Strategy, Tactics, and Movement Politics in Health Care Reform

It’s important to sharply distinguish strategy from tactics in health care reform. I think strategy is about your goal and overall orientation toward getting health care reform, while tactics are about the low-level things you do to get from point-to-point in getting the strategy implemented. Tactics are influenced by strategy in the sense that tactics need always to be evaluated from the viewpoint of whether they advance strategy or not. If they don’t they’re counter-productive and need to be put aside in favor of other tactics.

In my view, much of the health care reform movement made a great strategic error in this fight. And that error was to make the strategic goal a Public Option (PO) solution, rather than to make it a Medicare for All solution. That error has shaped everything else that much of the health care reform movement has done for the last year, and is the one thing primarily responsible for the sorry outcome we have on our hands now in both Houses of Congresses. I think we have to learn from the experience of the past ten months and stop boosting the PO, even a very strong PO, as if it were a strategic goal. Medicare for All, should be our standard, and we should evaluate our success or failure in political activity by how far we’ve moved the ball toward this goal, not by how far we’ve moved the ball toward getting a PO. The PO, even a Jacob Hacker-type PO, is at best a tactic relative to the overall strategic goal of getting to Medicare for All, and we should never forget that, or let other people forget that. Since it is a tactic, we should be treating it as a tactic, something we resort to in order to overcome blocking or resistance, not something we pre-compromise on, before even testing the strength of resistance to our efforts to get something better.

I think, also, that treating the PO, as if it were our strategic goal, was a very bad tactic. It did not elicit the limited opposition and pragmatic, but useful compromise for our side, that many progressives anticipated, and talked about as a benefit of going the PO route, and its messaging has been, and still is, horribly confusing and disingenuous. It has elicited all kinds of fears from the public that Medicare for All would never have elicited.

Since tactics are not independent of strategy, but are always shaped in the context of it, adopting the PO as a strategic goal has shaped our tactics, by constraining us from doing some things. We could never call on a mass movement to support us in getting health care reform, because who can really get excited over a PO that won’t produce universal coverage? We could never develop simple messaging that was honest, because all the simple verities about stopping the fatalities, providing universal coverage, making things really affordable, and really saving money for the country, don’t really apply to the PO plans we’ve been seeing in House and Senate bills. Even now, nearing the end of the current legislative process, we are seeing simple messaging about the great “victory,” a bill with a shrunken PO, that is not honest, since it greatly exaggerates the expected positive effects of the legislation, while ignoring its many downsides.

The kinds of claims we are seeing now from Democrats in Congress would be honest justifications for Medicare for All, if Congress were passing HR 676, but they are dishonest ones for the PO plans we are seeing in HR 3962 and Harry Reid’s new Senate compromise. And who can get excited and fight hard while using messages that you know are not true? Maybe conservative apparatchiks can do that, but liberals and progressives find that very hard. They need to believe in what they are doing, and what they are saying.

I agree with Jane Hamsher that Medicare for All supporters, ought to ask what they could have done differently to have produced more success for their favored alternative, but I think an important related question is what can Medicare for All reform advocates do differently now? What can give a different result that is closer to the strategic goal we’re pursuing? And I think the answer to that at the level of high-level tactics is that we have to build a mass movement in the background of what we do day-to-day, because without that we aren’t going to get Medicare for All through the Congress. Some groups out there are trying to build that movement, and it may be gaining steam. This terrible health care reform bill will fuel the movement for Medicare for All, whether or not it passes, but realistically, I don’t think that movement will be a factor for a few years at the earliest. So what do we do now day-to-day?

I think we ought to pressure progressive politicians in the House and the Senate to become movement politicians. Movement politics is different from conventional politics, and movement politicians often have to use different tactics because they are trying to get principles adopted, and so they have to defend those principles, and not easily compromise them except perhaps at the end of a lengthy legislative process, when there is no other alternative, and they can get something very, very valuable for the compromise. It’s important to get people to understand that movement politics is not about not compromising. Instead it’s about not pre-compromising, or abandoning one’s strategic goal, or making compromises that mortgage the future of movement possibilities. One of the worst things about the current House bill is that it risks wholesale rejection by the public of the very idea that support of progressives and Democrats can really help them against the insurance companies, and in getting affordable health care. That’s why this bill must be killed. It has been oversold, and the backlash from it is very dangerous to the whole health care reform movement.

We need to persuade, cajole, urge, threaten, and organize their constituents to get our Congress people to become movement politicians. We have to call on them to believe again, and rip the hell out of them when they act as if they don’t. When they produce a piece of crap legislation we need to not be balanced and moderate in cataloging the pros and cons of the legislation in two matching lists. We have to evaluate their legislation from the point of view of the principles and strategic goals of our movement, and we need to call a spade a spade if their legislation gives up core principles, gets us no closer to our strategic goals, and even falls short from a moral point of view.

Progressive politicians in Congress are not acting like movement politicians who are coming from principle, they are acting like politicians trying to get something, anything, done at any cost as long as it carries the health care reform label. This may seem practical, because “the perfect is the enemy of the good,” and they don’t want to go against their leadership and their President, but in the long run, it’s a tactic that won’t get them and us to Medicare for All, because a) it makes them look like corrupt politicians, and b) no one will take Medicare for All seriously, unless its advocates are willing to make everyone pay a price for trying to marginalize their strategic goal, and laugh at it in the legislative process.

In my view, the first thing for Medicare for All advocates in Congress to do is to defeat any other health care reform bill that either 1) doesn’t provide a clear possibility of getting to Medicare for All in a reasonable time, or 2) threatens the political prospects for getting further reforms that will provide that clear possibility. There are currently, 87 co-sponsors of HR 676 in the House. That many representatives would have blocked any health care reform bill that wasn’t Medicare for All the first time around if they were playing movement politics. Unfortunately, they were playing at merely symbolic stuff – kabuki, in their co-sponsorship, not making a real commitment to HR 676.

Had those progressives put themselves on the line and made the leadership and the Administration taste defeat for trying to marginalize HR 676, people wouldn’t laugh at Medicare for All, or progressives anymore. Instead the leadership and the Administration would start to bargain, and the progressives would have had an opportunity to drive a hard one. That bargain could have ensured 1) or 2) above, even if the resulting bill was no more than something like ending all insurance company abuses and stopping there, leaving the future unconstrained for a much more effective health care reform bill than we are contemplating now.

In writing all of this, I’m painfully aware of not answering the question: “yes, but what do we do right now?” I think the answer to this is implied in what I’ve already said. It is to do everything we can to kill the bills now emerging from the House and the Senate. First in the Senate, and if that fails, then turning again to the House to once again try to get enough of the progressives to stand up to the leadership and vote against it, when it comes out of conference. For health care reform that won’t mortgage the future, we need to kill these bills, and in the process we need to get the Democrats and the progressives to stop being less than honest about what they do and what they don’t do. Then, when the leadership and the Administration goes back to the drawing board, which they certainly would very soon, we would need to go back to HR 676, not compromise until the end of the process when the leadership and the Administration need progressive votes to put it over, and then adhere to principles 1) and 2) above in negotiating any compromise.

If we do these things, I think we’ll get a much better bill than we have now. It won’t be perfect, since “the perfect is the enemy of the good,” and nothing in this whole health care reform debate has been “perfect.” But even though it will fall short of perfection, it will be much closer to being “good” than what we have now. And the truth is that what we have now, is not just "not perfect." It is not good at all. It leaves too many to enjoy that well-known Republican solution to health care: “Don’t get sick. But if you do, then die quickly.”

(Also posted at the Alllifeisproblemsolving blog where there may be more comments)

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