While the pundit class has been fretting over Democrats not having a message in the 2018, surprise! They’ve got one, as a recent New York Times Upshot article noted: Health care! And, more specifically, the threat of losing health care because of pre-existing conditions. As the article notes:
In June, Senator Claire McCaskill of Missouri asked voters at a big political dinner to stand up if they had a pre-existing health condition….
The room was suddenly filled with standing voters. “Even I was stunned just how few people kept their seats,” she said.
Now, Ms. McCaskill asks the question at every event.
After McCaskill shared the experience with Sen. Joe Donnelly of Indiana, another red-state Democrat fighting hard for re-election, he adopted it as well. They have plenty of company, the Upshot noted, quoting Tyler Law, a spokesman for the Democratic Congressional Campaign Committee:
“We’re seeing candidates in every single district talking about health care,” law said. “There is nowhere this does not play.”
The Upshot also cited research from the Kaiser Family Foundation that more than a quarter of working-age adults have a pre-existing health condition (57 percent have a pre-existing condition in their household, according to another KFF survey, not mentioned in the story), and it’s become the top health care concern in Kaiser’s most recent survey, even “ranked the most important campaign issue for many of them over all.” (Kaiser itself reported that 63 percent of voters rated it the “most important” or a “very important” factor.)
Analysis of television ads through from the Wesleyan Media Project found that health care was the most common subject of Democratic campaign ads.
The Upshot notes that this is a huge turn-around from past elections, when health care was the GOP’s favored issue, but as important as that fact may be, it could just be part of an even bigger story. By stumbling into making pre-existing conditions a unifying cross-categorical concern for all sorts of voters, the GOP has not helped Democrats with their perennial problem of appealing to diverse interest groups and social identities (à la “Asymmetric Politics: Ideological Republicans and Group Interest Democrats,” Salon review here). That has also created an experiential framework that can help personalize the big picture problem of health care in a way that favors Democrats’ aspirations for Medicare for All, which again came under a deceptive attack this week, followed by Trump’s most recent effort to undermine Obamacare. The blizzard of confusion is nothing new — but the chance to cut through it may well be.
Consider the attack: a Koch-funded report was touted showing the plan would cost $32 trillion, although it was then pointed out that this would actually save $2 trillion over our existing system — a point most media outlets somehow seemed to miss. But beyond the deceptive framing, the underlying reason the costs will still be so high is the pre-existing condition of American health care — how enormously costly and wasteful our current system is, largely due to a long history of oligopoly price-setting. According to the lastest OECD data, America spends 17.15 percent of its GDP on health care, which is 40 percent more than Switzerland (at 12.26 percent), the next most costly country, and more than double the OECD average of 8.12 percent. Even saving $2 trillion over the next decade would still leave our costs much higher than Switzerland’s.
This enormous cost difference — despite the lack of universal coverage — has long been a well-known fact among experts. But it’s never gotten the political traction it ought to, even if only in terms of international competitiveness, that perennial centrist fetish. In the near future it finally might, seen through the lens of pre-existing conditions. It’s not as if a clever act of framing can be a silver bullet to solve America’s intractable health care dilemma. But it can play a crucial part in helping to facilitate a shift in thinking that’s already well under way.
Younger voters are already much more open to bold, activist government approaches to the major problems they see — student debt, income inequality, global warming, etc. — as well as health care. But older voters are even more likely to have family member with a pre-existing condition, as KFF data shows:
This doesn’t mean it will be an easy sell. Between now and the midterms the immediate battle is to preserve what we have, and pre-existing conditions to worry about are strictly individual. But after that, the push towards Medicare for All seems virtually inevitable, and the framing in terms of pre-existing conditions is a natural way to root more abstract arguments directly in people’s lived experience.
At Vox, Matt Yglesias made the inevitability argument clear: market solutions can only work if Republicans will let them, which it’s now clear they won’t
thanks to the Trump administration, which, having failed to repeal the Affordable Care Act, has undertaken a nearly unprecedented campaign of regulatory malfeasance that aims to prevent it from functioning and minimize the number of people on whom it bestows comprehensive health coverage.
He goes on to say that "in a democracy, a workable regulatory system needs to be able to survive the regular alternation of parties in power. The lesson of the Trump era is that the Obamacare approach can’t do that.
This actually isn’t a new development, just the last straw. As David Hopkins, co-author of "Asymmetric Politics," told me last year,
[H]ealth care debates often take the form of Democrats arguing in favor of specific policies and Republicans respond by saying, “That’s big government, that that’s infringing on individual liberty, that’s violating free market principles,” and so on. The entire time we’ve been debating health care in this country as a federal issue, going all the way back to the 1930s and ’40s, the debate has taken that form.
Over the years, Republicans have repeatedly made gestures towards offering their own plans for giving Americans health coverage, just like other countries do, only to withdraw when things might turn serious. At the same time, they’ve moved increasingly far to the right, so the ideas they champion at one time become unacceptable later on. Perhaps most notoriously, the Heritage Foundation was a key source for Republican ideas offered to counter Democrats in the 1990s, with publications starting in 1989. These were later taken up by Mitt Romney as governor of Massachusetts, then by Obama, and then roundly denounced as “socialism!” Which is how we got to where we are today.
Democrats have always had the advantage in actually solving concrete real-world problems. Republicans have had the advantage in abstract framing. But when the abstract idea is that your baby will die, it’s no longer so abstract, and the advantage fades. That’s how pre-existing conditions took center stage with the Jimmy Kimmel test last year, and they’ve only seem to have become more deeply rooted in people’s thinking since then.
The question is: Can Democrats seize the advantage for themselves? Can they take it to a higher level? It’s a metaphorical leap from you or your loved one’s pre-existing condition to the pre-existing condition of our whole medical system, but the hardest part of making such a leap is having somewhere to start from — and that’s already been done. The metaphorical leap from the personal or familial level to that of society or the nation is one that’s made all the time, as George Lakoff explained in his 1996 book “Moral Politics” (my review here). It underlies the whole framework of how strict father family values drive and give coherence to conservative politics, and how nurturant parent values do the same for progressive politics.
But it also underlies conservative arguments like “government should balance its budget just like your family does,” which were used to cripple the sustained social spending that was needed in response to the Great Recession. That metaphorical leap is misleading, because it fuels a vicious cycle of less and less spending throughout all of society. Government needs to spend money when no one else will, in order to get the economy growing again. This is consistent with the larger progressive view, enshrined in our Constitution, that government exists to promote the general welfare — that it’s how we, the people, take action collectively to accomplish things that individuals can’t do alone. But we’ve been neglectful in developing the language to talk about it.
In her book, “Don't Buy It: The Trouble with Talking Nonsense about the Economy,” (my review here) linguist Anat Shenker-Osorio explains how conservative’s more disciplined use of conceptual models in economics to drive their metaphors has helped them win elections and dominate policy debates. Two are key: “the economy as a natural entity and the economy as a moral enforcer." But she also explains that progressives — though less disciplined — have a very good metaphor of their own, as I describe in my review: “the economy as a human-made object in motion -- ideally, a vehicle -- which sends the factually accurate message that the economy would not even exist without human involvement, and needs conscious controlling in order to avoid disastrous results.”
The metaphors we use have enormous power to shape our thinking — especially when we’re not even aware of them. Discovering and developing new metaphors is a crucial part of progressive political struggle. It’s a key part of how we “make a way out of no way,” in the words of John Lewis. Connecting individual experience with shared experience is crucial, too. All of which points to why the time is ripe to start seeing pre-existing conditions as a way of describing the problems with our health care system as a whole— and even more.
The health care situation is not an isolated example. But it is the most personally invasive facet of a broader pattern. In 2010, after panic about rising deficits served to trigger a world-wide shift away from economic expansion and toward austerity economics, Roosevelt Institute fellows Thomas Ferguson and Robert Johnson wrote a paper, "A World Upside Down? Deficit Fantasies in the Great Recession," in which they wrote, "Our analysis of threats to the budget finds that not entitlement spending or Social Security, but the excessive costs of oligopoly in health care and defense spending play a large role in current concerns. So does the contingent liability of another financial crisis."
The oligopoly costs of health care are, in short, part of a more general problem, a larger pre-existing condition of concentrated political power that unfairly burdens the vast majority of the American people. For the most part, this pre-existing condition is simply too vast and intricately structured for the average American to make sense of — which is in large part how it manages to survive. But people involved in many different struggles have made sense of bits and pieces of it, and have made connections between their struggles as well. The description of “pre-existing conditions” fits well into this ongoing process of developing a common language in which a wide diversity of views, experiences, lessons, and ideas for the future can be shared.
Another way of seeing the significance of this description ties into Suzanne Mettler’s new book, “The Government-Citizen Disconnect” (Salon interview here), in which she explores a strange divergence. In it, she wrote "while trust in government has eroded and suspicion and hostility have grown [since the 1970s], people are more reliant on government than ever." Almost all American adults — 96 percent — have received some form of government assistance, yet hostility to government is at or near an historic high. While Democrats have long been obsessed with creating social programs that help solve real world problems — as “Asymmetric Politics” argues — they have not been focused on communicating the success of programs, and as a result, voter attitudes generally fail to reflect how well programs work. As a result, she concludes, "What is at stake here is not only the future of American social provision but, more importantly, the well-being of democratic governance." Voters’ attitudes do not generally reflect their actual experience.
Instead, one could argue, they reflect the pre-existing condition of American political culture. As Mettler explained in the interview, “One factor that was consistently significant, and shaped people's attitudes about government in a negative direction, was their views about welfare.” America has a much smaller welfare state than others in a direct government spending sense, but a large one when all the submerged and hidden channels are taken into account — such how tax codes and other government policies have supported the private health care system.
One way that Democrats have tried to cope with Republicans’ anti-government rhetoric is by using such hidden means, which make government’s role difficult, if not impossible to see. The cumulative effect of this repeatedly over time is that it only helps feed the disconnect Mettler describes. Indeed, as she’s argued, that disconnect, that pre-existing condition only gets worse, the more that Democrats respond to it defensively. Which is why she thinks we need to try a different way.
“I've been talking for a while in my work about how we ought to create policies where government's role is more visible, and we ought to deliver policies in a way where we're trying to make that evident to people,” Mettler said toward the end of the interview. “For those things to happen, I think you have to have the political will, and right now that's not the case. What I actually think is more significant now is organizing on the ground, interacting with people and helping to connect the dots for them.” This is not a new idea, it has a history, she said:
If you go back to the middle of the 20th century, when many more Americans belonged to labor unions than today, labor unions helped to make it more evident to people what difference government makes to them, and what policies were helpful. The AARP does that and continues to do that for retired people, on the role of Medicare and Social Security in their lives. But we don't have many other organizations that do that. For these problems we have been talking about, and lots of others that are confronting American democracy these days, it's necessary for people to become active at the grassroots level in organizations, and for those organizations to make these connections with people.
At its most basic, an activized grassroots base is about changing the pre-existing conditions in which all other politics happens. It’s about making connections where they are missing now — connections between government programs and their results, connections between people who’ve been artificially divided against each other, connections between struggles that confront different aspects of our current dysfunctional pre-existing condition. Healthcare, even at 17 percent of our economy, is only one facet of that larger dysfunction.
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