Some Health Care Policy History

Zachary Robinson, CCDS, June 28, 2012

For an analysis of how the positions of Democrats and Republicans on health care have evolved, please see this interesting article by Ezra Klein in last Monday's New Yorker, entitled "Unpopular Mandate, Why Do Politicians Reverse Their Positions."

Klein's view is the best of the mainstream liberal pundits, who have been abuzz lately about all these Republican politicians whose flip-flopping can only be understood using theories of social psychology.

The liberal pundits' analyses, based as they are on psychological theories of "right-wing" and "left-wing" groupthink, is ultimately an incoherent "contribution" to the political theater of the 2012 presidential campaign.

On the other hand, a simplified analysis of this critically important public policy topic that is based on class interests and the changing balance of class forces renders the shifting positions of Democrats and Republicans perfectly intelligible. Background information is linked below. Here's my simplified class-based analysis:

What we call Obamacare today began its life at the Heritage Foundation in 1989. By the late 1980s, projections of the economic drag created by spiraling health care costs had convinced the ruling class that comprehensive US health care reform was long overdue. Indeed, the topic had been taken up in earnest through successive presidential administrations from the conclusion of WWII onward.

The working class made great economic sacrifices during WWII. When the war ended, organized labor launched an all-out struggle to realize Roosevelt's Second Bill of Rights. Under Cold War political pressure, however, social unionism began a long retreat. Gradually, the social insurance model, long seen as essentially unavoidable, was restricted to the aged and the impoverished. This culminated in the Medicare and Medicaid programs that were signed into law by President Johnson in the Social Security Act of 1965.

But this didn't resolve the economic problem of health care. The problem, in fact, became even more urgent when President Reagan signed the socially-minded Emergency Medical Treatment and Active Labor Act (EMTALA) in 1986. EMTALA requires virtually all US hospitals and ambulance services to provide basic emergency care without regard to citizenship, legal status or ability to pay. Though the Reagan administration clearly made a step forward in health care reform, EMTALA is an unfunded federal mandate that actually added to the economic problems created by the US health care system.

Yet with the main organized working class forces now in full retreat, the ruling class was eager to back away from the social security state. They came up with a market-based reform scheme that protected the financial interests of the insurance industry. After all, insurance forms a key part of FIRE (finance, insurance, real estate), the sector that was by the 1980s on its way to complete economic and political domination of the capitalist class. Health care reform modeled after the auto insurance market became their preferred solution.

In the Kabuki theater that is the US Congress, the market-based reform scheme was first introduced by a bipartisan, but heavily Republican, group of senators in 1993, ostensibly as a polemical response to the Clintons' ostensible health care reform efforts based on an employer mandate. (Obamacare does incorporate this aspect of Hilary Clinton's proposal.) But it was Mitt Romney, Republican, who as governor of Massachusetts, was the first to realize the proposal when he signed An Act Providing Access to Affordable, Quality, Accountable Health Care in 2006. (At the time, he also vetoed the employer mandate along with some proposed extensions to the state's Medicaid program.) Shortly after signing the act, Romney bragged that the biggest difference between his health care policy and that of Hilary Clinton was that his passed and hers didn't.

Ultimately, Romney's market-based health care reform victory in liberal Massachusetts signaled the inability (or unwillingness?) of the main forces of organized labor to vigorously defend the social security state. Pleased with this outcome, the ruling class again brought its market-based reform scheme to the national level though Hilary Clinton's 2008 Democratic presidential campaign. Clinton's individual mandate was staunchly opposed by then Senator Barack Obama who ran to the left of Clinton, though he ultimately created his presidential administration around the Clinton core.

The Republican Party is often on the leading edge of the long ruling class assault on the working class and the US social security state that it had built up during the Soviet era. However, with its larger base among the working class, the Democratic Party has become, for obvious reasons, the vehicle most preferred (but not always used) by the ruling class to secure final victory on its major legislative offenses. This pattern is borne out not only with today's victory for "Obamacare" at the Supreme Court, but also, for example, in legislation such as NAFTA and the repeal of the Glass-Steagall act.

Despite all, the working class-led fight to defend and extend the social security state with universal, public, single-payer health care continues. Perhaps this will be the issue on which social unionism makes a comeback.

The brief history of what is now known as Obamacare is this:

1) It has its roots in a proposal backed by the "right-wing" Heritage Foundation in 1989 entitled "A National Health System for America."

2) Obamacare was taken up by Newt Gingrich:

3) And then brought before Congress in a 1993 bill sponsored by 18 Republican and 2 Democratic senators that was entitled the "Health Equity and Access Reform Today Act of 1993,"

4) The proposal was finally realized by Mitt Romney in Masachusetts, who still stands squarely behind Romneycare:

5) It was revived at the national level by Hilary Clinton in her 2008 presidential campaign

6) While then-senator Obama vigorously opposed it

7) Ultimately, President Obama adopted the Romney-Clinton initiative and defeated his challengers at the Supreme Court. This is the signature legislative achievement on which the president bases his re-election campaign.

Politics Trumps Policy

Or, as I've said before and will surely say again, politics trumps policy, especially in an election year. - Sandy Eaton, RN