Battle over health-care reform: vital lessons from America's founding fathers

History lights a path out of partisan morass, if we will but see. The new Republican House has read the Constitution, reverently, voted to repeal and defund health-care reform, defiantly, and listened to the president’s views on health care and our union, dutifully.

As a next step, I highly recommend they read Pauline Maier’s masterful “Ratification: The People Debate the Constitution, 1787-88,” before plunging back into business as usual. Two lessons in particular speak to our recent health-reform debate: 1) Complex proposals may be best worked out in secret, but must be made clear before too long; 2) State-level debates can play essential roles in the acceptance of fundamental change in our country, if debaters are honest with one another.

Four ways to kick the polarized partisan habit

Whatever Glenn Beck may tell his admirers, our Constitution was written by elites behind closed doors. George Washington, coaxed out of retirement so that “better” men would also agree to become convention delegates, insisted that no one talk about deliberations outside their meetings in Philadelphia.

An elite, discreet, group

Washington’s authority was complete; for four months our most thoughtful founding fathers wrote, debated, compromised, stood firm, and rewrote it, without press leaks or contraband drafts being circulated for public effect. He understood the final product would be stronger and more durable if debates were not hamstrung by specific constituencies’ demands. He asked for intellectual and moral judgments from the individual delegates themselves, and in so doing was able to keep the focus on what mattered most, making a government strong enough to enable our new country of free citizens to stand among the family of nations, then and now. Importantly, they agreed upon the goal, and in the end, all but a handful signed the document. It was then revealed to a public that became as divided as the rhetorical attacks were sharp.

Sound familiar? An unsustainable status quo, partially remedied by a complicated document that was badly explained initially, whose provisions were falsely accused of heinous implications (death panels, job killing, budget busting, etc.), that then led to “patriotic” calls for outright rejection.

The foundational public debate over the Constitution was then conducted in the individual states, separately and mostly sequentially, but with the benefit of knowing arguments pro and con used in other states. This enabled claims and counterclaims to be anticipated, sharpened, and improved as time passed. In quite a few cases the majority of state convention delegates were against ratification at the outset, but only Rhode Island and North Carolina failed to ratify in the end. And both of them came around very soon, by large margins, after the new government was formed and operating.

What were the major objections to the Constitution as it emerged from Philadelphia?

There were many specifics – unlimited number of terms for national office holders, the power to set conditions for state elections and to levy direct taxes on the people – but the unifying theme was a fear of federal power that could be checked neither by the states nor the people, for there was no Bill of Rights in the original Constitution. This fear was palpable, since the costly war with Britain over their, and our, essential liberties was so fresh.

Similarly today, the core argument in the constitutional objection to the individual mandate is not about ways to make private insurance markets work better for more people, but reflects the fear that a federal government that can require people to purchase insurance has limitless power to restrict our freedom.

Fears mollified

So how was such a profound fear of all powerful government mollified in the 18th century?

By listening to the skeptics and meeting their fears with modifications that addressed them. None of the founders thought the Philadelphia Constitution was perfect. Versions of our Bill of Rights (and other amendments) were offered in the Philadelphia convention and in most state ratifying conventions as well, and before long it was clear even to the most ardent Federalists (James Madison, George Washington, Alexander Hamilton, Thomas Jefferson) that amendments guaranteeing individual liberties against this new, more-powerful federal government were absolutely necessary. And so, the first Congress operating under the new Constitution quickly passed and sent 12 amendments to the states for ratification, of which 10 became the Bill of Rights we know today. Seeing these amendments, and the new government in action, made it easier for North Carolina and Rhode Island to ratify and join the growing union.

And what did implacable opponents, like Patrick Henry and George Mason, provide as their part? First, they acknowledged that there was a serious problem to be solved (the Articles of Confederation were inadequate), and they agreed to have an honest and fair debate. They did not reject the process, continually suggested amendments, and did not label the majority un-American. Some skeptics had the courage to admit, as state conventions came to their closures, that most of their initial fears had been overcome by the logic and facts and the respectful nature of the pro-constitution debaters. Fears are easily exaggerated by emotion fueled on partisan distrust. Supporters also admitted the skeptics had many good points, which improved the final product. On the whole there was a great deal more intellectual honesty and mutual respect than we’ve seen in the past two (10? 20?) years in Washington.

Reasons for optimism

So why does this history make me more optimistic about health reform being accepted, improved, and implemented?

Because our debate is now moving to the states, where many leaders who are closer to real people’s lives – people who want better health-care choices – know and admit the status quo is unsatisfactory and unsustainable.

Because I know many clinician leaders see how the tools of the new law can help them deliver higher quality care more efficiently and humanely. Because the “amendments” that would reduce opponents’ fears actually do make sense – for example, malpractice reform, more state flexibility in how to re-organize Medicaid and insurance markets, plus stronger budget protections if the savings from delivery system reform provisions do not materialize.

And because I know most Democrats and the president are willing to engage in honest debate about amendments and improvements. The question is, now that they’ve kept their campaign promise to their excitable base, are Republicans in Congress more interested in focusing on what matters most, actually solving our health-care problems, or in polarizing politics? Will the pragmatic preferences of independent voters push them to rise to the level of the 18th century statesmen they claim to admire? I choose to believe, when push comes to shove, the best interests of our country will once again become self-evident and govern the choices of the people’s representatives.

Len M. Nichols is director of the Center for Health Policy Research and Ethics at George Mason University.