Beatrix Hoffman*
Jacob Hacker has an important proposal and people should be listening. His ideas about domestic reform stand out from the current crop for several reasons. He proposes a simple but powerful economic message under the overarching concept of “security.”1 Hacker’s linkage of security with opportunity should resonate beyond ideological boundaries, and his vision of economic security – protection against devastating job loss, health crises, and family changes – has the potential to improve the lives of poor and working-class Americans as well as the middle class on which he focuses. Equally important to Hacker’s ideas are his realistic and no-nonsense proposals for bringing them to fruition. “General Insurance” has the simplicity and the appeal of building on an already popular system of social security; his plan for universal health care would expand on Medicare’s success while allowing employers and workers to keep their current private insurance if they wish. Hacker’s fiscal analysis of these plans provides evidence of what they would cost and how they would work. Finally, in a rare feat for an academic, Hacker has worked successfully to attract the attention of policymakers: his health care proposal has already found Congressional sponsors.
Having laid out some of the merits of Hacker’s work,2 I want to discuss why the details of such a plan are not necessarily the most important pieces of the puzzle when it comes to enacting reform in the United States. The large amount of discussion generated by Hacker’s The Great Risk Shift3 in the blogosphere and elsewhere has revolved around the merits of its core ideas and resulting proposals.4 Some of these discussions suggest that it is the wisdom and feasibility of a plan that will lead to its political appeal and its eventual adoption. Yet there is little recognition of the historical truth that many people have come up with great ideas that went nowhere. The history of health care reform, in particular, is a history of leadership by elite “experts” whose grand schemes (which they thought foolproof) failed in the face of special interest opposition and/or public indifference. As the Clinton health care debacle showed, traditional political power is not enough. Discussions of implementing ideas for reform like Hacker’s must concentrate not only on the plan’s virtues, but also on ways to mobilize the power of ordinary people – social movements – on their behalf.
Leadership is crucial, and I hope that a political leader will emerge from this long election season to take up Hacker’s call for a universal economic and health security plan. But even though we associate powerful leaders like Franklin Roosevelt and Lyndon Johnson with reform success, these presidents were only able to achieve their goals in the presence of movements of ordinary people pushing them to do more. FDR was strongly influenced by the Townsend Movement, an organization that demanded large payments to senior citizens as a way to improve the lives of the elderly and restart the Depression economy. Francis Townsend and his followers did not come close to getting what they wanted – they thought each senior should get $200 a month (a fortune at the time) and be required to spend it all5 – but Social Security was initially created for retirees rather than other types of workers or citizens because of the Townsend movement’s influence. Congressional and presidential action on unemployment during the Depression was spurred by people’s movements such as the veterans’ Bonus Army and the Unemployed Councils. As for Lyndon Johnson, it is widely known that the civil rights movement helped push him into becoming a reform leader and proposing the sweeping programs of the Great Society. Less well known is the role of the National Council of Senior Citizens, a labor-led movement of retirees who bombarded Congress with letters and held hearings and marches around the country in support of Medicare.6
In contrast, when committees of experts in the 1930s tried to push Roosevelt into adding a carefully thought out health insurance program to the Social Security system, he refused, wanting to avoid a confrontation with the organized medical profession. There was no citizens’ movement in favor of national health insurance at the time to put pressure on Roosevelt or to counter the pressure tactics of the American Medical Association. When President Harry Truman threw his support behind a universal health program, he lost not only because of an unprecedented campaign by the opposition, but also because there was no equally vigorous movement of supporters willing or able to take up the fight at the grassroots.
The history of social movements in the United States shows us that they have not always achieved all their goals, but this has not prevented many of them from powerfully influencing events. In this day of instant polling and sound bites, we have lost sight of the role of people’s movements in social and political change. Social movements have little to do with poll numbers, focus groups, or “public opinion.” Citizen leaders and activists may be few in number and not even represent “majority” views, but they can have influence far out of proportion to their numbers. Think, for example, of AIDS activists in the 1980s, who with carefully-aimed direct actions succeeded in wresting major concessions from pharmaceutical and insurance companies, and even in forcing fundamental changes in those institutions and in the entire nation’s response to the AIDS epidemic.7
In the present context, reform leaders in Washington need not wait for a social movement to guide them because there already exists widespread and determined activism demanding a response to the dismantling of protections for working Americans. It may be that the Hacker proposal could be a rallying point for disparate groups that have long worked for universal health care and economic security. Within the demographic changes that so concern Hacker lies the potential for a new and powerful social movement.
Hacker, as well as many others, view the transition to a service economy, an aging population, two-income families, globalization, the decline of traditional labor unions, and Republican attacks on worker protections as giving rise to the current age of economic insecurity. However, these changes represent not only challenges that must be overcome, but also new possibilities for citizen action. Some of today’s most active and prominent social movements have arisen from previously marginalized groups, such as service workers and immigrants (for example, the huge immigration marches of 2006). Organizations such as service and government workers’ unions, associations of health care and child care workers, and senior citizens’ groups see demographic and economic change not as an obstacle but as an opportunity for mobilizing potentially powerful new constituencies and voters. This is realism, not idealism. The number of health care and personal care workers will continue to grow as the population ages; more working women means more child care workers. As others have recognized, these types of jobs cannot be outsourced. These groups and many others have a great stake in the type of universal reforms proposed by Hacker, but these groups and their organizations (most, of course, remain unorganized) are just the tip of the social movement iceberg.
Organizations representing people in the sectors of the new economy can speak for and even mobilize more than just their own members. Many service and health care workers, for example, encounter the public every day. Behind cash registers, in health clinics and emergency rooms, in insurance offices, nursing homes, private homes, day care centers, these workers are in touch with the people – poor, working class, and middle class – who need health coverage and other protections the most. Reform opponents have long recognized the importance of this kind of mobilization. The American Medical Association’s huge campaigns against national health insurance in the 1940s and 1960s were won not just by public relations savvy, but also with a grassroots effort carried out by organized physicians in their own offices who distributed anti-reform literature to patients in their waiting rooms.8 Political leaders and reformers should think about how organized workers, unorganized workers, and the public they serve every day have many interests in common and how they might be mobilized together in support of universal protections.
Leaders within the Beltway are making a mistake when they lump together grassroots reform groups as “special interests.” Certainly many citizens’ and labor organizations work for the interests of their own constituencies, but a defining characteristic of new social movements is their universalist bent. Many grassroots groups and unions are no longer fighting only to improve the lives of their own members, but rather for universal protections. By dismissing grassroots action as mere interest group politics, these leaders lose sight of many possibilities for citizen participation and universalist demands.
Nurses’ associations, service workers’ unions, seniors, and consumer groups have been at work on the grassroots level for years advocating reform, particularly universal health care, and they have been at least partly successful. After national health reform was declared dead in 1994, it was local grassroots groups who kept pushing for expanded coverage in the states.9As a result, Maine10 and Massachusetts11 have adopted programs to insure all state residents, and a similar program has been proposed in California.12 Whether these new programs are successful or not, they are at least a start, and provide evidence of the urgency of the health insurance crisis in the states and the vigor of local activism, even as both have been ignored in Washington.
People’s movements have been inspired by charismatic leaders and smart organizations, but also by powerful ideas. The question then is whether Hacker’s “security and opportunity society” is an idea powerful enough for people to rally around. Can the idea of protecting individuals and families from risk ever move as many people to action as have grand notions of justice or human rights? Some have argued that these concepts are out of date when it comes to winning elections. But, let us remember that the conservative right decided that liberty and freedom were not out of date, and consequently managed to capture and redefine – for a time, successfully – these ideas for their own ends. Hacker’s idea and plans for a “security and opportunity society” could similarly be thrust into the mainstream and inspire a movement and a revival and redefinition of the national discussion. For this to happen, however, Hacker’s ideas must be made accessible, relevant, and immediate to those whom they affect the most. I would like Hacker and other reform leaders to go further in their rhetoric – to identify the problems with our current benefits system not just as a crisis for Americans’ security, but as a direct threat to freedom, dignity, and democratic values. Job-based benefits compromise citizens’ freedom of movement, and most Americans with health insurance are denied free choice of doctors or hospitals.13 Everyone knows someone who lay sick, suffering or dying while their misery was compounded and their dignity attacked by having to fight with an insurance company for coverage of procedures or treatments. People cannot get health insurance because of a preexisting condition, or they lose it because they get sick. Middle-class, hardworking Americans lose their homes, and their children lose any inheritance, for the crime of having to enter a nursing home. The problem is not just that Americans are increasingly insecure, but that the current system assaults so many of our core values. Reform leaders should emphasize that universal protections are intended not only to ensure security, but also to restore freedom, dignity, and democracy to our shared institutions.
A strategy for reform will not succeed without inspiring and harnessing citizen action on its behalf. I make this argument not out of some romantic notion of “people power,” but out of political realism. Much of the concern about Hacker’s proposal, as with the Clinton initiative over a decade ago, is that even though it preserves a major role for private actors in health care it will undoubtedly engender massive opposition from those who profit from the status quo. Endless tinkering to placate private health care interests was a feature of the Clinton proposal, and to no avail: insurance companies and others still came out in full force and defeated the legislation.14 Such powerful interests will only back down if they are confronted directly, both by a political leader – preferably the President – and a people’s movement that will mobilize supporters in workplaces, homes, and public spaces, and that is willing and able to take to the streets, or the Internet, or whatever form citizens’ action will take in the new millennium.
Perhaps we should focus less on proposals that placate powerful interests and more on those that can inspire citizen participation, support, and even passion. I hope that whoever next takes up the cause of health care and security for all will build on Hacker’s notion of protection from risk, but will also go further to portray universal access as a human right essential to the maintenance of Americans’ freedom and dignity. Bold reformers need a bold political strategy for confronting entrenched interests. This must include a recognition and utilization of the power of social movements, or else good ideas will once again go nowhere fast.
* Beatrix Hoffman is Associate Professor of History at Northern Illinois University. Her work is supported by the Robert Wood Johnson Foundation and the National Endowment for the Humanities.
[1] Jacob S. Hacker, The New Economic Insecurity – And What Can Be Done About It, 1 HARV. L. & POL’Y REV. 111 (2007).
[2] For purposes of this article, I will not discuss the drawbacks to Hacker’s proposal, except to say that, as a believer in the efficacy of a single-payer health system, I have concerns about his retention of employment-based benefits and for-profit health insurance.
[3] JACOB S. HACKER, THE GREAT RISK SHIFT: THE ASSAULT ON AMERICAN JOBS, FAMILIES, AND HEALTH CARE – AND HOW YOU CAN FIGHT BACK (2006).
[4] See, e.g., Review: Jacob Hacker – The Great Risk Shift, Posting of Henry Farrell to Crooked Timber, http://crookedtimber.org/2006/10/16/review-jacob-hacker-the-great-risk-shift/ (Oct. 16, 2006); The Great Risk Shift, Posting of Tyler Cowen to Marginal Revolution, http://www.marginalrevolution.com/marginalrevolution/2006/09/the_great_risk_.html (Sept. 16, 2006).
[5] FRANCIS E. TOWNSEND, NEW HORIZONS: AN AUTOBIOGRAPHY 116-17 (Jesse George Murray ed., 1943).
[6] See JILL QUADAGNO, ONE NATION, UNINSURED: WHY THE UNITED STATES HAS NO NATIONAL HEALTH INSURANCE 64-67 (2005).
[7] See, e.g., STEVEN EPSTEIN, IMPURE SCIENCE: AIDS AND THE POLITICS OF KNOWLEDGE (1996); Jason DeParle, Rude, Rash, Effective, Act-Up Shifts AIDS Policy, N.Y. TIMES, Jan. 3, 1990, at B1.
[8] Jill Quadagno, Why the United States Has No National Health Insurance: Stakeholder Mobilization Against the Welfare State, 1945-1996, 45 J. HEALTH & SOC. BEHAV. 25, 30,available at http://www.chas.uchicago.edu/documents/MD0506/JHSB04ExtraQuadagno.pdf.
[9] Julie Kosterlitz, A Grassroots Wave of Reform, 38 NAT’L J. 23, 30-31 (2006).
[10] Maine Lawmakers Approve Plan for Universal Health Coverage, N.Y. TIMES, June 14, 2003, at A10.
[11] Pam Belluck & Katie Zezima, Massachusetts Legislation on Insurance Becomes Law, N.Y. TIMES, Apr. 13, 2006, at A13.
[12] Jennifer Steinhauer, California Plan for Health Care Would Cover All, N.Y. TIMES, Jan. 9, 2007, at A1.
[13] See, e.g., Michelle Conlin, Held Hostage By Health Care, BUSINESS WEEK, Jan. 29, 2007; Richard Perez-Pena, When Choice Of a Doctor Drives Up Other Bills, N.Y. TIMES, Sept. 11, 2006 at A1.
[14] See generally Raymond L. Goldsteen et al., Harry and Louise and Health Care Reform: Romancing Public Opinion, 26 J. HEALTH. POL. POL’Y & L. 1325 (2001).