Politics. Few people remember that prior to then First Lady Hillary Clinton’s “Hillarycare” effort of 1993, health care lacked the prestige afforded other policy areas like international relations and tax.
Those who did pursue work in health policy were almost always attracted to it because of its strong connection to the goals of organized labor. That affinity, of course, meant health policy was interesting to Democrats, nearly exclusively.
The original idea, emanating from both the ashes of World War II and President Harry Truman’s Democratic Party bona fides, was that a national health care system would eliminate one bargaining chip on the contract negotiation table. The result would leave room for other priorities like pay, hours and safety.
More recently, health policy has served the interests of organized labor and its political allies by expanding the workforce and, with it, union members. Fueled by unprecedent transfers from the Treasury to the health care sector, health care employment has swelled 26% since 2008.
Union membership in health care and social assistance, like all industries, has declined over the last 20 years. However, it remains above other industry averages, giving hope to organizers.
The shift – from organizing labor for pay, benefits and safety to simply expanding the union census – is a cynical one, of course. It also stands as an important impediment to right-sizing the health care infrastructure after the post-war generation moves on to its reward.
Policy. As health policy overwhelmed other priorities of the Democratic party, the methodical and purposeful policy apparatus has been subsumed by short term priorities and a heavy reliance on creative rulemaking.
(The latter, I should, add is a bipartisan endeavor)
The resulting unpredictability is the sort of things that can drive a health policy analyst mad.
For example, out of nowhere and without any of the preliminaries like a speech or two, a conference appearance, or a blog post, the Biden administration proposed a maximum operating margin for Home and Community-based Services contractors in Medicaid.
Sitting at the Office of Management and Budget is a rule that would establish, in some form, minimum staffing ratios for nursing facilities. Research has suggested staffing should be nuanced and flexible, which is generally does not suggest mandated minimums.
These provider types are target-rich environments for the SEIU, a union largely representing low skill and low wage workers. The SEIU has been organizing labor for decades but ascended to a new level when their candidate, Barack Obama won election in 2008.
Other than pure political objectives there is little evidence either effort will result in better health care outcomes – the normal goal of sound policy making.
Power. If trying to game out a policy outcome that is really a political campaign can be difficult, try it when the power of the White House is ebbing.
As Richard Nixon learned in the summer of 1975, the power of the president isn’t worth a lot if people do not think you will be president much longer. Jimmy Carter had the same experience as he tried desperately to return Americans held hostage in Iran in 1979.
If this history is any guide, President Biden will be as accommodating to his core constituencies as he possibly can. There are contenders for his seat and the last thing he would want is for labor to get out the long knives and jump ship to an alternative nominee.
That is the bad news, the good news is that, while well considered policies tend to stick around, bad politics do not always.
Have a great rest of your weekend.
Emily Evans
Managing Director – Health Policy
Twitter
(Politics, Policy & Power is published in the quiet of Sunday afternoon or holiday Monday and attempts to weave together the disparate forces shaping health care. It makes no attempt to defend or prosecute the views of any established political party or cause. Any conclusions to the contrary rest with the reader alone.)
