Obama Needs to Reframe the Health-Care Debate

The United States has two parties now—the Obama Party and the Fox Party. The Obama Party is larger, but it is unfocused and its troops are whiny. The Fox Party, which shows up en masse to harass politicians, is noisy and practiced in the art of simplistic obstruction. As the health-care debate rages, it's the Party of Sort-of-Maybe-Yes versus the Party of Hell No! The Yessers are more lackadaisical because they've forgotten the stakes—they've forgotten that this is the most important civil-rights bill in a generation, though it is rarely framed that way.

The main reason that the bill isn't sold as civil rights is that most Americans don't believe there's a "right" to health care. They see their rights as inalienable, and thus free, which health care isn't. Serious illness is an abstraction (thankfully) for younger Americans. It's something that happens to someone else, and if that someone else is older than 65, we know that Medicare will take care of it. Polls show that the 87 percent of Americans who have health insurance aren't much interested in giving any new rights and entitlements to "them"—the uninsured.

But how about if you or someone you know loses a job and the them becomes "us"? The recession, which is thought to be harming the cause of reform, could be aiding it if the story were told with the proper sense of drama and fright. Since all versions of the pending bill ban discrimination by insurance companies against people with preexisting conditions, that provision isn't controversial. Which means it gets little attention. Which means that the deep moral wrong that passage of this bill would remedy is somehow missing from the debate.

Sure, it's important to fight for a public option (or a souped-up cooperative that can be made nearly as good). And we need to stand against a secret deal with Big Pharma, tighten insurance regulation, and assure that the bill includes language establishing clearly that doctors and patients—not bureaucrats, who are no better than insurers—make medical decisions. But these worthy goals have overshadowed the moral principle of nondiscrimination. The well-meaning woman who left a message at my office saying that she wouldn't demonstrate in support of any bill without a public option has lost her perspective.

The same goes for those who focus on cost ahead of principle. Whether we can "bend the cost curve" in five years or 10 years is fundamentally unknowable. Washington's elite policy mandarins obsess over "out-year" projections that never prove accurate. We must "pay" for the bill with new revenue streams, but let's not pretend that any of the real costs (and incentivized cost savings) are discernible now. Look at "cash for clunkers." The money that Congress set aside for a year lasted less than a week. The short-term projections were off by 99 percent. Any bill this big will be full of unintended consequences and will have to be fixed. The only way the system can't be fixed is if the bill dies and no one tries reform again for many years.

History suggests that major social policy unfolds on a continuum. The Social Security Act of 1935 disappointed liberal New Dealers because what was called "old-age insurance" covered only about half the adult population. It excluded farmhands, domestics, employees of small businesses, and most blacks. That was because FDR needed the votes of Southern Democrats, the Blue Dogs of their day. (The bill cleared the House Ways and Means Committee with only one Republican vote.) Similarly, the Civil Rights Act of 1957, immortalized in Robert Caro's Master of the Senate, was weak tea. It had to be strengthened by the Civil Rights Act of 1964 and the Voting Rights Act of 1965. In the later bills, Lyndon Johnson betrayed Southerners he had made deals with in 1957. If Nancy Pelosi can't break Rahm Emanuel's promise to Big Pharma's Billy Tauzin this year, she can try to break it in the future. And Tauzin will lobby for more favors as the all-important new regulations are issued. Nothing in Washington is ever set in stone.

The only thing that should be unbreakable in a piece of legislation is the principle behind it. In the case of Social Security, it was the security and peace of mind that came with the knowledge of a guaranteed old-age benefit. (Ronald Reagan and George W. Bush got slam-dunked when they tried to mess with that.) In the civil-rights bills, the principle was no discrimination on the basis of an unavoidable, preexisting "condition" like race.

The core principle behind health-care reform is—or should be—a combination of Social Security insurance and civil rights. Passage would end the shameful era in our nation's history when we discriminated against people for no other reason than that they were sick. A decade from now, we will look back in wonder that we once lived in a country where half of all personal bankruptcies were caused by illness, where Americans lacked the basic security of knowing that if they lost their jobs they wouldn't have to sell the house to pay for the medical treatments to keep them alive. We'll look back in wonder—that is, if we pass the bill.

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