Larry Jacobs: This is a 'pivotal historic moment'

Chances are you've seen or heard University of Minnesota political scientist Larry Jacobs' comments about politics, polling and elections for the news media. As director of the Humphrey Institute's Center for the Study of Politics and Governance, he is frequently in demand for his analysis of state and national politics.

Outside of Minnesota, however, Jacobs is known primarily for his studies of health policy and politics. He has conducted health policy research for 25 years, and has published several books and papers on the topic. He also analyzed the Clinton administration's health-care reform effort in his book "Politicians Don't Pander" and is in the process of studying the Obama effort for the Russell Sage Foundation.

I stumbled upon Jacobs' other expertise when he spoke about the history of U.S. health-care reform as part of a lecture series in the U's College of Continuing Education. (You can read my report here.) I wanted to hear more of his insights, so I invited him to participate in MinnPost's Q&A series with thought leaders about their best hopes and worst fears for health-care reform.

As reform dominates the domestic agenda, this is an exciting time for health-policy researchers like Jacobs.

"I do think this is a pivotal historic moment," Jacobs says in our Q&A. "I think for the first time in almost half a century there will be a bill introduced onto the floor of the House of Representatives and perhaps the Senate that will be passed."

MinnPost: What sparked your interest in health-care policy?

Larry Jacobs: My mom was a registered nurse and my dad worked in the court system on medical issues … so I grew up in a "health-care household." In graduate school I was working on my dissertation when I became interested in health policy as a portal into politics and policy.

The battle over health policy crystallizes the dynamics of American politics — the legislative process, presidential leadership and the role of public opinion.

My first work was a comparison of Medicare and Britain's National Health Service Act and the reasons these two very similar countries developed such different health-care systems. For me, that was a fascinating question.

MP: You've written "Healthy, Wealthy, and Fair" and "The Health of Nations: Public Opinion and the Making of U.S and British Health Policy." What key points from those books would be helpful in today's health-care reform debate?

LJ: I'd like to mention one other book: "Politicians Don't Pander" was a book in part about the Clinton health-reform effort. I spent more than a year interviewing Democrats, Republicans and a number of people in the White House, including the first lady and senior administration folks, and I published not only that book but a number of articles on the Clinton episode. I'm now involved in helping lead a project for the Russell Sage Foundation on the Obama White House and the Obama health-reform effort.

There are several things [key points from books], and maybe this is the most important: We tend to get very shortsighted when these health reform episodes break out. It tends to be on the Democratic side that "the train is in the station; we've got to get everything on board possible because this moment won't happen again." It's almost kind of a panic. If the public option isn't there, the whole thing is not worth it. On the Republican side there tends to be a panic about where will this go? It's "socialism is going to take over the country" or it's "death panels."

What I've seen, having studied the development of health policy in the United States and in a number of European countries — including in Britain and Germany and France — is that health policy takes a long time. It is constantly evolving, and it evolves in response to breakthroughs in medical technology, changing society and the expectations of everyday people.

So, about the fears on the right about death panels, I haven't seen them. I'm not going to say they never happened, but I haven't seen them. It's not like all of a sudden you're going to have a new society in which the idea of a death panel is going to become acceptable. The horror we have about a death panel today will be there tomorrow because it's [health policy] never a finished product. It's constantly evolving. And if there was a death panel, there would be outrage in the community and there would be backlash in Congress, and it would be stopped.

Now on the Democratic side — their panic about not getting things right at this one moment is off the mark because it's never right, no matter what. There's an endless and continuous process of addressing unmet needs and improving quality and controlling costs. I don't care what health system you look at in the world, there are enormous and intense debates about reform. There is no kind of endpoint. And so the very concept that liberals have of "the train is in the station, this is our one point" is historically shortsighted. It's a myth.

Instead, what I see is a process of evolution over many, many decades in response, as I said, to medical technology breakthroughs, changing patterns of medical care and public expectations. 

MP: What's your latest book?

LJ: My last book is called "Class War?" [which] shows that there's very broad agreement that is supported by majorities of Democrats and Republicans behind the conservative philosophy of individual self-reliance AND a pragmatic acceptance of the significant government role in providing the tools for individuals to take care of themselves like education.

MP: And like health insurance?

LJ: And health insurance, so that people have the good health to take care of themselves and to work hard in the pursuit of their interests. If you're sick, you can't do those things.

What was really striking about this book is sometimes there are quite large majorities of Democrats and Republicans supporting the conservative philosophy and majorities of Republicans supporting government programs. One of the bottom lines here is that the polarization we see in Washington — in which we're not going to get more than one or maybe two Republicans supporting Democrats' health reform proposals — that's not what's going on in our neighborhoods. There's a lot more agreement among our neighbors from the conservative side and the liberal side.

It's striking how uneasy even Democrats are about government. This is not the type of happy government crowd that you might assume when you hear some of the criticism of Democrats in Washington. Democrats do have a conservative orientation; many do. They prefer to see individuals take care of themselves and to have the real opportunity to do that.

MP: So, when did Democrats and Republicans diverge? If they share that orientation, then why can't they come together?
 
LJ: There's a big gap between our neighbors and what's going on in Washington, and that's a long story having to do with the nomination of candidates, which is controlled by very small, ideologically pure groups, the campaign contributors and some other factors. Those most active in the political parties with the most influence on the nomination process tend to be focused on single issues and to take more ideologically extreme positions — for example, a flat tax or abolition of "death tax" on the right and single-payer on the left.

MP: You've already answered this question to some extent, but do you have anything you'd like to add to what are the biggest political misconceptions about the history of health-care reform in the United States?

LJ: Let me add one that I think is an important one. There tends to be a myth that's created about the power of the president. In every episode of health reform in this country, the president becomes kind of a scapegoat for what didn't happen. Democrats are furious that Lyndon Johnson or Bill Clinton or Barack Obama didn't force Congress to take certain required steps. Republicans are furious that the president didn't reach out more, didn't create a genuine bipartisan effort despite their interest in doing so.

The reality is that presidents are checked and hemmed in by the realities they face in Washington. The biggest reality in the contemporary period is the historic polarization of the Democratic and Republican parties. The idea of bipartisanship is a myth. It's not possible. And the idea that any president, including Barack Obama, could force a member of Congress — including a Democratic member of Congress — to do anything is also a myth. It truly is the case that the legislative branch is independent. Each of those 535 legislators will run on their own record, will make their own decisions and are quite capable of disagreeing with the White House.

So, the bottom line here is that the weight that's put on presidential leadership is grossly exaggerated. There are things that presidents do that are very important in terms of setting the overall agenda. But beyond that when it comes to shaping the detailed content of health reform, presidents are weak.

MP: In a recent lecture, you discussed how James Madison's influence on the Constitution makes it difficult to reach consensus in Congress and the White House. Could you elaborate a little on that, and then give your best guess on what we'll end up with after this round of health-care reform?

LJ: James Madison faced two fears when he led the effort to design the American Constitution. One was that we would have a tyranny of the majority — and he was particularly afraid of landless peasants rising up and seizing the larger plantations. He says in Federalist Papers 51 that his first job was to control the government. So, how do you control the government is in part the nature of American society, which is very fragmented, very diverse. You've got the western United States, which is very different from the southern United States. There are racial and ethnic differences and religious differences, so it's hard for majorities to form.

The second concern that Madison had is that in creating a new government that would help maintain the social order and prevent this tyranny of a majority, it could itself become a threat to individual liberty. So, on the one hand you've got the threat of the mob taking property and violating individual rights to property; on the other hand you've got the threat of creating a government trying to maintain order and it becomes a threat to individual liberty.

So, Madison deliberately invited division and conflict. He wanted to make it very, very hard for government to do much. About 100 years after Madison's work, Woodrow Wilson wrote a series of seminal books and one of his most consistent criticisms of Madison was that he created a system that Wilson described, for the first time, as a system of checks and balances. Wilson meant that in a very critical way. He thought this was irresponsible and led to unaccountability because power was so diffuse. It was very hard to hold anyone responsible when things didn't go well and it was very hard for government to do the things it needed to do in an industrial period in a time of enormous economic change.

The point here is that Madison's system, which was deliberately created to foster disagreement, division, continues to haunt health reform today. As we can see, the president puts forth some ideas, principles, and we've got a very different set of ideas in the House of Representatives, from the Senate, and within the Senate, you need 60 votes to overcome a filibuster.

So, the potential for deadlock, delay is enormous. And that's not the fault of President Obama or the speaker of the House of Representatives or Republicans. It's a fully intentioned, deliberate strategy to make it very hard for government to do much. This is exactly what Madison wanted. In that sense, things are going according to plan.

MP: What's a taxpayer and voter supposed to think about all this and how do you fix it or can you fix it? Do we want to fix it?

LJ: I think Americans usually get very frustrated with the legislative process. Madison's system of a convoluted, slow-moving, frustrating process is a recipe for very low approval ratings for Congress as a body. Now, for folks worried about paying more taxes, Madison's system is, or should be, a relief because it is consistently a block to efforts to expand government in ways that would increase taxes.

I think for many Americans who are hoping that Barack Obama's election would lead to health reform it's an enormous frustration to see the slow progress. … So, the ghost of James Madison continues to haunt health reform as we move into the 21st century.

MP: What are your best hopes, worst fears for health-care reform?

LJ: I think for the first time in almost half a century there will be a bill introduced onto the floor of the House of Representatives and perhaps the Senate that will be passed. Now that is a huge accomplishment in and of itself. That has not happened since Medicare was enacted in 1965. Nixon's effort, Carter's effort, Clinton's effort were all stymied in the committees and never made it to the floor of the House and the Senate and got passed.

I think we're at the cusp of a historic moment. I also think there's a real chance that some health reform will be passed by Congress. I think it will be short of what liberals wanted and in fact there may be some liberals in the House of Representatives that vote against it. But I think some health reform will pass. I don't say that is guaranteed, but there's a possibility of that, and again that would be historic. It would be kind of a new chapter in the development of the American welfare state and despite the frustration of many liberals today, Barack Obama may emerge by the end of his first term as the most progressive government-expanding president since LBJ — with health reform as the leading case.

MP: And what are your worst fears?

LJ: I think the potential for passing reform that speaks to frustration on the part of Americans to an explosion of costs is real. For instance, the Democrats and the White House are caught in a cross-fire between wanting to expand access to health insurance and wanting to keep costs down. If a mandate is imposed on all Americans to get health insurance and millions of Americans can't afford to do that, that's a recipe for a pretty significant backlash. I think that's a real possibility.

The other possibility is that Democrats will pass health reform but won't pass the necessary provisions to control costs, particularly in the short term. Now we saw this scenario play out after Medicare was enacted, in which costs absolutely skyrocketed. Part of the reason is the lack of health insurance depresses the demand for medical care among the uninsured, and so when you provide them with insurance they're able to get the care they've been denying themselves.

In addition, I think the providers of medical care and prescription medication will be eager to capitalize on the new system by providing large volumes of care. It's quite possible, particularly in the beginning, that the costs for this new program could exceed even the higher estimate.

Robert Myers, who is a famed actuary in the development in Medicare, was in the Johnson administration and worked closely with the congressional committees in estimating the costs of Medicare. He later conceded that even his high estimates of what Medicare would cost were far short of the mark. After accounting for a number of factors including the decision of Congress to expand the benefits, inflation and some other factors, he conceded that his estimate was off by about 165 percent.

In other words, costs were about 165 percent higher by 1990 than what he had estimated in 1965. In truth a lot of that cost explosion occurred in the first decade after Medicare was enacted.

MP: Is it reasonable then to set a $1 trillion limit on health-care reform spending?

LJ: I think it's reasonable to build a program that's less than $1 trillion, but whether the actual program costs less than $1 trillion is a different question. What's required is some very hard-headed thinking about cost control before you enact the reform.

There's a little bit of a game going on behind the scenes. The Democrats are talking about cost control but they're leery of actually spelling out how to do it because they know the stakeholders — the doctors, the hospitals, the pharmaceutical manufacturers, the Medicare beneficiaries and others — will be outraged by the fact that their ox is being gored for health reform.

So it seems to me that there's a real possibility, particularly in the first few years, if health reform is enacted we would see a very sharp rise in costs.

MP: We're seeing that in Massachusetts, right?

LJ: We've seen a little of it in Massachusetts. It's not as bad as was estimated and claimed. There have been some studies that have said it's within the estimates that were made. Massachusetts is a fairly developed, sophisticated state. We're going to have a whole lot of states engaged and it will be a different ballgame.

MP: Would you like to say anything about Minnesota?

LJ: I think Minnesota offers a model for Washington in thinking about how to get the right balance of cost and quality. Minnesota was recently ranked along with Wisconsin as providing the best value in terms of producing good quality care at below-average costs, and we've done that through a number of steps. A lot has to do with our medical care providers and the way they approach their work. There's also been some outstanding leadership from St. Paul, in the Department of Health, the governor's office and the Legislature, over many years to encourage access, cost control and quality.

And those efforts are continuing, but I think Minnesota has some very good ideas and some good practices that Washington would be smart to draw on. Unfortunately, a lot of the attention goes to the high-profile issues about access. But access alone is not adequate.

MP: Are there any other fears or hopes you want to mention?

LJ: I've got hopes but I'm also realistic. I think this is an important moment and despite the hammering all-around, I think we're engaged and I think there's a kind of seriousness about what's going on. I do think this is a pivotal historic moment. If health reform passes, it will change both the financing and delivery of medical care. It will usher in a new era in the role of government.

One thing the political scientist in me also wonders is, if health reform passes, whether the Republican strategy of almost uniform opposition will turn out to be a smart or not-so-smart approach. That is, if health reform passes, is it going to be the impetus for creating a new durable Democratic majority as voters see Democrats as responding to their hopes and Republicans as opposed?

On the other hand, if costs are out of control and many millions of Americans feel oppressed by a mandate to get health insurance they can't afford, then Republicans could be beneficiaries of that backlash.

In 1988, the Catastrophic Health Insurance Program [long-term care for Medicare recipients] was passed and then revoked. One of the reasons it was revoked was the sense in Washington of a very intense backlash against the program. I think that's kind of a warning to Democrats about the pitfall of overpromising.

That program was actually passed under Ronald Reagan and then revoked in a very short period of time because there was a backlash. The backlash was very intense and it turned out to come from a very small number of people. But Congress perceived it as a broader backlash and I think in some ways they were panicked about that. They ended up revoking what they just passed, which is very unusual.

MP: Who was responsible for the backlash?

LJ: It was led by an organization called the Committee to Preserve Medicare and Social Security [a rival of AARP], and it included this iconic image of the chair of the House Ways and Means Committee, Dan Rostenkowski, being back in his district (in Illinois) and having his car egged by seniors.

Casey Selix, a news editor and staff writer for MinnPost.com, can be reached at cselix[at]minnpost[dot]com.