Monday, August 08, 2016

Yes We HCAN, sort of: Richard Kirsch's blow-by-blow account of the grassroots battle for health reform

I have been picking my Twitter-induced-ADHD-addled way through Richard Kirsch's Fighting for Our Health: The Epic Battle to Make Health Care a Right in the United States, published in 2012. Kirsch, a lifelong public action exec trained by Ralph Nader, was national campaign manager from 2008-12 for Health Care for America Now (HCAN), a massive umbrella group formed by unions and progressive nonprofits to advocate for universal health care. The book is a blow-by-blow account of the organizing and lobbying efforts that built support for the ACA and pushed it over the finsih line.

This is one of those blog-as-you-read posts, which you could make a case against, but which I enjoy doing as a book pulls me in various directions. I'm on vacation this week and will not trouble myself with excerpts. So far (I'm a bit more than halfway through), the two themes dominate:

o The ACA would not have been possible without massive, coordinated grassroots organizing -- meeting constantly with congressional reps, recruiting people who suffered for lack of health insurance access to tell their stories, raising large numbers of demonstrators to counter the Tea Party at Town Halls, calibrating support for and pressure on wavering reps, etc.

o Squishiness on the public option on the part of Obama and the Democratic Party as a whole was a self-inflicted wound that gravely weakened reform. I do not entirely buy into this, and I have much more yet to read about how that fight played out. That said, a few takeaways and preliminary thoughts:

1. The Tea Party's hysterical, misinformation-fueled, rage-filled hijackings of congressional reps' town hall meetings focused on health care in the summer of 2009 anticipate the Trump rallies of today -- with reps shouted down and drowned out by chants, disabled citizens testifying about their health care struggles booed off the stage, posters of Obama with a Hitler mustache, and equations of end-of-life counseling with genocide.  The funding of these oppo efforts by the Kochs' Americans for Prosperity trace a line from hardcore ideological libertarianism to Trumpian fascism, the common denominator being the sabotage of fact-based discourse.

2. A key under-reported part of the ACA's story is the extent to which HCAN (an umbrella for over 1000 progressive groups) successfully countered the Tea Parry, particularly by recruiting counter-demonstrators in the long hot summer of 2009. That's a natural theme for the HCAN campaign manger, but it's well-documented, and tempered by his account of the effort's failures.

3. During the interminable slog to get the ACA drafted and enacted, the public option became the symbolic focal point for activists desperate for some evidence that progressive action could counter corporate control of healthcare.

4. HCAN always reflexively demonized the insurance industry as public enemy #1 in the fight for health reform. Given the dysfunctional rules under which the individual market in particular functioned, there was some basis for this. But as with progressive politicians, doctors and hospitals got a relative free ride -- though providers' interest in preventing a plan that would pay Medicare rates or something close to them is more direct than the insurers'. Kirsch does note that while Dem elected officials could muster the wherewithal to counter insurers, they were more susceptible to provider pressure.

5. In my view, while a nationally established public option might push or enable insurers to negotiate lower rates paid to providers, the main weakness of the ACA marketplace is not the lack of a public option but a too-skimpy subsidy structure. For many buyers in the upper range of subsidy eligiblity in particular (say 200-400% FPL), and for healthier uninsureds generally, premiums and out-of-pocket costs are simply too high to render the insurance affordable or attractive. Hence the smaller-and-sicker-than-forecast risk pool,which is now reducing competition and raising prices on the unsubsidized. A higher benchmark AV and a universal cap on premiums as a percentage of income, as proposed last summer by the Urban Institute's Linda Blumberg and John Holahan, would have been affordable and would have rendered the marketplace more competitive. And still could, if by some miracle Democrats retake both houses of Congress.

Now, to the beach.

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