The Ideas That Changed Healthcare

Question: How did the ideas in “Healthcare for America” go from theory to policy?


Jacob Hacker: Well, it's been a bracing experience in some ways, because every academic dreams in their spare time, or at least a lot of academics dream in their spare time, that they're going to have a big influence on national policy debates. But I think our vision of what that would be like is sort of similar to our own experiences in the academic world, that somehow going into a Washington policy debate is like having a seminar where you're talking about your ideas and other people are respectively disagreeing or agreeing. It's been really exciting to be involved in the debate, but it's very tough. There is a lot of criticism of some of the ideas that I put out, and I feel enormously gratified that I've had influence. At the same time, I've definitely learned that being involved in big policy debates is not for the faint of heart. I think the main thing is that I got involved in this debate because I feel as if the system we have today is failing too many Americans and that we have to act to reform American healthcare. It was clear that we weren't going to be doing something on either of the ideological poles.


We weren't going to move toward some radical free-market solution that had everyone getting tax breaks—tax credits to buy healthcare insurance outside of employment. And on the other hand, we weren't going to move towards a universal single payer system where the government was insuring everyone. We really had to work within the confines of the system we have, but building on the existing system is not easy and in particular there is a really big problem at the heart of our existing system that most of the reform ideas that were on the table when I started getting involved in this debate weren't addressing.


That is, private insurance companies simply do not have an interest in containing cost and providing health security. They are in the business of making money and paying for healthcare. Many insurance companies are also in this business because they want to keep shareholder values up and earn profits. To me, it was the need to have some kind of counterweight to the private insurance companies even as we built on the present system that led me to argue for having a competing government public insurance plan that would be offering some discipline in the market, so that the private companies would feel the heat of having a strong competitor and would be pressed to improve their performance. Even though I understood that this public insurance plan would be just one part of the market, that private insurance plans would still have primary role. But the idea would be that they wouldn't have this kind of exclusive lock on the health security of Americans.


Question: Have your ideas about healthcare changed since “Healthcare for America”?


Jacob Hacker: So when I wrote Healthcare for America in 2007, I was building on a proposal I developed back in 2001 called Medicare Plus, and in that transformation from Medicare Plus to Healthcare for America was one of the journeys I took as I developed the idea. It became clear to me that although I wanted to make sure that people understood that we were building on the Medicare program and offering an alternative to private insurance plans, one of the reasons I emphasize in Healthcare for America that this was a separate program for Medicare—and I have in my work since then—was that I really wanted to argue, and I still argue, that this is just one component of a crucial set of reforms that needs to happen.


Those reforms have three basic elements. First, that you have shared risk. That people are in a common insurance pool, or they're in insurance plans that are regulated to make sure that they have protection against having unexpected medical costs and the insurance that's there when you actually need it most. That, unfortunately, is not always the case today. So the idea is that if you don't have coverage through your employer, you should be able to get coverage through some kind of new system—a “national insurance exchange,” it's sometimes called. And one of the choices you should have within that exchange, and I've always argued, is a public health insurance plan modeled after Medicare. 


The other two elements are really important too, and we tend to lose sight of them in the debate because we've been talking so much about the public health insurance plan. As crucial as it is, there are also two other elements that we need to pay attention to. First, is we need to have shared responsibility. We have to have employers contributing to the system. That means that if they're not providing health insurance directly to their employees, they need to help pay for the cost of that coverage. I'm afraid that there is movement away from that in some of the existing bills on Capitol Hill. The House legislation that was just passed has a strong element of shared responsibility, but the Senate Finance Committee bill that was considered and passed through the committee earlier this year doesn't and needs to have that change made before Senate passes a bill.


The third element is individual responsibility. I always have argued that there should be a requirement on individuals to have coverage if, and this is a really crucial if, if there are affordable insurance options available. And one of the most interesting things, and I don't think I recognized this before, is the degree to which that individual requirement and the public health insurance option go hand-and-hand politically. When you ask people would you agree to be required to have health insurance. Americans are pretty weary about only about 40 percent of Americans are supportive of an individual mandate in surveys. But then if you say, "Look, people who are required to have health insurance will have the choice of a new public health insurance plan that will make sure they have affordable options." Then people are much more supportive of that individual requirement.


So to me that's an element that I just didn't recognize when I was developing this proposal, is how interwoven those three big aspects of my reform proposal are: shared risk, shared responsibility, and individual responsibility.

Recorded on November 9, 2009
Interviewed by Austin Allen

Jacob Hacker’s 2007 "Healthcare for America" was the rare academic paper that transforms policy debate. Have Hacker’s ideas themselves changed since?

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Political division is nothing new. Throughout American history there have been numerous flare ups in which the political arena was more than just tense but incideniary. In a letter addressed to William Hamilton in 1800, Thomas Jefferson once lamented about how an emotional fervor had swept over the populace in regards to a certain political issue at the time. It disturbed him greatly to see how these political issues seemed to seep into every area of life and even affect people's interpersonal relationships. At one point in the letter he states:

"I never considered a difference of opinion in politics, in religion, in philosophy, as cause for withdrawing from a friend."

Today, we Americans find ourselves in a similar situation, with our political environment even more splintered due to a number of factors. The advent of mass digital media, siloed identity-driven political groups, and a societal lack of understanding of basic discursive fundamentals all contribute to the problem.

Civil discourse has fallen to an all time low.

The question that the American populace needs to ask itself now is: how do we fix it?

Discursive fundamentals need to be taught to preserve free expression

In a 2017 Free Speech and Tolerance Survey by Cato, it was found that 71% of Americans believe that political correctness had silenced important discussions necessary to our society. Many have pointed to draconian university policies regarding political correctness as a contributing factor to this phenomenon.

It's a great irony that, colleges, once true bastions of free-speech, counterculture and progressiveness, have now devolved into reactionary tribal politics.

Many years ago, one could count on the fact that universities would be the first places where you could espouse and debate any controversial idea without consequence. The decline of staple subjects that deal with the wisdom of the ancients, historical reference points, and civic discourse could be to blame for this exaggerated partisanship boiling on campuses.

Young people seeking an education are given a disservice when fed biased ideology, even if such ideology is presented with the best of intentions. Politics are but one small sliver for society and the human condition at large. Universities would do well to instead teach the principles of healthy discourse and engagement across the ideological spectrum.

The fundamentals of logic, debate and the rich artistic heritage of western civilization need to be the central focus of an education. They help to create a well-rounded citizen that can deal with controversial political issues.

It has been found that in the abstract, college students generally support and endorse the first amendment, but there's a catch when it comes to actually practicing it. This was explored in a Gallup survey titled: Free Expression on Campus: What college students think about First amendment issues.

In their findings the authors state:

"The vast majority say free speech is important to democracy and favor an open learning environment that promotes the airing of a wide variety of ideas. However, the actions of some students in recent years — from milder actions such as claiming to be threatened by messages written in chalk promoting Trump's candidacy to the most extreme acts of engaging in violence to stop attempted speeches — raise issues of just how committed college students are to
upholding First Amendment ideals.

Most college students do not condone more aggressive actions to squelch speech, like violence and shouting down speakers, although there are some who do. However, students do support many policies or actions that place limits on speech, including free speech zones, speech codes and campus prohibitions on hate speech, suggesting that their commitment to free speech has limits. As one example, barely a majority think handing out literature on controversial issues is "always acceptable."

With this in mind, the problems seen on college campuses are also being seen on a whole through other pockets of society and regular everyday civic discourse. Look no further than the dreaded and cliche prospect of political discussion at Thanksgiving dinner.

Talking politics at Thanksgiving dinner

As a result of this increased tribalization of views, it's becoming increasingly more difficult to engage in polite conversation with people possessing opposing viewpoints. The authors of a recent Hidden Tribes study broke down the political "tribes" in which many find themselves in:

  • Progressive Activists: younger, highly engaged, secular, cosmopolitan, angry.
  • Traditional Liberals: older, retired, open to compromise, rational, cautious.
  • Passive Liberals: unhappy, insecure, distrustful, disillusioned.
  • Politically Disengaged: young, low income, distrustful, detached, patriotic, conspiratorial
  • Moderates: engaged, civic-minded, middle-of-the-road, pessimistic, Protestant.
  • Traditional Conservatives: religious, middle class, patriotic, moralistic.
  • Devoted Conservatives: white, retired, highly engaged, uncompromising,

Understanding these different viewpoints and the hidden tribes we may belong to will be essential in having conversations with those we disagree with. This might just come to a head when it's Thanksgiving and you have a mix of many different personalities, ages, and viewpoints.

It's interesting to note the authors found that:

"Tribe membership shows strong reliability in predicting views across different political topics."

You'll find that depending on what group you identify with, that nearly 100 percent of the time you'll believe in the same way the rest of your group constituents do.

Here are some statistics on differing viewpoints according to political party:

  • 51% of staunch liberals say it's "morally acceptable" to punch Nazis.
  • 53% of Republicans favor stripping U.S. citizenship from people who burn the American flag.
  • 51% of Democrats support a law that requires Americans use transgender people's preferred gender pronouns.
  • 65% of Republicans say NFL players should be fired if they refuse to stand for the anthem.
  • 58% of Democrats say employers should punish employees for offensive Facebook posts.
  • 47% of Republicans favor bans on building new mosques.

Understanding the fact that tribal membership indicates what you believe, can help you return to the fundamentals for proper political engagement

Here are some guidelines for civic discourse that might come in handy:

  • Avoid logical fallacies. Essentially at the core, a logical fallacy is anything that detracts from the debate and seeks to attack the person rather than the idea and stray from the topic at hand.
  • Practice inclusion and listen to who you're speaking to.
  • Have the idea that there is nothing out of bounds for inquiry or conversation once you get down to an even stronger or new perspective of whatever you were discussing.
  • Keep in mind the maxim of : Do not listen with the intent to reply. But with the intent to understand.
  • We're not trying to proselytize nor shout others down with our rhetoric, but come to understand one another again.
  • If we're tied too closely to some in-group we no longer become an individual but a clone of someone else's ideology.

Civic discourse in the divisive age

Debate and civic discourse is inherently messy. Add into the mix an ignorance of history, rabid politicization and debased political discourse, you can see that it will be very difficult in mending this discursive staple of a functional civilization.

There is still hope that this great divide can be mended, because it has to be. The Hidden Tribes authors at one point state:

"In the era of social media and partisan news outlets, America's differences have become
dangerously tribal, fueled by a culture of outrage and taking offense. For the combatants,
the other side can no longer be tolerated, and no price is too high to defeat them.
These tensions are poisoning personal relationships, consuming our politics and
putting our democracy in peril.

Once a country has become tribalized, debates about contested issues from
immigration and trade to economic management, climate change and national security,
become shaped by larger tribal identities. Policy debate gives way to tribal conflicts.
Polarization and tribalism are self-reinforcing and will likely continue to accelerate.
The work of rebuilding our fragmented society needs to start now. It extends from
re-connecting people across the lines of division in local communities all the way to
building a renewed sense of national identity: a bigger story of us."

We need to start teaching people how to approach subjects from less of an emotional or baseless educational bias or identity, especially in the event that the subject matter could be construed to be controversial or uncomfortable.

This will be the beginning of a new era of understanding, inclusion and the defeat of regressive philosophies that threaten the core of our nation and civilization.