Healthcare!

Absolut Hostage Tape. (It's actually a healthcare townhall.)

As little as I agree with President Obama on pretty much all of his policy moves, or at least, the ones I feel informed enough about to disagree with, I never wake up and think to myself that I wish John McCain were President. The guy's a nut and doesn't know or care much about anything, and when it comes to the stuff he does know or at least care about, foreign policy, he's pretty wacked-out and bellicose. And until now I've never thought at any point that Hillary could've done a better job at this or that than Obama. Actually, I've been pretty sure that she would've done a lot worse. But with healthcare reform in its current treacherous state, I wonder if you're not for the first time seeing something that Hillary couldn't have done much better.

In Obama's defense, the politics of healthcare (and that's all I'm going to be talking about because I don't know shit about healthcare itself) is very tough. Outside of the uninsured themselves and the fairly small number of bleeding heart types who spend their lives worrying about distributive injustice, the constituency for insuring the uninsured just isn't that big. Especially if you can't come up with a simple narrative about how you're going to pay for it and those who don't need the help start to worry that their taxes will have to go up, or that their own care will get worse. So the obvious move is to claim that somehow healthcare reform will benefit everybody, even people who already have insurance they're reasonably happy with. To do that, though, you have to convince satisfied people that, previously unknown to them, there's something wrong with their insurance that needs fixing. And once you do that, once you've attempted to sell reform as a global improvement and not just a hand-out to to the people who lack insurance, you have to assure the reasonably content majority that, though the reform is global, it's not so sweeping that much of anything will change about the way they get their healthcare. Meanwhile, your political opponents, along with the interest groups whom your reforms will hurt, will be feverishly spreading misinformation about what your plan does, and you have to deny that your plan does these things convincingly and pretty loudly, while at the same time not issuing denials so often that people start to think what you're denying is true.

But as tough as the healthcare politics calculus is, one can't escape the conclusion that Obama's utterly failed to strike the proper balance between harping on the rights of the uninsured so much that everyone who has insurance sees reform as a welfare state giveaway and avoiding talking about the actual purpose of reform to the point that nobody gets what the reform's for. And beyond the poor messaging itself, I think you have to wonder whether Obama's really any good at selling policy in a way that resonates with people who aren't policy wonks. But first on the messaging. It's been comically bad. I can understand why a Democratic President would want to push the matter of covering the uninsured under the rug and focus on the benefits his proposal affords the vast insured majority, although not to the absurd extremes he's done it, where he'll literally go a 60-minute press conference or town hall without a single mention of the uninsured. What I can't understand is that instead of framing reform as a matter of insurance security - if you lose your job, if you get sick, you'll still have insurance - he's chosen to frame reform as a solution to the problem of out-of-control costs. Huh? People aren't into signing onto solutions for problems that they're not aware exist. And the average voter just isn't that aware of how much prescription drugs, tests, and surgery cost, much less how much more they cost here than in other nations. Even if they are aware, the fact that rising health costs cause the price of Medicare to go up, which causes the deficit to grow, just isn't something that keeps a ton of folks awake at night. Yet that, of all things, is the problem Obama's chosen to spotlight as the one reform will solve:

But we all know that right now, we've got a problem that threatens Medicare and our entire health care system, and that is the spiraling cost of health care in America today. As costs balloon, so does Medicare's budget. And unless we act, within a decade -- within a decade -- the Medicare trust fund will be in the red. Now, I want to be clear: I don't want to do anything that will stop you from getting the care you need -- and I won't. But you know and I know that right now we spend a lot of money in our health care system that doesn't do a thing to improve people's health. And that has to stop. We've got to get a better bang for health care dollar.

Besides cost control's being a woefully inadequate and unexciting answer to the "why must we reform" question, it induces problematic fears about the content of the reform. When you say that your reform package is all about cutting the cost of healthcare, people reasonably fear that the government is going to control how much they can spend on healthcare. When you then claim that in some mysterious way two thirds of the costs can be paid for "by reallocating money that is simply being wasted in federal health-care programs," people start to think you're bullshitting them. When you then say that all people will have to give up in this brave new cost-controlled world is "paying for things that don't make them healthier," you're in Clinton-on-Monica land. Who's seriously going to believe that we can save ourselves from those big scary spiraling costs simply by somehow getting doctors to "make those decisions just based on whether you really need your kid's tonsils out or whether it might make more sense just to change -- maybe they have allergies, maybe they have something else that would make a difference"? Or requiring people to take the blue pill "if the blue pill is half the price of the red pill and works just as well"? Or solving this puzzler:

Look, if right now hospitals and -- and doctors aren't coordinating enough to have you just take one test when you come in because of an illness but instead have you take one test; then you go to another specialist, you take a second test, then you go to another specialist, you take a third test; and nobody's bothering to send the first test that you took -- same test -- to the next doctors, you're wasting money.

Who gets a test that they've already gotten? Isn't this where the patient says, "I think I've had this test before"? Healthcare's expensive for the most part because it's expensive, not because people get the same test over and over. People get that much, and once you pitch your plan as a cost control mechanism, and then claim that your only cost controls are digitizing medical records and encouraging people to take blue pills instead of red, people think rationing. Which is why polling increasingly says that people believe Obama's reforms will make their healthcare worse. (In June, just 28% were very worried that reform would harm the quality of their care - today, since Obama's gone out on the Cost Control Tour, that number's up to 41%. In just one month!) Not because Republicans or opposition ads are saying it, or because people distrust Obama, but because it's what Obama's own messaging leads people to believe. How incompetent can you get? Because he's terrified of making out his plan to be Great Society-style socialized medicine, he's made it out to be... cheap rationed-out socialized medicine. And having left that impression, he's forced to spend half the time he talks on this issue talking about how little reform will affect the vast majority of Americans in any noticeable way. Straining our credulity, and raising the question of what the point of it all is if so little is changing.

Then, when he finally gets to talking about the uninsured, instead of simply saying that he's going to give insurance to poor people who need it and would otherwise die, he delves into the arcana of the health insurance exchange he proposes to create, sucking all human interest out of the issue, and insists on making this bizarre comparison between the options the uninsured will be given and the options available to members of Congress. Because, you know, if the 535 men and women we entrust with running the country deserve good healthcare, so do unemployed people. Seriously, he makes that argument. It's a line he took from Hillary, but when Hillary said it, she was just trying to stress the normality and quality of the public option she proposed to offer to the uninsured - that is, it must be a good plan and not some terrifying healthcare gulag because Congress elected to give it to themselves. For Obama, it's an argument that if Congress has it, we should have it too. Which is about the dumbest and weirdest argument you could make for insuring the uninsured and pretty symptomatic of how lame-brained his healthcare pitch has been.

That said, Obama's saving grace, here, will probably be his sincerity. People may not believe that Obama can make good on his healthcare promises, but I feel we're long away from the point where any substantial amount of the public (excluding people who would hate any Democratic president) could suspect the guy of intentionally deceiving them. People may worry that Obama's plan will make their care worse, but I think they believe that (a) Obama sincerely thinks it will make their care better and (b) is an awfully smart guy, so therefore (c) we should give the fact that he likes his plan at least some credence. His fumbling communication on the issue comes off less like someone trying to fool us than someone who's confused about how to present this complex issue in the best way and is getting really bad advice on how to do so from his consultants. But though Obama's thankfully lacking the affect of a Bill Clinton or, worse still, an Al Gore is probably the only reason reform hasn't gone down in flames already, his sincerity may also be his downfall.

If you hadn't noticed, Obama has two rhetorical modalities. One, inspired and inspiring sixth-rate MLK knockoff, all grandiose generalities that wouldn't sound too out of place in one of Michael Jackson's world-saving ditties. Two, professorial, dull, and policy-obsessed. And the weird thing is that he's pretty incapable of working a synthesis of the two, that is offering inspiration that's actually about anything. In fact, during the campaign the two often existed alongside each other in the same speech, the cornball but pretty great, by contemporary standards, peroration about making the world a better place and, in the middle, the mind-numbing list of policy proposals that supposedly would help achieve that goal. Now, both these modalities strike me as parts of the "real Obama." That is, he really is professorial and dull, he doesn't just play it on TV, and he really is someone who enjoys entertaining vague messianic fantasies about ushering in a post-political politics. What I doubt you would see in Obama behind closed doors is much or any passion about policy. He's not twisting Senators' arms and telling them that they've got to do healthcare reform for some woman he met on the campaign trail named Sally who told a tale of woe that just broke his heart. In private, I'm sure he talks about policy like an economist, and in public he talks about it the same way. Now, for the average politician, how they really talked about a policy behind closed doors wouldn't have the slightest bearing on how they talked about that policy in public. But Obama isn't like other politicians; he may occasionally lie, but he refuses to act to an alarming extent. So you're never going to see that emotional pitch; because emotion is foreign to his actual thinking on the subject, it's foreign to his communication on the subject. Hillary, on the other hand, whose public persona is about as contrived as Britney Spears's comeback album, eventually learned to do a great healthcare pitch, largely by telling totally made-up horror stories about pregnant women who died, baby and all, for lack of insurance. I'm not suggesting that Obama tell made-up stories, but he could manifest some phony emotion about some real ones.