As you may have heard, Hillary Clinton recently blasted Barack Obama over a piece of campaign literature, in which the Obama campaign insinuated that Clinton's health care plan would force people to buy insurance they couldn't afford. Clinton objected both to the substance of the claim, which she said was inaccurate, and the imagery, which was evocative of the infamous Harry and Louise advertisements insurance lobbyists used to kill universal coverage back in 1993 and 1994.
early in the monthWhile Clinton's statement succeeded in generating attention, it also sparked some derision. My friend Andrew Sullivan, for example, said Clinton sounded "desperate and whiny," while noting that "the mailer isn't that bad, for Pete's sake."
Well, it seems a group of distinguished health care policy experts beg to disagree with that assessment, at least when it comes to the content of the mailer. In a joint letter released late Monday, they condemn the ad in no uncertain terms -- and call for Obama to stop using it. Here's the key passage (full text and signatories below):
Unfortunately, the Obama campaign is circulating in Ohio and elsewhere its “Harry and Louise” mailers that unfairly and unconstructively attack Senator Clinton’s universal health care reform plan. These mailers purposely revive “Harry and Louise,” the actors hired by the insurance industry to help destroy health reform in the first Clinton Administration. They make the inaccurate claim that the plan would force people to purchase unaffordable health insurance. Senator Clinton’s plan clearly recognizes that universal coverage cannot be achieved unless health coverage is affordable, and her plan provides subsidies to ensure it is affordable.
The “Harry and Louise” mailer literally takes a page from the playbook of the health insurance industry and other special interests which spent over $300 million to kill any meaningful healthcare reform in 1993-94. It undermines serious dialogue on needed changes to the health care system.
We call on all candidates for President to recommit to a civil, positive discourse that does not undermine the larger goal of quality, affordable healthcare for all Americans. To that end, we urge Senator Obama’s campaign to cease using a mailing that is clearly inconsistent with this goal.
The list of signatories includes some pretty impressive names -- from economists like Columbia's Sherry Glied, MIT's Jonathan Gruber, and Princeton Uwe's Reinhardt; to people like Nancy Min DeParle and Bruce Vladeck, each of whom had stints running Medicare and Medicaid during the Clinton Administration. (As far as I know, neither Glied, Gruber, nor Reinhdart have formal ties to any single candidate; I don't know about the others.*) Also on the letter: Peter Harbage, who was John Edwards' health care adviser.
But forget the names. The letter's importance is its focus on why the Obama mailer is so disturbing. As readers of this space know well (maybe too well?), the key difference between Clinton and Obama on health care is that she'd require everybody to have insurance and he wouldn't. And, as I've written a gazillion times, I think the evidence suggests pretty strongly that Clinton has made the technically correct, if politically difficult, call: In a system based on private insurance, a lot of people won't obtain even affordable insurance without some sort of requirement. (A single-payer system would probably be even better, but Obama isn't proposing that.)
There is, to be sure, a legitimate debate to be had over exactly how big a difference a mandate would make -- and how just how close to truly universal coverage a mandate can get us. That's particularly true given the fact that Clinton has not specificed exactly how she'd enforce her mandate, although she has indicated she'd be willing to look at garnishing wages and imposing financial penalties if that's what it takes. Insofar as Clinton has said her plan would definitively achieve universal coverage, that's a stretch (although hardly as big a stretch as the one Obama has made when he said his plan would reach as many, if not more, than hers would).
Another argument Obama has made -- that it's better to wait on a mandate, until other reforms are in place -- is also a reasonable one. I don't agree with it, for reasons I've stated before, but it's an honest and legitimate difference of opinon.
But those aren't the sorts of arguments the campaign is making in this mailer. Instead, they are suggesting Clinton would force people to put up cash for insurance they couldn't afford. That's an explosive charge -- one that evokes the very worst stereotypes of overbearing liberalism and hands opponents of universal coverage a rhetorical bludgeon. If Congress tries to pass a mandate, which after all is a key element of many reform bills, opponents can always say "even Barack Obama says it's a bad idea."
More important, though, the claim just doesn't stand up under scrutiny. Clinton has allocated $110 billion a year for her health care program, which is actually a lot more than Obama has dedicated to his. (He assumes greater cost savings; I"m still trying to figure out if that's fair.) Some of Clinton's money will go to bolster Medicaid and the State Children's Health Insurance Program; most of the rest will go to providing subsidies, so that even middle class people get assistance buying insurance if they need it. Kenneth Thorpe, an Emory Univeristy economist, told the Wall Street Journal that in his estimates that sum of money was sufficient to make insurance accessible to everybody. But -- and this is essential -- Clinton has also indicated that if it takes even more money to make insurance affordable, she'll find it somewhere in the budget.
The email with this letter arrived in my inbox late, so I haven't had a chance to get official word from the Obama campaign. (I'll update as soon as I do.) In the past, campaign spokesmen have said they think it's a fair mailer. If they have more to say, I'm guessing that they will argue that, until Clinton provides a precise definition of "affordability," there's always the possibility she'd be asking people to pay more than they should. But that seems like a pretty remote possibility to me, given not just the budgetary commitment Clinton has made but also her own political history. Does anybody seriously believe she would sign a law forcing families making $40,000 a year to give up basic necessities in order to pay for exorbitantly priced health insurance? (For that matter, does anybody believe Ted Kennedy, John Dingell, and the rest of the Democrats in Congress would ever vote for such a measure?)
Obama says he's genuinely committed both to universal health insurance and to fostering a new politics free of old-fashioned demogoguery. I'd like to believe him and, more often than not, I do. But the reemergence of this mailer makes me wonder if I'm being naive.
Still, I'd be remiss if I didn't mention one other thing: Notwithstanding these attacks and the fact that Obama's plan seems less appealing to me than Clinton's, the differences between the two still pale in comparison to the differences they both have with presumptive Republican nominee John McCain. But you can read about that here, in the dead-tree edition of TNR.
--Jonathan Cohn
*UPDATE: Just to be clear, one of the signatories, Cal-Berkeley economist and former Clinton Administration official Laura Tyson, is a senior economic adviser to the Clinton campaign. Jeanne Lambrew of the University of Texas-Austin has said she advised the Clinton campaign on a few occasions, although my understanding is that it was all rather informal. In any event, I didn't mean to imply none of the people signing the letter had formally backed Clinton. (Looking down the list, there may be some others.) As with the last group letter in this debate, which also came with an impressive list of intellectuals backing it, the signatories include some people tied to the campaign. But I was more struck -- as I was then -- by the high-profile names like Gruber, Glied, and Reinhardt whom I know not to be affiliated.
**ANOTHER UPDATE: Just to be clear about one more thing, if you're sick of reading about this, believe me when I say I'm sick of writing about it. So for something different, follow the link to the article about McCain's health plan at the end of the item. That's where the debate is going in the future, as it should.
FULL TEXT OF LETTER
February 25, 2008
To Interested Parties:
This presidential campaign has lived up to its historic potential. Bold visions and policies have been offered. And the debate has been vigorous. However, a debate that generates more heat than light sets back rather than advances shared goals. This has happened in health care.
Senators Clinton and Obama have both embraced what should be a non-partisan goal: ensuring affordable, quality coverage for all Americans. They both have policies to ensure access to affordable health insurance. Both rely on an individual requirement with enforcement provisions to ensure universality for targeted populations. The main difference between their plans is that Senator Clinton would make health security a right and responsibility for all Americans, while Senator Obama would do so only for children and thereby cover fewer Americans.
Regardless of one’s views about whether the individual requirements in healthcare should apply to all American adults or just American parents of children, all people committed to universal healthcare can agree that our policy debates should focus on substance.
Unfortunately, the Obama campaign is circulating in Ohio and elsewhere its “Harry and Louise” mailers that unfairly and unconstructively attack Senator Clinton’s universal health care reform plan. These mailers purposely revive “Harry and Louise,” the actors hired by the insurance industry to help destroy health reform in the first Clinton Administration. They make the inaccurate claim that the plan would force people to purchase unaffordable health insurance. Senator Clinton’s plan clearly recognizes that universal coverage cannot be achieved unless health coverage is affordable, and her plan provides subsidies to ensure it is affordable.
The “Harry and Louise” mailer literally takes a page from the playbook of the health insurance industry and other special interests which spent over $300 million to kill any meaningful healthcare reform in 1993-94. It undermines serious dialogue on needed changes to the health care system.
We call on all candidates for President to recommit to a civil, positive discourse that does not undermine the larger goal of quality, affordable healthcare for all Americans. To that end, we urge Senator Obama’s campaign to cease using a mailing that is clearly inconsistent with this goal.
While the current and/or past affiliation of the individuals are listed, please note that the individuals listed are representing themselves and not their institutions.
Signed by (in alphabetical order):
Louis Cooper, MD
Former President, American Academy of Pediatrics
Nancy-Ann DeParle, JD
Former Administrator, HCFA (now CMS)
Sherry Glied, PhD
Mailman School of Public Health, Columbia University
Jonathan Gruber, PhD
Massachusetts Institute of Technology
Peter Harbage
Former Edwards Health Advisor
David Kessler, MD
Former Commissioner, FDA
Jeanne Lambrew, PhD
LBJ School of Public Affairs, University of Texas at Austin
Jack Lewin, MD
American College of Cardiology
Karen Pollitz
Health Policy Institute, Georgetown University
Irwin Redlener, MD
Children’s Health Fund
Uwe Reinhardt, PhD
Princeton University
Elena Rios, MD
National Hispanic Medical Association
Alice Rivlin, PhD
Former Director, Congressional Budget Office
Sara Rosenbaum, JD
School of Public health and Health Services, The George Washington University
Allan Rosenfeld, MD
Mailman School of Public Health, Columbia University
Donna Shalala, PhD
Former Secretary of Health and Human Services
Laura Tyson, PhD
Haas School of Business, University of California, Berkeley
Bruce Vladeck, PhD
Former Administrator, HCFA (now CMS)
Alan Weil, JD
National Academy for State Health Policy