Michael F. Cannon, a pundit at the libertarian Cato Institute [3], has written a blog post that highlights the importance of what I believe will be one of the most important issues in play once Barack Obama [4] assumes the U.S. presidency. "Blocking Obama's health plan," he writes, is "key to the GOP's survival [5]." To explain this point, Cannon cites the analysis of Norman Markowitz [6], a professor of history at Rutgers University. Cannon gasps with horror that Markowitz is some kind of Marxist, but he nevertheless agrees with Markowitz on the following points:

A "single payer" national health system [7] -- known as "socialized medicine" in the rest of the developed world -- should be an essential part of the change that the core constituencies which elected Obama desperately need. Britain serves as an important political lesson for strategists. After the Labor Party established the National Health Service after World War II, supposedly conservative workers and low-income people under religious and other influences who tended to support the Conservatives were much more likely to vote for the Labor Party when health care, social welfare, education and pro-working class policies were enacted by labor-supported governments. ... The best way to win over the the portion of the working class in the South or the West that supported McCain and the Republicans is to create important new public programs and improve the social safety net. National health care, significantly higher minimum wages, support for trade union organizing, aid to education should all be on the agenda. These programs will improve the quality of our lives lives directly, giving us greater security and establishing the social economic changes that will bring reluctant voters into the Obama coalition. That is how progress works.

What Markowitz sees as progress is Cannon's big fear -- a fear that has been haunting conservatives in the United States for more than a decade. They worry that a universal government health plan, if it should ever come to pass, will be so wildly popular with the public that they will reward Democrats for passing it. The same fear was expressed in 1997 by Grover Norquist [8], the conservative activist who famously declared that his goal is to shrink government "down to the size where we can drown it in the bathtub." In an interview with the libertarian Reason magazine, Norquist said that he was motivated in the early 1990s to organize his conservative coalition by "sheer terror of Clinton's health-care plan [9]. The goal was to stop the government seizure of the health-care industry. Had the Democrats taken over health care, I think we would have become a social democracy and we could have never undone it. We wouldn’t have won in '94, and even if we did, it wouldn’t matter because 50 percent of the population would be on the take. The government has your kids' education, your health care, your parents' health care, and your pension. You want to argue with that government? There isn’t an anti-government party in Germany, Sweden, or France. ... There’s not an anti-government conservatism as a functioning, competing political party that might win an election, because everybody agrees that the government is going to run your health care. Even Margaret Thatcher was really pissy at anybody who wanted to talk about doing something with the National Health Service." This is a point on which conservatives have good reason to worry. The public already believes, by a strong majority, in government-funded universal health care. As the Gallup polling service reported last year, "69% of the public believes [10] it is the federal government's responsibility to make sure all Americans have healthcare coverage. What may be surprising is that many of the nation's small-business owners -- known for their fierce independence and entrepreneurship -- not only believe that the current U.S. healthcare system needs a complete overhaul, but also support the idea of a taxpayer-funded national health insurance program." This poll is not a fluke or a temporary mood swing on the part of the public. Gallup has been measuring public opinion on health care for years, and attitudes on this issue have been remarkably consistent [11]. Surveys on this issue by other polling agencies also reach the same conclusions. In June of this year, for example, a survey by ABC News and the Washington Post found that 66 percent of Americans support "providing health care coverage for all Americans [12], even if it means raising taxes." In short, a majority of Americans -- including traditionally-conservative small-business owners, favor a health care policy that is to the left of the policies proposed by either Hillary Clinton [13] or Barack Obama (let along John McCain [14]) during the recent U.S. presidential campaign. None of those politicians has proposed a universal, taxpayer-funded health system, even though the public wants it.

On This Issue, Public Opinion Is Correct

Conservative pundits like Cannon, in league with the private U.S. healthcare industry, have spent vast sums of money to discredit the idea of a publicly-funded healthcare system for the United States. The healthcare industry has been campaigning against what it calls "socialized medicine" since the days of Harry S. Truman. They argue that a national health system will bankrupt the country and lead to substandard services. In fact, however, the lack of a national health system is already costing much more and delivering much less than what people are getting through government health plans in virtually every other country in the industrialized world. According to a study a few years ago [15] by the Institute of Health of the National Academies of Science, lack of health insurance causes roughly 18,000 unnecessary deaths every year in the United States. More than 45 million Americans lack health insurance [16] -- 15 percent of the population. Even for those who can obtain insurance, costs are spiraling rapidly out of control. As the U.S. Congressional Research Service (CRS) noted in a recent study,

The United States spends more money on health care than any other country [17] in the Organization for Economic Cooperation and Development [18] (OECD). The OECD consists of 30 democracies, most of which are considered the most economically advanced countries in the world. According to OECD data, the United States spent $6,102 per capita on health care in 2004 -- more than double the OECD average and 19.9% more than Luxembourg, the second-highest spending country. In 2004, 15.3% of the U.S. economy was devoted to health care, compared with 8.9% in the average OECD country and 11.6% in second-placed Switzerland.

What are Americans getting in exchange for all this health care spending? The CRS reported that the U.S. has one of the lowest numbers of acute care hospital beds per 1,000 population (ranking just slightly better than Turkey or Mexico). Among the 30 nations in the OECD, the U.S. ranks 21st in number of practicing physicians. Opponents of national health care often claim that it would lead to longer waits for treatment, and this is actually true with regard to elective surgeries such as knee replacements. For the health care that matters most, however, Americans wait longer than in the OECD countries with government health plans. A 2004 study looked at patients' experiences in five English-speaking countries (Australia, Canada, New Zealand, the United Kingdom and the United States). It found that U.S. respondents were the second-least able to make a same-day doctor's appointment [19] when sick and had the most difficulty getting care on nights and weekends. They were also the most likely to delay or forgo treatment because of cost. Yet another study [20] found that the United States had the third-highest rate of deaths from medical errors, among 26 countries reporting. One of the most obvious ways to evaluate performance of a health care system is to ask about the health and longevity of people who live under it. Here also, the U.S. performs badly. The American Human Development Report [21], a 2008 study funded by Oxfam America, the Rockefeller Foundation and the Conrad Hilton Foundation, found that the US ranked 42nd in the world for life expectancy [22] and that "Americans live shorter lives [23] than citizens of virtually every Western European and Nordic country." Moreover, the infant mortality rate [24] is "substantially higher in the United States than in other affluent nations" and is "on par with that of Croatia, Cuba, Estonia, and Poland."

Back to the Future

During the 2008 presidential election, Barack Obama said that serious health-care reform would be one of the priorities of his administration. Recently pundits such as David Broder at the Washington Post have pointed to Obama's choice of Tom Daschle [25] to run the Department of Health and Human Services as a signal that "Obama is serious about his campaign promise [26]." However, we've seen this situation before. The incoming administration of Bill Clinton [27] also promised serious health care reform but failed to do so, after it encountered a concerted grassroots [28] campaign led by the healthcare and insurance industries, using front groups [29] such as the Coalition for Health Insurance Choices [30]. CHIC ran the "Harry and Louise" ads pictured above, which featured actors depicting everyday people complaining that the Clinton plan would drive up health care costs to as much as "$3,200 a year" -- a figure that actually sounds quaint today. One of the people leading the campaign against Clinton's health plan was Robert Hoopes [31], who started his career working for liberal Democrats (including incoming vice president Joe Biden [32]). To defeat the Clinton health plan, Hoopes acted as "grassroots coordinator/political education specialist" for the Independent Insurance Agents of America. Speaking at a PR conference after the plan had been defeated, he explained how they did it: "Health care was a very slow moving train. We saw it coming in Clinton's State of the Union address. We had time to gin up the grassroots, mail our letters, educate our membership, have town hall meetings; I could travel all over the country and get my members excited about it. When it came time for a vote we were ready." Rest assured, they're planning to be ready this time too. During the 2008 election campaign, the health care industry was already working to position itself for the coming debate. Leaders in the health industry even sponsored new ads [33] called "Harry and Louise Return [34]," in which the same actors now say they support health reform. But reform of what kind? It would be naive to imagine that the industry itself will support anything that undermines the very lucrative opportunities it has enjoyed until now. The commentary that I quoted above from Michael Cannon suggests that the industry and the political right will bring out all their guns to fight health care reform this time too. For the private health care industry, money is at stake. For the right wing, the political viability of their libertarian ideology depends on preventing the United States from adoping an effective government health system. The upcoming battle over health reform may boil down again to a choice between your health and their political future.