"They saw everything through the prism of healthcare" -- Pelosi at Health Action 2019

I've just started going through my notes from Health Action 2019, Families USA's annual conference, which is always a delight to me, as recounted here (for 2018) and here (2017). I'm reminded that in her 15 minute keynote, Nancy Pelosi actually said something of substance It's here, beginning at about 12:15 (my emphasis):

God truly blessed America with the activism of all of you. It made so much difference..we not only want the grass roots to mobilize, we want them to give us their view of what public policy should be, and how we message that public policy. That was our success in the last two years, because we would say, 'this is what we need to do, how does this translate to the people who are out there?' And they saw everything, the grassroots we were working with  -- including many of you --  through the prism of healthcare. If you want to talk about the tax bill, talk about healthcare...Republicans say about the tax bill, it doesn't really increase the deficit, but if it does, we'll take a trillion dollars out of Medicaid, we'll take a half a trillion dollars out of Medicare. So again, the point being, the effective messaging is what worked at the grassroots level, which encourages people to take advocacy action, to make the calls, to show up at the town halls, to do the sit-ins, all the activism that you know very well. So I'm here to say thank you in all of you. I hope again that you take satisfaction in all you do.

This strikes as more than just flattery and in-group reinforcement on a couple of levels. First, I don't think anyone anticipated the full force of popular passion and grassroots action that arose in response to the threat of ACA repeal. When Pelosi says that elected Democrats channeled the grassroots passion, effectively rode the wave, that''s the simple truth. I had the privilege at Health Action of meeting Elena Hung and Rebecca Wood, activist mothers of children with intense medical needs. Both have been embraced (literally) by Pelosi and dozens of Democratic senators and congressional reps. Hung is cofounder of Little Lobbyists, forged on the fly in the crucible of the 2017 repeal fight, and that group's articulation of the stakes for their children was match to the tinder of the massive Medicaid cuts and undermining of ACA pre-ex protections in the Republican repeal bills.

Second, healthcare is the right "prism" through which to view the partisan struggles of the past two years in that it was the fulcrum of the financial fight. Pelosi references the Republican House budget for 2019, which called for $1.5 trillion in spending cuts to Medicaid and $537 billion to Medicare over ten years. The ACA repeal bills would have reduced Medicaid spending by $700-800 billion over ten years (and over $2 trillion in the second ten-year period) and spending on private plan premiums by $200-300 billion. Medicaid and Medicare together account for about three eighths of federal mandatory spending; they are the focal point of Republican efforts to reduce taxes and government spending, as Social Security has its own dedicated tax and defense spending is sacrosanct to Republicans.

Finally, Pelosi implicitly identifies Medicaid as the central battleground in the partisan healthcare fight. While the threat to ACA protections for people with pre-existing conditions, codified mostly in rules for individual market coverage, dominated the war of words in both the repeal fight and the election contests, Republican attempts to eviscerate Medicaid would have done more sweeping and lasting damage.  By pairing the fights over taxes and healthcare, Pelosi foregrounded finance, and that fight was more about Medicaid than anything else.

That political perspective was prelude to, and in a sense somewhat in tension with, the conference's central theme, which was, I think, that we view "healthcare" through too narrow a prism,that the problems with our system go beyond inadequate access and high cost for the services we think of as healthcare. The focus in other plenary sessions was on bringing questions of equity into efforts at payment delivery reform; refocusing spending on the social determinants of health; and bringing the perspectives of those who have lived and worked with underserved and under-represented groups into the center of policymaking. More on those themes in the next post...

Related:
Beyond healthcare reform at Health Action 2019
Democrats and activists prepare health care offensive (Health Action 2018)
At Health Action 2018, a focus on racial discrimination in healthcare
Affordable Care Act supporters gird for battle (Health Action 2017)
I was spanked by a nun on a bus (Health Action 2017)