What Reformers Are Up Against

Sunday, Republican Senate leader, Mitch McConnell told CNN that even if Democrats made a significant concession— such as a provision that would limit malpractice suits against health-care providers — this would not persuade Republicans to vote for health reform legislation. He added that there is probably no way that Democrats could win a single Republican vote—even if they revised their plan.

I think McConnell is right. Republican politicians know that many of the voters who elected them oppose reform.

While responding to a comment by Health Beat reader Greg P. I ran into this statement by a North Carolina college student who opposes reform. She does a good job of articulating why conservatives oppose the entire idea of universal coverage:

“The U.S. Constitution guarantees its citizens the right to life, liberty, and pursuit of happiness, yet our country's forefathers never intended to provide our citizens with free health services. If we guarantee it for all citizens, doctors will be overstretched and our tax dollars will pay for the problems of the unhealthy, plunging our economy even further into debt. Health care is a privilege that all Americans have the chance to obtain, not a right that all Americans are guaranteed. . . .

“Guaranteeing free health care to all citizens will increase the demand for medical services which will diminish the quality and accessibility of care because health care providers will be overstretched. The 60 percent of doctors who are self-employed will be hardest hit. That includes specialists, such as dermatologists and surgeons, who see a lot of private patients. Doctors will consolidate into larger practices to spread overhead costs, and they will cram more patients into tight schedules to make up in volume what is lost in margin. Visits will be shortened and new appointments harder to secure, according to Dr. Scott Gottlieb, resident fellow at the American Enterprise Institute. This means that the quality of doctors will decrease, appointments will be harder to schedule, and the overall system will become less effective.

“Health care is the individual’s responsibility, not the government’s. It is our own responsibility to ensure personal health. Health problems such as obesity, lung cancer, and diabetes can often be prevented by choosing to live a healthier lifestyle. According to the National Center for Health Statistics, 34 percent of Americans are obese and 32 percent are overweight. If health care is guaranteed for everyone, then our tax dollars will be paying for the health problems many citizens who chose not to live a healthy lifestyle. Also, if these citizens are guaranteed health care what incentive would they have to be healthy?"


These are the "philosophical differences" that Obama acknowledged at the summit. I think it is important to recognize that not only Republican politicians but a fair number of our fellow citizens share this point of view. They really don’t believe that health care is a right; they don’t want to pay for someone else's care; and they fear that if we have universal coverage, they will receive less medical attention.

This is why some moderate Democrats are afraid that they will be voted out of office if they vote for health reform.  At the other end of the political spectrum, some liberal Democrats in  the House are reluctant to vote for the legislation because it doesn’t go far enough.

Conservative voters are warning moderate Democrats that they may lose their seats if they vote for reform. Liberal voters should be equally persistent in expressing their political will— and let liberal Democrats know that they will be in trouble if they vote against reform.

The alternative is neither single-payer nor a public option. It’s no reform—for at least three and probably seven years.  The recession guarantees that Democrats will lose votes this fall. And if health care reform legislation fails this year, President Obama’s chances of being re-elected fade.  I very much doubt that he would be replaced by a more liberal Democrat.

Conservatives will re-take Washington.



22 thoughts on “What Reformers Are Up Against

  1. “The alternative is neither single-payer nor a public option. It’s no reform—for at least three and probably seven years.”
    I disagree. The alternatives are either no reform, or letting the bipartisan Healthy Americans Act (Wyden/Bennett) have its day in the sun.
    How come people aren’t demanding their representatives to revisit this bill?

  2. This piece by the North Carolina student is well articulated, but totally devoid of common sense.
    Suggest she study harder before “articulating” a opinion piece.

  3. Let me amend my previous post: she reflect the lack of common sense of a lot of people, especially:
    “They really don’t believe that health care is a right; they don’t want to pay for someone else’s care”
    Guess what? Why do you think happens when you get group insurance? You’ll pay for “someone else” within the group if he/she get sick, and in turn they’ll pay yours if you get sick. That is supposed to be heard to fathom?
    And no! health care isn’t a right, NOR is it a privilege…it’s an investment in ourselves. Any of these clowns would like to make all education in the US private? Think the school system is bad now? Take a look at these countries that have an almost inexistent public school system; they’re among the poorest in the world, and guaranteed to stay that way.
    By the same token, how do we expect to have a productive, but unhealthy work force? This is just not possible.
    “and they fear that if we have universal coverage, they will receive less medical attention.”
    When was the last time these people went to their doctor? Like your physician has a full hour to dedicate to you every time you go in?
    I don’t think so.
    “Guaranteeing free health care to all citizens will increase the demand for medical services which will diminish the quality and accessibility of care because health care providers will be overstretched.”
    Like we can’t produce more health care professionals? Like all the countries that have a universal system have a chronic lack of personal?
    Makes you wonder on what planet do these conservatives live. makes also wonder by which miracle they can muster the capacity to think.

  4. The whole “doctors will be overstretched” seems kind of silly – in this era of 10% unemployment, it shouldn’t be hard to find people willing to train to be doctors – this would be a good way to create quality jobs and help spur the economy, in addition to providing help to people in need.
    The following sounds more like fear-mongering than philosophical differences: “Visits will be shortened and new appointments harder to secure…This means that the quality of doctors will decrease, appointments will be harder to schedule, and the overall system will become less effective.”
    Our health care system is not fixed quantitatively – it can expand to meet demand, especially if that demand is slowly implemented and telegraphed in advance, as it is in the current proposals.

  5. As an emergency physician let me say that what is saliently lacking in this “logic” is that when people who don’t have access to health care (whether they are obese or not) get very sick and end up on the doorstep of my emergency room, I must care for them, regardless of cost. When they can’t pay their bill, we all end up paying for it anyway in higher prices.
    Do we want to live in a society where it is OK to let someone die on the doorsteps of our hospitals because they don’t have insurance?
    Sixty percent of all our health care dollars is taxpayer money. WE ARE ALREADY ALL PAYING FOR EVERYBODY ANYWAY.
    That said why not have s system that yields most health for our health care dollars… instead of what we have now which is a non-system designed to be profitable for an industry that does NOTHING to produce health. That would be the insurance industry that adds 20% to total cost and zero to the quality of the product.

  6. Dr. Paul Hochfeld is certainly correct in his comments. We don’t (for the most part)allow citizens to die on the doorstep.
    I’m curious about the Republicans who voted for the requirement that emergency rooms must treat all comers. How did they suppose it would be paid for.
    I also believe that a portion of the demands on the Healthcare System are driven by unnecessary demand as opposed to real medical necessity (“I want the best, and I’ll decide what that is”). I believe this is an issue that must be addressed in any healthcare fix.
    Finally, in my experience, many of the opposition have healthcare through their employer or Medicare. They are clueless about the real costs, and employers in particular are facing costs that they won’t be able to afford.

  7. Dr. David–
    The problem with the Wyden plan is that it makes no attempt to contain costs.
    Unlike the Senate bill it does not propose changing how we pay for health care or what we pay for; the Senate bill would reward quality and penalize ineffiency and errors. The Wyden bill does neither.
    The Senate and House bills would move away from fee-for-service. The Wyden bill makes no attempt to do that.
    In fact, the Wyden supporters admit that under this bill, the cost of health care will continue to go up faster than wages.
    And–most importantly-individuals will face that inflation alone. No help from employers; govt’ subsidies for people earning under $40,000. That’s it.
    Individuals will be expected to buy their own insurance in a market where only private insurers compete for their business. The private insurers will all have to offer basic benefits worth the same dollar amount (though the benefits themselves are no specified) , so the theory is that they will compete by offering more benefits or lower prices, and consumers will “shop” to get the best deal.
    Wyden’s theory is that this market competition will bring prices down to some degree–though he acknowledges that prices will rise faster than inflation.
    Note that today, when large employers buy insurance they acutally have some clout to negotiate with insurers because they represent a group of 20,000 customers. Individuals buying their own insurance will have no such clout.
    Moreover–and this is the killer, there is no effort to limit the increases that powerful hosptials and physicains’ groups demand from insurers.
    See my recent post on Providers with Clout.
    Presumably providers will continue to hike their fees as much as they can, and in many cases insurers will have to pay whatever they demand. (Patients will still want the brand-name hospitals and physicians’ groups in their insurance networks.)
    Insurers will pass the hikes on to the individual in the form of higher premiums–and No One– not government, not a large employer will intervene to protect the individual family.
    In a nutshell the burden of contracting for health care will move from your company to you. You would be given a standard tax deduction to help pay for it.
    But the tax deduction will grow only as fast as the consumer price index (CPI) while the cost of health insurance is projected to grow twice as fast. (see The Walker Report, August 10, 2009).
    The idea is that we’ll be free of “govt’ intervention” and “employer involvement” in health care. Individuals will be on their own–and good luck to them!
    The Wyden plan also ignores over-treatment. I don’t think there is anything in it relating to have a disintersted board of medical experts looking at comparative effectiveness.
    Drug-makers and device-makers will continue to be free to charge whatever they like.
    Finally, Medicaid and SCHIP will be folded into this plan.
    In other words, families now on Medicaid and SCHIP will be forced to buy their own insurance for each and every adult and child in their family.
    Do you really think these famlies will be in a position to sift through 30 insurance plans and pick the ones with the best benefits at the lowest price?
    As the cost of insurance rises, subsidies to those earning less than $40,000 will grow only as fast as GDP grows– that’s about 1/5 as fast as insurance premiums will grow.
    In just a few years, mandated insurance will become unaffordable both for those low-income famlies and for those relying on the tax deduction to pay for care.

  8. Tom–
    Republicans don’t support a law that says ERs must take any sick person who shows up.
    The issue came up during the Bush presidency,and the president made it clear that ERs must treat a person only if he is too sick to walk out the door under his own power.
    In my book, Money-Driven medicine, I write about a man who was turned down by 2 ERS before a third one took him. He was a U.S. citizien–and had proof. But he didn’t have insurance.
    His jaw had been bashed in– he could barely talk, and was in danger of the jaw becomign infected (which could have proved fatal.) If he didn’t get help quickly, his jaw would have to be re-broken the next day before it could be “set.”
    At least one of the ERs that turned him away was a public hospital.
    ERS often reject uninsured patients simply by making them wait, and wait. Recently I read about a woman with a broken arm who waited 36 hours (1 1/2 days, sitting in the same chair) before she finally went home in disgust.
    Conservative REpublicans really do not believe that all human beings have a right to health care.

  9. I’d also like to repond to the North Carolina college student who opposes health reform. In a similar vein George Will recently (January 14, 2010) raised the issue of the constitutionality of mandatory health-care legislation and suggested that once Congress and the President had signed the bill there would be a challenge to its constitutionality.
    Out of curiosity I took a fresh look at the Constitution to see if there were expressions of the intent of the framers that might relate to the concept of universal health care for all Americans. I was immediately struck by the fact that a fundamental intent was to foster ‘a more perfect Union’. This says to me that the committees drafting the document were anxious to create a sense of unity and solidarity among citizens, emphasizing the importance of our common purpose and brotherhood. In the same phrase they also recognized that there would always be opportunities for improvements by emphasizing the fact that they were working toward ‘a more perfect Union’, recognizing, I believe, that what they were writing was not in fact ‘perfect’, not cast in stone. In this first sentence of the Preamble they acknowledged they could not anticipate all that the future might hold, implying that the Constitution would be a ‘Living Document’ capable of revision in response to new needs and desires of the American populace.
    I also note that the phrase ‘promote the general Welfare’ precedes ‘secure the blessings of Liberty’. This implies that the ‘blessings of Liberty ‘are not easily obtained without first having reached a certain level of ‘general Welfare’. I, for one, consider universal healthcare to fall into the category of ‘general Welfare’. The US Constitution Online (http://www.usconstitution.net) has an annotated copy with notes as to the framers original intent. It states that the whole point of having tranquility, justice, and defense is to promote the general welfare — to allow the common man to benefit from what the government could provide. It’s time for our government to acknowledge the constitutionality of universal health care and provide it.

  10. The Founding Fathers did believe that health care was important, so important they instituted the first income tax in the USA to pay for it.
    Here’s a quote from an article on the Marine Health Service:
    “Our Founders realized that a healthy work force was essential to our economic health and growth. It was for this reason that, in July of 1798, Congress passed, and President John Adams signed into law an act “For the Relief of Sick and Disabled Seamen,” establishing the Marine Hospital Service.
    “This Federal government socialized healthcare insurance was funded by a tax that was withheld from the sailor’s pay, and then turned over to the government by the ship’s owner. This first payroll tax amounted to slightly over 1% of the sailor’s wages. An injured or sick sailor would make a claim, his record of payments would be confirmed, and he would be given a “chit” for admission to the local hospital. Some of these healthcare facilities were private, but in the larger ports Federal maritime hospitals were built.”
    These were for private citizens, not the Navy (though the Navy was later added, then removed from the system). This was a mandate, supported by a tax imposed on all merchant seamen. Those who oppose current health care reform bills might try to explain why the men who founded the US thought it was Constitutional to tax people to make health care available.

  11. Patricia,Steve H., Paul
    Patricia–Thanks very much for your comment–and taking the time to look at the Constitution.
    So many people who evoke
    “the Founding Fathers” have never bothered to read the Constitution, let alone think about it.
    You write: “I also note that the phrase ‘promote the general Welfare’ precedes ‘secure the blessings of Liberty’. This implies that the ‘blessings of Liberty ‘are not easily obtained without first having reached a certain level of ‘general Welfare’. I, for one, consider universal healthcare to fall into the category of ‘general Welfare’.
    Yes. The constitution seems to be saying that the “blessing of liberty” (individual freedoms) should be grounded in a stable situation in which the country as a whole, has reached a certain level of “General Welfare.”
    I would add that this means Equality –an egalitarian society– is a necessary prerequisite for individual freedoms.
    And I can’t see how anyone could argue that healthcare is not part of “the General welfare”
    Finally, I agree that the Constitution was meant to be a “living document” that will grow and change as the country grows and changes. The Founding Father did not believe that they had achieved perfection.
    (Read Jefferson, Adams, et. al.)
    Steve H–
    Thank you! Excellent historical verification that the Founding Farmers believed that it was appropriate to mandate insurance, and to tax citizens to pay for it.
    And I agree that one can draw a straigiht line from mandating insurance for merchant seamen to the idea that “a healthy work force [is] essential to our economic health and growth.”
    It’s in everyone’s interest that each of us has access to good health care.
    Yes, today we have a non-system.
    Though I would add that while insurance companies add about of the cost of care (according to the Commonwealth fund, which does good reserach, a family plan under a government sponsored public option would cost $11,500 vs. $13,500 for private insurance, that’s still too expensive for most families.
    Our non-system isn’t just designed to be profitable for insurers (in recent years they actually have been making very low profits– aroudn 3% of revenues). It’s also designed to be profitable for drug makers, device-makers, health care “consultants,” and many (though not all) hospitals and doctors.
    Our health care system needs to be re-designed with an eye to what would provide the greatest benefit for Patients–not those who profit from the system.
    Insurers are far from the only problem.
    That said, I think that for-profit insurers add little value to the system.
    But some non-profits– notably Geisinger, Intermountain, Kaiser in Northen California, do. They actually have made health care better.
    We will need more primary care docs– and more nurse practioners.
    There is no evidence that we will need more specialists. (There may be a shortage of specialists in some part of the country but we have more specialsits than we need in many other areas. We can’t afford to train more specialists. (The cost of med school training far exceeds tuition.) And if we did, most of them would go to the areas where we don’t need them: NYC, Boston, LA, Miami, etc. etc.

  12. Those unfortunate misguided conservatives, this kind of poorly implemented psychology is a clear display of how emotive reasoning discolors an appropriate implementation of evolved and improved systems in our society. Consider this: When a company “borrows” successful behavioral techniques from a competitor to itself achieve success, it is called “best practices”. Companies do this all of the time and they prosper. Well, many, many countries have enormously successful healthcare systems that serve and appropriately benefit its own population, it doesn’t really matter who implements this (it’s own government, private enterprise, or a hybrid), what matters is that these systems are designed with the best health & welfare of the citizenry in mind and a structured framework to achieve this success is applied. This kind of beneficial stratagem does not exist in our nation via the current system, which is one that rewards financial gain but does not provide positive holistic healing as an desired result. Our nation, too, can utilize “best practices” and construct a new and greatly improved system here, provided by, yes, our government–you know, the one OF the people, BY the people, and FOR the people. You see, what a government can do for the people, it should do, and MUST do.
    The idea of conservatism is a dying philosophy, a cancer really, that does not nor has ever offered benefit to the nation that applies its “principles”. In every case, conservatism applied really serves only to enrich a few with financial prosperity through contrived ideals while relegating the remainder of the population to one of servitude and mindless observance of it’s perceived and often imaginary “principals”. The result really is a kind of defacto feudal system, which would eventually result in our nation as well…we are hurdling in that direction by plutocratic means, well supported by our homegrown version of conservatism and republicanism.
    With a determined will and a genuine concern to achieve the same kind of success that other countries know very well, we too, can apply on our own behalf, the best practices of other nations and provide our citizens with a positive framework and practical, meaningful healthcare solutions where the results would greatly succeed on behalf of the health and positive welfare of our citizenry.
    I have lived in England, Germany, Chile, and Canada, and have travelled to over 28 countries, and ALL of them have much more beneficial healthcare systems than ours and work exceedingly well. At this time, we need to eliminate conservatism and its erroneous influence and move forward toward meaningful improvement…all of us. This is what our nation’s founders really wanted to achieve so that future generations could continue to mold and model our framework for progress and attainable peace and evolved welfare in the best interests of the very citizens that live within its borders. To think that some inane idea of “small government” that does very little is a workable solution to today’s problems in a land of over 350 million people is simply insane at every level.
    Perhaps this student needs to reread “Money Driven Medicine” and reconsider her approach. What? She didn’t read it? Oh, well, then perhaps that is where we should begin.

  13. cyclebear–
    Thanks very much for your comments.
    You are right: “many, many countries have enormously successful healthcare systems that serve and appropriately benefit its own population, it doesn’t really matter who implements this (it’s own government, private enterprise, or a hybrid), what matters is that these systems are designed with the best health & welfare of the citizenry in mind and a structured framework to achieve this success is applied.”
    At the same time, I have to disagree as to whether we can “eliminate conservatism.”
    In an American-style capitalist economy, the rich will always be with us.
    What we can do is ask, teach, and ulimately require the rich to share more of their wealth with an eye to the public good–and the global public good.
    Some very wealthy Americans (Bill Gates,
    and Warren Buffet, for instance) already are doing that.
    I think that we need to make the idea of collective thinking part of the national consciousness, for all of us: rich, middle-class or poor.
    It’s actually a more comfortable way to live. People who think only in terms of “me and my family” are pretty parenoid and very anxious.

  14. Maggie – In my experience, the need to extend health care to all most resembles the effort to include all children in public schools, which finally was signed into law by Gerald Ford, in 1974. Before that, opponents used most of the arguments that your college student offered: that education was the responsibility of the family, that schools would be too crowded, that some children did not deserve to go to school because of their personal characteristics, and so on. Can you imagine suggesting these arguments to someone like Sarah Palin today?
    Not that long after the legislation passed, despite the resistance of some teachers, school boards, and parents, it became clear that there was no going back, and because the Feds enforced the law, the states and districts had to work out a way to do it. The system is not perfect even now, but it so much better than warehousing children in church basements as we did before. Every year we learn more and do better, with significant Federal support for the effort.
    Perhaps you cannot legislate attitudes or values, but if you create a situation that requires a substantial change in practice, the values will move along too. This is far more effective for building progressive actions than arguing the populists and Refusnicans into a wider worldview.
    Now after almost two generations of disabled children who went to school, the nation has changed in many important ways. Disabled people live in the same world as the rest of us, have access to public services, and many parents learned political leadership skills as they advocated for the education of their children. Some even because successful politicians.
    Another Republican president, George H W Bush, signed the ADA, to insure that fairness to the disabled extended to employment, and public services. Once again, attitudes and expectations are changing, and the next generation is more enlightened, due to broader experiences in schools and neighborhoods.
    As an uninsured person for more than 3 years, with a son who is also uninsured for 10 years, I would like to live in a country that believed that fairness and access for all was a good enough reason to pass health care reform. That is not the way populist USA thinks, about anything we haven’t tried yet.
    So we need the Dems to pass this health care reform legislation, and take their lumps, just as LBJ and Ford did, so that by the time Obama runs again, no one will want to see it reversed. That is, if implementation is not projected so far out that it waits until after the next election. We need the experience with better access and lower costs, to change opinions.
    As we consider what to do about the conflict between politics and governing, how about limiting Presidents to one term, of 6 or 8 years, so they will not be tempted to spend half the first term running for the second?

  15. “It is our own responsibility to ensure personal health. . . . If health care is guaranteed for everyone [and] these citizens are guaranteed health care what incentive would they have to be healthy?”
    How can people think like this? Being unhealthy is MISERABLE, everyone ipso facto has a STRONG incentive to be healthy. And much is beyond our control, the “responsibility to ensure personal health” is one that every single person will sooner or later fail at.
    If this argument held water, we would expect say French citizens say to be fatter than Americans since they all have access to healthcare, but this is not the case (although they do smoke more).
    These “let’s punish the unhealthy” arguments lack experience with the realities of life and how people act. And their adoption or lack of adoption of healthful practices is generally about other things besides whether they will receive healthcare when sick.

  16. It doesn’t take much to figure out that it’s not the logic, legality or legitimacy of health care reform – it’s the politics – pure and simple.
    I was recently asked to call my congressman and urge his support on health care reform. I wrote back and told the requestor it would be a waste of time. I explained it this way. If my congressman personally wrote a bill and learned that President Obama strongly supported it then he would immediately withdraw it. Seriously.
    Speaking of politics, the Democrats had better wake up and realize that progress requires risk. Remember the turtle. It also requires commitment to your principles. They know it’s right to pass reform. They know they can. The problem is they think that if they do the Republicans will defeat them in the next election. What they fail to realize is that the same folks who put Obama in the White House will defeat them in the next PRIMARY. That’s change.

  17. Mike , Annette, Barbara,
    Mike C, I think that at this point, the Democratic leadership “knows it’s right to pass reform. They know they can.”
    It’s only the past week that this has been clear.
    I believe that the rest of Congressional Democrats will, however, reluctantly, stiffed their spines and follow Obama, Pelosi and the rest of the leadership.
    Annette, yes the “let’s punish the sick” movement bothers me too. So very judgmental. I think it’s a way for people to tell themselves: “this can never happen to me. I take care of myself. I have control over my life.”
    But, of course, in the end, we don’t have control over our lives. Unless we’re hit by a truck, we get sick–and die. This is not a sign of weakness, just the fact that we are human and mortal.
    And so many things contribute to sickness that are outside our control.
    The idea of giving presidents one term of 6-8 years–so that they don’t spend a large part of their 1st 4 year term running for a second term is intruiging . .
    I’d be very interested in hearing what other people have to say about this.
    Do you have any papers or research that you could forward to me at maggiemahar@yahoo.com?
    You write: “Perhaps you cannot legislate attitudes or values, but if you create a situation that requires a substantial change in practice, the values will move along too.”
    I believe that is absolutely true. I think that over the next 1-3 years Medicare will create a stituation that requires a substantial change in values-and over time, we will all adapt. (I’ll be writing about the Medicare reforms that I expect in the near future.)

  18. “As we consider what to do about the conflict between politics and governing, how about limiting Presidents to one term, of 6 or 8 years, so they will not be tempted to spend half the first term running for the second?”
    The best argument I’ve heard against this is that four years is long enough for the people to have to wait to correct a mistake.

  19. Barry–
    Except, for some reason, they often don’t.
    Put it this way, in retrospect the majority of Americans seem to think that GWB was not, on balance, a good president.
    He left us with a heap of debt, a broken economy and a war that was supposed to end quickly and instead has gone on and one.
    By the end of his first term a great many people (including many Republicans) were very unhappy–especially about spending.
    Yet he was re-elected. (Or at least that’s what hte court decided.)
    Incumbency has many advantages.
    Too many not-very-good presidents have been elected to a second term.
    And it is true that presidents and their political strategists spending an inordinate amount of time and energy worrying about the second term.
    Too often they don’t do what they know is “the right thing” because they fear it would be political suicide.
    I wonder . . . if Obama had only one six-year term, would we have begun pulling out of Iraq and Afghanistan by now?
    We’re staying at such a high cost in terms of human lives and money– at this point, I don’t think many Americans believe that we are getting good value for the cost.
    But I’m sure Obama’s political advisers would tell him that he’ll be seen as “soft on national security” if he moves out too quickly.

  20. Maggie,
    Carter was a one termer and I’m glad we didn’t have to wait six or eight years to remove him from office.
    While this is certainly far away from my area of expertise, I think the relationship between members of Congress and a single term President could differ materially from what we have now. Would the President be perceived as a lame duck from the day he was elected? It could be easier than it is now to refuse to vote with the President to advance his/her agenda if it would hurt the individual member politically. The President would not have as many tools, including strong influence over fund raising apparatus, to reward allies and punish opponents. Senators already serve six year terms so they are not under pressure to constantly raise funds for the next election cycle. Overall, I’m inclined to stick with the current system.
    I think if the President and members of Congress, from both parties, were truly interested in leadership and bipartisan cooperation, both sides would show more willingness and inclination to stand up to and take on their own constituencies. As it relates to healthcare specifically, Democrats would need to stand up to unions regarding the tax preference for employer provided health insurance and to trial lawyers as it relates to tort reform. Republicans would need to accept the need for higher taxes to cover the uninsured and both sides would need to confront doctors, hospitals, drug companies and device manufacturers on the unsustainable growth in healthcare costs while convincing patients that they can’t have every conceivable service, test, procedure, referral or drug that might possibly benefit them and expect someone else (taxpayers or insurers) to pay for it. Right now, everyone wants to reform healthcare at someone else’s expense. It won’t work.

  21. Barry–
    I think that Carter is the best ex-presdient that we’ve ever had– certainly the best in recent history.
    So I have to disagree about whether it would have been good for the country if he won a second term. In his case, the problem was that he didn’t know Congress, and didn’t know how to get things done in Congress. He also had some bad advice.
    But if he had had a second term, by then, he might have found allies in Congress. We’ll never know.