Q&A: Fighting for Our Health January 2012

Fighting for Health Reform, Writing for the Record

An Interview with Richard Kirsch
Rockefeller Institute Fellow, author of Fighting For Our Health

Erika Martin

Q: Why did you write Fighting For Our Health, about your efforts to get health reform legislation passed?

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Rockefeller Institute Fellow Richard Kirsch was national campaign manager for Health Care for America Now, where he advocated for comprehensive health reform from 2008-2010. His book, Fighting For Our Health, tells the inside story of those efforts.

A: There are two reasons. One is, I wanted to write it for history. When you read American history, so often the role of people who are doing grassroots work — who are mobilizing from the bottom, who are protesting — is not told at all or is really underplayed. You see what presidents did. You may see what big industries did or what congressional leaders did. But the story of popular movements, with rare exceptions like the Civil Rights movement, is rarely part of the story. What we did at Health Care for America Now was build a movement with a huge amount of grassroots organizing. And I wanted that to be part of the history.

The second reason is I wanted people today to see the effectiveness of well-focused strategic organizing to demand that government respond to people’s needs. There is tremendous cynicism right now about whether Washington — with all the huge money from the very wealthy and big corporate interests — is ever accountable to ordinary people. What we demonstrated in the health-care campaign is that when you build a broad coalition — you organize at the grassroots and now with the netroots — and you have people bring their personal stories and demands to members of Congress in their districts in a powerful way, that ordinary people actually can make change. On a big issue like health care, you have to do it in a way that is strategic. It has to be a whole national strategy, as well as one that is tailored to the local community, to an individual member of Congress. But if you do that in a way that is smart and strategic and focused, the energy of ordinary people can carry the day. There’s a huge lesson in the book about how you make change.

Q: This is a personal story as well. When you were writing the book, what was the best or most interesting part to relive?

A: Part of the great fun of the book was doing 120 interviews, and most of those interviews were with people who had been doing the grassroots work — people who are paid organizers and a lot of volunteers who put a huge amount of their time into it — and hearing their stories. We developed a national strategy, and the heart of the strategy was organizing outside the Beltway. We had organizers working with a lot of volunteers, who were telling their stories. We organized people to tell their own stories about their own personal experiences with the health care system, to protest the insurance industry, to stand up to the Tea Party — to actually see and feel the power of that organizing.

Volunteers told me how this experience totally transformed their lives, their sense of their ability to make change, to have an impact, to build community, to make a difference in the country. Which is the biggest thrill when you are an organizer — that you actually get to engage people and give them a sense of their power. That was the most fun part of writing the book, to do these interviews, hear these stories, and then for me to get to write them.

The book also has my personal story of all the work that went into building the campaign — conceiving it and then all the tensions of navigating Washington politics, which is as byzantine and often discouraging and as out of touch as people think. But still, you have got to find a way through it and a way to make an impact and to ignore a lot of the nonsense that goes on.

Q: I want to ask about the Washington politics in a minute. But first, staying on this topic of writing the book, were there parts that were painful to go back over?

A: The most difficult stuff was tensions with the White House, which at times got personal.

I expected going into the campaign that we would have opposition from conservatives in Congress. I had thought Republicans would be uniformly opposed to our work; I had no illusions that they would be bipartisan. I knew we had conservative Democrats that would be difficult. I knew that generally the power of the insurance industry and the medical establishment would make it really hard. So I expected that.

I didn’t really expect, though, that the White House would be a major source of tension, that the administration would be so resistant to any kind of outside pressure to keep a strong bill. So that was really painful during the campaign, and reliving it was also not pleasant, although it did give me some perspective. I learned some interesting things, particularly about the background of (former White House Deputy Chief of Staff) Jim Messina. Doing research about his background in Montana really gave me some insights into what happened. Reliving that was good in terms of understanding the challenge of working to move an administration whose side you are basically on, but when you get past the basics there are a lot of tensions and differences.

Q: You discuss that issue in one chapter. Are there lessons about getting through that tension that you can pass along to other activists?

A: The problem was that the White House did not want an “outside strategy” — they did not want to be pushed by anyone on the outside, even if those outsiders were allies on this issue. They discouraged anybody on their left pushing them. And because many of the groups that were part of HCAN had strong relationships with the administration, those groups were reluctant to push them.

But the lesson is: You just have to push.

You don’t do the White House any good and you don’t do Democrats and Congress any good by following just what they want, because then the only place they can move is to the right. They have to have the pressure on the left in order for them to do keep to their values. Because if the only pressure they are getting is from the right, they are going to move to the right. You just have to be able to say to your friends in the administration, “Look, we’re doing everything we can to support you, but there are some differences here, and in the long run having us be aggressive in responsibly expressing our differences is actually going to make your job easier.” It’s not easy, because these are people you have relationships with or people who hold a lot of power, and between both the power and the relationships, it takes a lot of guts to stand up to them and say, “We’re going to do what we need to push for the best possible legislation. And that will actually in the long run make your job easier.”

Q: What other important lessons are there for activists in the book, especially from the period you focus on from 2008 to 2010?

A: The most important thing is to always appreciate the power of organizing people locally and bringing your concerns and your stories to the people who represent you in Congress. You can beat the most powerful interest groups if you do that aggressively and consistently — bringing people with stories over and over again and also being sure that they do that publicly as well. It can’t all just be private; you have to be demonstrating outside the Congress member’s office. You can do friendly demonstrations as well as negative demonstrations. You need to be doing demonstrations outside the local insurance company, or whatever your target is, to make it clear that the member of Congress or any elected official has to choose between you and the corporation. You have got to be both very, very visible and very much working directly. And the more people you organize and the more powerful the stories you tell are, the more the public is going to hear you, the more impact you’re going to have.

Second of all, you need to build coalitions. One group can’t do this by itself. You have to build as broad a coalition as possible. But at the same time, you have to stand for something. You don’t just want to have a coalition that is so broad that it doesn’t stand for anything. You’ve got to find some powerful principles and build a strong coalition around groups that embrace those principles.

And of course, all of these lessons are transferable to work people do in state capitals and local governments as well.

Q: Let’s jump to the present and look at the current status of health reform. The Supreme Court is taking a look in the spring at the constitutionality of the provision that requires all individuals to carry health insurance. Are you very concerned about that? How important is that so-called “individual mandate” to health reform?

A: People in the country remain really confused about the law right now. If you look at the polls, slightly more people disapprove than approve of it. But — as a recent Kaiser Health Tracking Poll found — if you ask people whether they would like the law expanded or kept the same, 32 percent want it expanded, 18 percent want it kept the same. So that is 50 percent, as opposed to 43 percent who want it repealed or replaced with a Republican version. So people are confused. And the reason they are confused is that the biggest parts of the law — the parts of the law that are really going to help people — haven’t kicked in yet.

What the law is designed to do is ensure that people, no matter what, are able to get decent health care they can afford. If you lose your job, you still can have decent health care you can afford. If you retire early, if you get laid off and can’t find another job, you still will be able to get decent health care you can afford. If you want to start a small business, you can have decent health care you can afford. But those parts of the law don’t kick in until 2014.

So right now people, particularly conservative Republicans, are attacking the law, because once those provisions kick in, it will prove that government can actually help people in a meaningful way. The same way that people support Medicare and Social Security, they’re going to see that the Affordable Care Act — “Obamacare” — means that you’re going to actually have care that’s affordable. Once it kicks in, in 2014, it’s going to be here for good, which is why the right is so desperate to stop it.

So what are the barriers to those provisions kicking in? The first is the Supreme Court. The big challenge there is around the individual mandate, the requirement that everybody get coverage. The individual mandate is the least popular part of the bill, and it is also the most widely misunderstood. If you made the mandate effective right now — to buy health insurance in the current system — it would of course be unfair, because everyone can’t afford health insurance now. But what’s going to happen when the individual mandate is put in place, is that the cost of insurance will be subsidized based on your income. So the amount you pay for care will depend on how much you make, and for most people that’s going to make it affordable. And for those people for whom it’s not affordable, the mandate won’t apply. In Massachusetts where this is working, the law is incredibly popular. People see that it works.

What’s the Supreme Court going to do? If you asked me a few months ago, I would have said the justices will overturn the individual mandate because this is such a right-wing court. However, two very well-respected, very conservative appeals court judges have ruled in favor of the mandate. So it may very well turn out that the Supreme Court does uphold the mandate. In which case, the law will proceed intact.

If the Supreme Court does overturn the mandate, it’s going to throw a lot up for grabs, because the sections of the law that guarantee quality, affordable coverage depend on the mandate. The whole basis of insurance is that we’re all in a big pool together. So for health care, you want the sick and the healthy in the same pool. That keeps the cost down. If you’re not required to get insurance, then some people wait until they’re sick, and that drives the cost up. This is particularly important for one of the most important provisions of the law, which says if you have a pre-existing medical condition, you can still get insurance. The only way you can make that affordable is to get everybody in the pool.

While the individual mandate is very important, if it’s overruled by the court, there are other ways you can bring a lot of people into the pool without a mandate, and Congress will have to debate those. The big problem there is that it opens the whole law up again. Once you go back to Congress, it’s going to open everything up, and that makes the law vulnerable to people who are opposed to it.

Q: How do you feel about the progress made toward health care reform if the individual mandate is overturned?

A: One thing that will continue under the law is a huge expansion of coverage through Medicaid, which will cover people who make up to a third more than the poverty level. In addition, even without the individual mandate, there are still going to be subsidies to cover people. So that’s still going to mean more people will be able to afford insurance.

There is a report that came out in December that two-and-a-half million adults under the age of 26 now have health insurance that they wouldn’t have had without the bill. That’s already a huge, huge increase in coverage. There are some 3 million senior citizens that are paying lower prescription drug prices under the law. There are about 1 million senior citizens who aren’t having to pay for preventive care under the law already. There are thousands of small businesses that are getting tax credits to help pay for coverage for their employees. Most health insurance policies at work no longer stop paying if you’re seriously ill; it used to be you could get cut off. There are already a lot of very concrete things the law has done even without the individual mandate.

Q: Where does the health care activist community stand now?

There are three areas that people are focusing on.

One is at the national level, implementing the law in the best way possible. One of the big items that has been debated is that the law basically says insurance companies have to spend at least 80 or 85 percent, depending on the plan, of premium dollars on medical care. Insurance company brokers have tried to pretend that their sales commissions are medical care. It’s obviously ridiculous. There are other regulations nationally that people are focused on in implementing the law. Also nationally, people are focused on protecting Medicare and Medicaid because the Affordable Care Act, Medicare and Medicaid are all related very closely.

The key thing about the Affordable Care Act is that a lot of it is implemented at the state level, where every state has the option of setting up its own new health care marketplace, called an exchange. This is where people who don’t get health coverage at work and aren’t eligible for Medicaid would go to buy insurance, using the subsidies that they get from the federal government to make it affordable. How are those health care exchanges structured, are they done in a way that protects consumers and gets the best value with a lower price? Who’s going to be governing them? Are insurance companies allowed to be on the board governing them? These are big battles that are happening in every state.

The states don’t have to operate an exchange. If a state doesn’t, its residents can access an exchange that will be run by the federal government. But many states are looking at doing it. About a dozen states did it in 2010 and 2011. But now states are saying, let’s see what the Supreme Court does. If the court goes ahead and keeps the law intact, people are going to be scrambling because they have to start getting a lot of this in place by the end of 2012. On the other hand, if the court overturns the individual mandate, that’s going to throw everything up in the air.

Of course the big question is: Who’s the next president and the next Congress? If President Obama is re-elected, he will veto any major gutting of the law. I write in the book that he tended to compromise more than he should have on some provisions. But when push came to shove, he always insisted on legislation that covered everyone. He will stick with that.

If President Obama loses, it depends on who’s in Congress, whether the Republicans control one house or both houses. It’s easy to say on the campaign trail, “I’m going to repeal the law.” But there are a lot of popular things in it. Like the provisions that provide affordable health care to young adults. Like lowering prescription drugs for seniors. And the promise of not having to worry about pre-existing conditions. These are things that people really, really care about. The public will hate it if Republicans repeal those. But the pre-existing condition law is tied to the mandate that is tied to the subsidies that is tied to the whole structure of the law. So it’s easy to say you will repeal it before you actually get down to the reality of it.

Right now people are focused on: Getting the federal government to defend consumers and stand up to interest groups like the insurance industry. Getting states to implement the law in the best way and to not allow insurance company representatives to be the foxes guarding the chicken coop. Defending the Medicaid and Medicare programs.

Q: What advice would you give the activist community for keeping the health reform conversation moving forward?

A: One thing that is important when you talk about health care now is to situate it in the big discussion going on in the country around the “99 percent” versus the “1 percent.” People say the Occupy movement doesn’t focus on Congress, they just focus on corporations. One thing that we really did well at Health Care for America Now was make the connections. So in March 2010, a couple weeks before the law passed, it was still in doubt whether it would pass, and the insurance industry had a lobbying conference at the Ritz Carlton in Washington. We had a huge demonstration. Our message was, “Tell Congress to Stop Big Insurance.” We made the connection between corporations and their influence on Congress. That’s a good lesson for people today who see how much control corporations have over our government and feel like we should be focusing on corporations or focusing on Congress. You can focus on them together.

Today so many people are unemployed or partially employed, looking for new jobs. In the recession from 2007 to 2010, 9.4 million people lost their health insurance. We have to continue to make that link right now that the problem of so much insecurity for health care is what the Affordable Care Act will solve. It’s a law that really helps the 99 percent, not the 1 percent. Right now, special interest groups and people who are partisan for ideological reasons are opposing it. We have to stop them because they’re the 1 percent. We have to stand with the 99 percent, and that’s what the law does.

Q: Thank you.


The Nelson A. Rockefeller Institute of Government, the public policy research arm of the State University of New York, conducts fiscal and programmatic research on American state and local governments. It works closely with federal, state, and local government agencies nationally and in New York, and draws on the State University’s rich intellectual resources and on networks of public policy academic experts throughout the country.