Tales From the Health Care Swamp
Uh, just a minute: How did we get to this point, poised to disassemble and haul away Obamacare and/or spend the next two years in recriminations having to do with how the job was done (or not done)?
Could these prospects have faced us under Washington, Jefferson, Jackson, Polk, Lincoln, Cleveland or McKinley? Not exactly.
In the old days, health care wasn’t a government concern at all, save here and there, on the local level: a municipal hospital, a state-funded medical school, that sort of thing. The provision and enjoyment of health care were personal, private-sector concerns. We got to this present point … how? And found ourselves doubtful of our ability to get out of the mud … why?
Consider: We got to this present point through decisive changes in how we understood governmental duty. Governmental duty had been understood mostly, on this side of the water, as the protection of society from violence and injustice. People otherwise tended to their own knitting — that was, until the New Deal, when the guaranteeing of jobs and opportunity lengthened the list of duties.
The Supreme Court provided constitutional cover for the new understanding, which, following the Kennedy assassination, came to cover health care. Lyndon Johnson, the One Great Scoutmaster (as the columnist James J. Kilpatrick named him) saw government as obliged to lead us to the camping ground of the Great Society, where we would all sit around the campfire holding hands. Medical care for our old folks became, through Medicare, an entitlement, paid for by present generations that would in time claim their own protections. There followed Medicaid for the poor and a prescription-drug benefit pushed by, of all people, the Republicans. The crowd around the campfire grew steadily.
Obamacare followed logically from these prior occasions. The government, it now seemed, owed everybody the chance to buy health insurance at a fair-seeming — to the government — price. You dream this way under the influence of hubris and ambition. You make the cynical calculation that an insured voter is a grateful voter.
Obamacare’s gap-toothed defects — the complexity, the cost to the government, the narrow choices afforded beneficiaries — make it widely unloved and ripe for replacement.
But here political reality rears its head, instructing us that taking from the voters is a different thing from giving to them. That is, politically speaking, Congress can’t strip Obamacare’s benefits from the customers and call it a day. There’s no Square 1, on the health care board, to return to. You’re on, probably, Square 36, and the sun’s going down. What are you going to do for the customers?
Here we see the dangers and perplexities that flow from leading those good little scouts — the voters — to the campfire of political dependency. You have to keep them happy, never mind the cost. They must be made to believe the reform scheme you offer them is at least as good as the one you propose to take from them, the campfire equally as inviting.
Behold the Republican dilemma. How to do this thing, with precarious majorities in both houses of Congress and a White House whose occupant is the furthest thing from a policy guy?
The image of Washington as a swamp has engaged the country for months. The health care imbroglio shows how Okefenokee-like the place has become: deep, dark, hard to turn around in without drowning or exposing hindquarters to the alligators.
We are living through the sour consequences of assigning to politicians and bureaucrats the duty to make our hearts glad rather than just protect us. Everyone from Nancy Pelosi to Paul Ryan would acknowledge the tenuousness of comparisons: the prudent, barely settled nation of George Washington’s day versus the teeming, industrialized empire that elected Donald Trump. It’s not 1789 anymore. Yet principles have a way of haunting the hearth in all ages: among them, the principle that bills come due, never mind how long you evade them.
The bills that have piled up on our trek to the Great Campout stare us in the face, as Congress considers how to administer, and pay for, health care. Nobody, something tells me, is going to love how this thing turns out.