tank becoming empty.  Do you think it would be less expensive to fill your car up if you filtered the cost through an insurance company?  WRONG. 

Insurance could be used as a catastrophic cap, but is not a good system to pay for day to day doctor visits and drug prescriptions.  These are the expenses of living, like home maintenance, car maintenance, etc.  (Though I know they have developed insurance mechanisms to pay for these items as well)  If there is a catastrophic element to it, insurance is not unrealistic, but if you use an insurance policy to pay for an oil change, you have just paid too much for your oil change.   

The idea of a “public option” which I have understood to be a government insurance option to keep the insurance companies honest, is doomed to the same sort of outrageous premiums as we are now experiencing.  If he government option is 5% less expensive it would be seen as a victory.  But be realistic, if gasoline was $50 per gallon, would it be a victory to provide it elsewhere for $47 per gallon.  No, it is still too expensive. 

I think ChaoticGood has made an excellent point, and I would add that I would have no problem with the government vigorously promoting and even paying for an effort to educate the public to healthy choices and healthy activity, and possibly fund catastrophic events.  This is constitutional. 

Beyond that, it is up to the individual to accept or reject health choices, and to pay for the consequences. 

If there were to be risk sharing mechanisms, such as insurance, private or public, it should be for catastrophic events, and it should provide for cost sharing amongst like classes, ie: don’t put me in the same risk sharing group of people that think living on diet coke, cigarettes, promiscous sexual activity and 10 hours a day of television is going to promote health. 

The consequences of exhibiting the behavior of a bad risk group should be that you share the costs of the bad risk group.  This would promote the idea that healthy activity is not only healthy, but less expensive and would also result in other social benefits as well.

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By Lary, November 2, 2009 at 8:59 am Link to this comment

OK , perhaps all that’s left is the doting of some I’s and the crossing of some t’s, but from where I sit, the wedge, cedar wedge, nice soft wood, is in the door. Now as Americans realize the advantages to Single Payer Health Care coverage, and the press continues to reveal the money spent to deny claims and pay CEO’s it is only a matter of time before the US joins the rest of the world and views medical health care a a service which should be provided to all people, and that profit from it’s use, like the profit from slavery was immoral. I know, people think everything in America, should have shareholders, and should be profit motivated, outsource the IRS, FBI, CIA, etc. and perhaps while we slept this has already been done, but the time will come, down the road where all people except perhaps for a stubborn few, after all there are still people who think smoking is not bad for your health, that a universal health care policy works for America.It is just to bad it could not come as a tidal wave but rather as a gentle current, but come it will, and happiness and contentment will reign over the land.

Lary Waldman

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By C.Curtis.Dillon, November 2, 2009 at 4:28 am Link to this comment

You can only count on one thing going forward ... they will screw it up so the whole mess needs to be revisited again in the future.  Then they can get the insurance companies and others all pumped up and get lots of money to make fixes that should have been there to begin with.  But that’s how congress works.

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By ardee, November 2, 2009 at 4:12 am Link to this comment

I concur with the assessment of ChaoticGood, and note that there seems to be a trending towards such care in among our health care professionals.

I think that the current efforts by Congress will be a compromise bill at best, one that will fail to resolve all our health care woes in this nation. One that might defeat in a small way, the tens of millions spent by the industry to block such progress. That the expenditures seem a failure points to the overwhelming support for health care reform among our citizenry, despite, I might add, the almost one hundred percent negativity we see in the media towards said reform.

But, if optimism is your thing, then this might be seen as a good start..or just a start.

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By ChaoticGood, November 2, 2009 at 12:06 am Link to this comment

Above all else, the new Health Care System should have something to do with Health instead of Sickness. The real reform will come when we realize that HealthCare professionals should be paid to keep us well.  They should get less money if we get sick. If you want to be well, thats what you should pay for and you might just get more of it. Right now the incentive is to make you sick and then keep you sick and treat you with drugs and you never get really well, do you?
Have you ever thought that it might be better to pay to be well instead?

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