[Congressional Record (Bound Edition), Volume 155 (2009), Part 2]
[House]
[Pages 2735-2742]
[From the U.S. Government Publishing Office, www.gpo.gov]




                    CONGRESSIONAL PROGRESSIVE CAUCUS

  The SPEAKER pro tempore. Under the Speaker's announced policy of 
January 6, 2009, the gentleman from Minnesota (Mr. Ellison) is 
recognized for 60 minutes as the designee of the majority leader.
  Mr. ELLISON. Thank you, Madam Speaker.
  Tonight we're here for the Congressional Progressive Caucus, and I'm 
joined by my colleague, the honorable Hank Johnson, who hails from the 
State of Georgia. And we are the Progressive Caucus. And we're here 
week after week, month after month to help the American people 
understand that the progressive community throughout America has a 
group of people in Congress who are willing to stand up and stand 
strong and project a progressive vision for all of the Nation.
  The Progressive Caucus has designed something we call the progressive 
message. So this is what we do. We come together, and we talk about our 
progressive vision for our country.
  We started off only a few weeks ago talking about the need to hold 
the executives accountable and to not simply wipe things that happened 
in the past 8 years under the rug. Then we came back last week to talk 
about the economy and the stimulus package. And because we're facing a 
rising unemployment rate, foreclosure rate that is increasing, because 
people are losing their jobs, because things are getting tougher every 
day, we've got to stick with this issue of the economy so we can talk 
to people about which way forward, what do we do, what is the 
progressive message to help America go forward.
  So with that, I want to introduce my colleague, my good friend from 
the great State of Georgia, to introduce himself and the topic tonight, 
Mr. Hank Johnson. 
  Congressman, let me yield to you. How are you doing?
  Mr. JOHNSON of Georgia. I'm doing great.
  Mr. Ellison, you have been a shining light and a great example of a 
courageous congressman who doesn't run with the crowd and do what's 
popular but you do what's right, and I'm happy to join you tonight.
  You know, I am deeply concerned--and have always been deeply 
concerned--about the fact that there's been a transfer of wealth in 
this country, a shift of the money from the middle class to the upper 
10 percent of earners here in this country. In fact, since 2001, the 
figures show that worker productivity went up, while at the same time, 
96 percent of the income growth went to the wealthiest 10 percent of 
this country. And so that's a clear indication that something is wrong 
with the policies that we have been following over the last 8 years.
  And despite the wealth that has been transferred into the hands of a 
small minority of Americans, we still see that the pursuit of greed has 
brought us to the point where we're closer to a depression than we have 
been since the Great Depression. And so I'm happy to be a progressive.
  The other side of that is conservative. Let's leave everything the 
way we want to leave it, and let's do business as usual.
  We cannot do that.
  So I'm happy to be a member of the Progressive Caucus espousing, 
along with yourself, new ideas; and it's a new time. It's time for 
change.
  Mr. ELLISON. If the gentleman yields back.
  Congressman Johnson, you know, we are the progressives. We want 
progress. And if you say you're a conservative, what, over the past 8 
years, do you want to conserve? Do you want to conserve these exploding 
unemployment rates they've handed us? Do you want to conserve this war 
in Iraq and Afghanistan? Maybe you want to conserve this regime of 
deregulation which has allowed businesses, and particularly in the 
financial sector, to do whatever they want and not have to worry about 
consumers. Is that what you're trying to conserve?
  The fact is the people of America don't want conservatism. They want 
a progressive vision. They're looking at things like I have up on this 
graph right here.
  They're looking at Minnesota. We have an unemployment rate in 2008 of 
6.9 percent. Last year, 2007, it was 4.7. In California, they're 
looking at 9.3 percent unemployment this year, 5.9 percent the year 
before.
  What about our colleagues from Michigan, Congressman Johnson? We've 
got a serious problem.
  The question is if you look at these high unemployment rates, and you 
look at every blue line is 2007 and every red line is 2008, as you can 
tell, unemployment is up all across the Nation everywhere.
  These things did not happen by accident. They are the product of a 
set of policies, many of which were promulgated right in this gallery 
you and I are in right now. Many of the policies saying that poor 
people have too much money and rich people don't have enough money 
promulgated right here. Tax cuts for the wealthiest Americans, no 
accountability. As a matter of fact, it was put into legislation that 
the whole credit default swap market would be excluded from regulation, 
and now we know that these derivative products cause so much risk in 
the system that we don't know what to do about it.

[[Page 2736]]

  The fact is, the policies and the procedures that have brought this 
about were done right here during the last 8 years, and we are now 
going to project a progressive vision to get us out of it.
  Let me just say this before I turn it over to you, Congressman.
  America has suffered 11 straight months of joblessness, of increasing 
job losses, totaling more than two million in the last year, 1.3 
million jobs lost in the last 3 months alone. The job losses totaled 
over 500,000 in November, the biggest 1-month jump in 34 years. Now 
that's serious business.
  So, facing these kinds of things, Congressman, what would be your 
thought as to what we should be thinking about right now?
  Let me yield to you.
  Mr. JOHNSON of Georgia. Okay. Before I answer that, Congressman, I do 
want to talk about--you mentioned something very interesting and that 
is the lack of regulation in the financial markets. Oil futures 
contracts were taken out of the regulatory process by the laws of a 
senator who would become the Republican nominee for president's 
financial adviser. And now we have that candidate, that unsuccessful 
candidate for President, proposing his own economic plan, is what he 
said he was going to do.
  And it took me back to as a young man, my dad decided that he wanted 
to get under the sink and do something with the plumbing. And he's like 
a college-educated guy. Never took any plumbing classes or anything. 
But anyway, we came out of that situation with puddles and puddles of 
water in the kitchen. So, you know, my mother called in the plumber. 
She did not entrust fixing what had been messed up to the guy who 
messed it up.
  And so that's where we are right now with our economic plans in this 
country, our--we call it the stimulus package.
  Mr. ELLISON. If I can reclaim my time.
  The American Recovery and Reinvestment Act.
  I yield back to the gentleman.
  Mr. JOHNSON of Georgia. Yes. Thank you.
  So we've got a group of folks who were right here as you say, 
Congressman Ellison, they were right here in this very Chamber, and 
they had the leadership up until 2006; and they aided and abetted this 
country's decline and all of the things that contributed to it.
  And so but now they want to dictate the solutions to getting us out 
of this morass. And it just doesn't make sense.
  I hope the American people are paying great attention because my 
friends on the other side of the aisle, the only thing that they 
propose is more tax cuts for the wealthiest 10 percent, and that's 
certainly not going to work.
  We've got to take care of our basic safety net. We've got people in 
this country who've lost their jobs, they've lost their homes. They are 
on the street--families, no place to live, no food. And so we've got to 
fix those things while we also pay attention to the future needs of 
this country preparing us for the global economy and the long-term 
future.
  And with that, Congressman. I'm going to yield back.

                              {time}  1845

  Mr. ELLISON. Congressman Johnson has correctly pointed out that we 
have got people losing their jobs. Unemployment is climbing up to 10 
percent in many States, and we don't want to reach that point 
nationally. But one of the things that I think you will agree with me, 
Congressman Johnson, is that when you lose your job in America, so 
often you also lose something else--your health care.
  You and I have been joined by Jim McDermott from the great State of 
Washington, who has been fighting the good fight for so long, knows 
this issue of health care, and many other issues as well.
  Congressman McDermott, welcome. What can you tell us about the other 
side of losing a job, or even folks who do have a job, their health 
care crisis?
  Mr. McDERMOTT. You know, first, I want to say that I want to commend 
you, Keith, for bringing this issue of the real vision we need at a 
time like this. People are looking out there and feeling pretty bummed 
out by an awful lot of what is going on. Yet, America has been able to 
rise above things like this in the past, and we are going to do it 
again.
  One of the issues the last time we had this kind of mess--in 1932--
that we didn't get done, was health care for everybody. Now, when you 
lose your job, that is bad enough. Not to have money to send your kids 
to college, just to barely pay the mortgage and maybe keep some food on 
the table, keep the car running, and that is all, and suddenly not be 
able to take your kids to the doctor when you're sick is a horrible 
feeling as a parent because your kids look to you to take care of them. 
They haven't got anybody else.
  And so what we did today on SCHIP was really the beginning of the 
vision of what needs to be happening for all Americans because today we 
were talking about 8 million kids in this country that don't have 
health insurance, and we took care of 4 million of them, but we didn't 
talk about the 40-some million adults who don't have health insurance, 
many of whom are being added to the roles every day as they lose their 
insurance when they lose their job.
  Now, in this country we have always said the market will take care of 
them; that people can go out and buy their own health insurance, and 
the insurance companies will have some kind of plan. But it flat is not 
true. When you lose your job, the likelihood of you being able to find 
an insurance policy that you can afford and still pay your mortgage and 
still pay some money for food and run the car and a few things, is 
absolutely zero.
  I mean, in the State of Washington, the highest paid unemployed 
person gets $518 a week. That is $2,000 a month. Now that is a very 
slim group of people. Most people are getting the average in the State 
of Washington--$360 a week. So that is a little over $1,200, $1,300, 
$1,400 a month to live on. And to be able to buy a policy that can 
cover the problems of your family is almost nonexistent.
  So what I am here to talk about is the fact that this country needs a 
national health insurance. Buried in this economic recovery package are 
the seeds of beginning that process. What we have said is if you are 
losing your job--and we have a program today called COBRA. I don't know 
what it stands for. It's some acronym in the government. But what it 
means is when you lose your job, you can keep your health insurance in 
the company you work for if you can pay the premium.
  You have to pay the premium plus 2 percent. So you have to pay 102 
percent of the premium, right. So here you are, unemployed, and you get 
out there and you're supposed to come up with the money to pay 102 
percent of the premium. Most people can't do it.
  So in this bill we made it possible. We put money in there for us to 
pay 65 percent of the premium for people who have lost their job and 
are eligible to take advantage of staying in their company plan under 
the COBRA program.
  It's the first step because the people that are losing their jobs--if 
you think about it, if you're 65, you're taken care of. You have got 
Medicare. But if you're below 65, you're really dependent on where your 
employment is or how rich you are. Most people are getting their health 
insurance through their employment.
  Well, between 55 and 65 is when the wheels start falling off your 
wagon. When you're 30, you're never going to be sick. You're going to 
be able to do anything you want in your life. When you get to 50, maybe 
a little high blood pressure, a little arthritis. Things start to 
happen to people. It's just at that point they lose their job. They are 
absolutely uncovered.
  So this provision buried in this $900- or $800-some-odd-billion is 
the first step toward dealing with the problem of people who are under 
65 and not children. We took care of most of the children today, and we 
have taken care of the seniors, but we have got this whole other group 
of people between the ages of 18 and 65 who it's a lottery--where do 
you work, who covers you.

[[Page 2737]]

  We really need a single-payer health care system, in my view. People 
immediately say, oh, no, no. You're talking about Canada, you're 
talking about Great Britain.
  Mr. ELLISON. Would the gentleman yield for just a moment?
  Mr. McDERMOTT. Sure.
  Mr. ELLISON. So you think America should join the 36 other countries 
in the world that have a single-payer system?
  Mr. McDERMOTT. Absolutely. It's ridiculous that we are the only 
industrialized country who have never figured out how to do this. And I 
am going to enter into the Record an article from the New Yorker 
Magazine by Atul Gawande, who is a doctor and a medical writer, about 
the process by which we are going to get to a plan. Let me just lay it 
out for you. I think people out there ought to be thinking about it.
  Every country in the industrialized world has a different plan. None 
of the plans are the same. Germany started in 1883. The Prime Minister 
at that point was worried about the social disruption and said, Let's 
give them some health care benefits. So they got started on this 
process, and it's been going since 1883, through two world wars, the 
German system.
  The German system is different than ours would be. The French system, 
the British system, the Canadian system. The Canadian system started in 
British Colombia in Saskatchewan, one of the central provinces of the 
country. Different circumstances.
  In British Colombia, the doctors said we can't take care of these old 
people in the hospitals. We have got to start a health insurance plan. 
So they started the BC health program.
  Saskatchewan, they had a socialist government in that province at 
that point. They started the system, and it gradually spread all across 
Canada, and finally at the end they put together an umbrella that sort 
of tied it all together.
  Now, Great Britain started in a different way. Great Britain started 
in the middle of the Second World War. They realized they had to have 
healthy people. So the government built hospitals, the government hired 
the doctors. It was all government everything. And that is their 
system. Every system comes in a different way.
  Now, the United States in 2009 is not going to have Canada, it's not 
going to have Great Britain, it's not going to have France, it's not 
going to have anybody else. It's going to have an American system 
designed by this Congress, with the leadership of President Obama, that 
deals with the problems as they are today in this country.
  Mr. JOHNSON of Georgia. Would the gentleman yield?
  Mr. McDERMOTT. Sure.
  Mr. JOHNSON of Georgia. Congressman, it's nice to have you with us, 
and I admire you so much, both in your foreign affairs philosophy as 
well as your domestic philosophy. I appreciate the fight that you have 
put up over many years.
  You know, as I see it, health care is also an economic issue, and 
it's an issue of education as well, because if you have got children 
who are not healthy, when they go to school, they can't give their 
best. And so, as they grow up, they can't compete with other students 
from other countries who have had a healthy preventive health-type of 
experience.
  It's an economic issue because we have got to compete in a global 
economy now. American workers--and it's so important that our workers, 
our middle-class workers, that they are able to access health care, 
remain healthy, wealthy, and wise, if you will. And so it's an economic 
issue. It's like removing termites from your house. If you know you 
have got termites, you know that they are going to at some point eat up 
the whole frame. And so to prevent that from happening is very 
important.
  Health care is one of those important areas that has been neglected 
for so long for working-class people. And so I am glad that we have a 
President that is going to be assertive in terms of changing this 
system that does not work for anybody but the insurance companies as 
far as I can see.
  And so this American Recovery and Reinvestment Plan includes, of 
course, some outlay for health care. If you could comment, if I might 
ask.
  Mr. McDERMOTT. There's another piece. I have got to say I am excited 
because I was just down at the White House and the President just 
signed SCHIP. He gave a wonderful speech before he signed the bill, and 
said, This is just a start. We are going to take some more steps.
  It's exciting to have somebody leading. And a part of what he has 
asked us to do in this economic recovery bill is begin the IT buildup 
that we need in our health care system. When you go to a doctor, and I 
practiced medicine for 20 years, so I wrote all my stuff out. And if 
you went to see a doctor somewhere else across the country, there's no 
way that doctor would know what I had done for you or what I might have 
prescribed for you, or anything else.
  But if we have an electronic system that is protected so privacy is 
protected--I mean you have got to protect people's privacy. But if you 
get sick in Minneapolis--or St. Paul, I guess more like it--and you 
then come to Seattle, the doctor who sees you in Seattle doesn't know 
anything, because if you don't remember what the medications are or 
what the x-rays showed or anything else, there's no way he is going to 
know it.
  But with the money that is invested in this economic recovery package 
for medical technology, for IT work, intellectual properties, you are 
making it possible for a doctor in Seattle to sit down at his computer 
with the numbers that Mr. Ellison would give him and find out what went 
on with him when he was treated in St. Paul.
  Mr. JOHNSON of Georgia. Would the gentleman yield?
  Mr. McDERMOTT. Sure.
  Mr. JOHNSON of Georgia. We have cut down on so many medical errors. I 
know that you being a doctor, you could probably relate to this. The 
penmanship of the average doctor is quite, some say, arrogant. You 
can't understand what is written.
  So electronic medical records would be a clear communications device 
that would cut down on medical mistakes, pharmaceutical errors, and the 
like. That is an investment in the future of this country, and also it 
sets up our entrepreneurs, Congressman Ellison. It sets us up to lead 
the way as future developing nations see the need to bring that kind of 
technical expertise to their own health care systems.
  And so it puts us in a great position in the future, as does the 
recovery package with respect to energy.
  Congressman Ellison.
  Mr. ELLISON. Thank you, Congressman. I am going to yield back to Dr. 
McDermott because he was driving at a point that I think the American 
people need to hear about.
  Congressman McDermott, when you were there at the White House and 
President Obama had just given his speech, all you guys who were 
instrumental in getting SCHIP together probably gathered around the 
desk and you saw him write his name on that bill which, in effect, 
makes SCHIP law, as a medical professional, as a person dedicated to 
the health of our Nation, what did you feel?
  Mr. McDERMOTT. You know, I have got to admit, it brought a tear to my 
eye when he talked in his speech about the fact that when your kids 
look at you, they expect you to be able to take care of them. And if 
you haven't got health insurance, then you're caught between a kid that 
has got a problem and, Can I fill the prescription? Or, If I go and get 
a big hospital bill with my kid, how am I going to deal with that?

                              {time}  1900

  It is a terrible feeling. I remember once when my daughter was in the 
hospital and she was in the ICU, and you are sitting there wondering if 
your child is going to make it or not. It is a scary kind of thing as a 
parent. And to see the President talk about it and say we are going to 
fix this was really very exciting. And I think that, although I was 
here in 1993 when we tried it with Mrs. Clinton and at that time 
business was opposed to us and the medical profession was opposed to us 
and some labor unions were opposed, and it was really tough going.

[[Page 2738]]

  Things have changed today. Business wants to have a change, the 
medical professions want to have a change, and labor unions. And I 
think it is not going to come quickly and easily, because the status 
quo is always hard to change in a country. But I bring this article, 
and I am going to put it in the Record, because I want people to read 
it and realize that it is absolutely possible for us to make a major 
change, not just tinkering around the edges, but to really make a 
change that will make it possible to take away from all of us any fear 
that we are ever going to be economically destroyed, as Mr. Johnson 
says, or that we are going to be not able to be taken care of when we 
are sick, just on a human basis.
  Mr. ELLISON. If the gentleman would yield back for a moment. I want 
to thank Congressman Johnson and you, Congressman McDermott, for coming 
here today, because what you are talking about is not just dealing with 
the immediate situation. We are not saying, well, we are on the 
Titanic, let's put the deck chairs over there. No, let's move them back 
over there. We are projecting a progressive vision for our Nation. We 
are saying we are going this way. And that is why we are here with the 
progressive message today.
  I just want to remind people, we are here with the Progressive Caucus 
projecting a progressive message, talking about economic prosperity for 
all Americans. We have talked about unemployment. And Congressman 
Johnson and I had a great dialogue; and when you came, Congressman 
McDermott, we began an important conversation about how health care has 
a vital role to play in the economic health of a family and a Nation. I 
think we pointed out, when General Mills spends more money on health 
care than it does on steel, we have got a problem. When Starbucks 
spends more money on health care than it does on coffee beans, we have 
got a problem. Both things are true. It is time to move forward. 
Medical debt being one of the major drivers in bankruptcy. This is the 
time. The time is now to begin universal health care. And signing SCHIP 
I believe was the beginning of good times to come.
  Mr. McDERMOTT. You are going to hear people say it is too much, it is 
too big, we can't do it. But all you have to do is look back at what 
Franklin Delano Roosevelt did in 1932, when he came into office, with 
25 percent unemployment in this country, and he sat down with his 
people and he said, ``We have got to have Social Security because old 
people don't have any money to live on when they get old. We don't have 
any money for poor people, so we are going to have a welfare program. 
We don't have any money for workers when they lose their jobs, so we 
are going to have unemployment insurance. And we don't have any money 
for kids that get dropped off in orphanages because their parents can't 
take care of them, so we are going to put together a foster care 
program.'' That was all done in 1935, in the Social Security Act of 
1935. It was a huge step forward. And we have a progressive message for 
this country that we can do that again.
  Even in the midst of our darkest hours with all the banks and 
foreclosures and all this stuff, if we think small, we are going to do 
small; but if we do and we think big, we can actually get some major 
steps forward. And I think the American people are ready to listen to 
this. I think that they have listened to the fiscal conservatives say, 
``We are going to be a fiscal conservative; we are going to waste $1 
trillion on a war, and we are going to run the banks into the ditch and 
we are going to bail them out,'' people are tired of hearing that. I 
fly home on the planes, and the flight attendants say to me, ``My tax 
money is going to bail out those guys. I want my tax money to go for 
things that will help me and my family and all the Americans.''
  And I think that the progressive message, its time is now. So I 
really commend you guys for coming down here and doing this. I have to 
run off, but I will come back another night and work with you.
  Mr. JOHNSON of Georgia. If the gentleman will yield for just one 
second. Let me start by saying this. The new deal and the investment 
that was made in this country after the great depression caused this 
country to prosper; and the money, there were jobs for middle class, 
and people accumulated wealth. They were able to buy their homes, buy 
their cars, send their kids to college. But back then there was a whole 
set of conditions in existence that are not in existence now. But 
things like infrastructure, health care, which have gone neglected for 
so long, these are the new areas that we can create jobs. We are 
talking about 3 million to 4 million jobs will be saved or created by 
this American Recovery and Reinvestment Act, and we have got to think 
out of the box in terms of what these long-term measures that are 
included in the stimulus package will produce in the long term. And if 
I could get you to just comment on that.
  Mr. McDERMOTT. You go back and you look at history; and I was reading 
something just today in the Smithsonian magazine. Do you realize that 
the land grant colleges, the universities in this country were started 
in the middle of the civil war by Abraham Lincoln? I mean, the country 
is in chaos, people are dying everywhere. All this is going on, and he 
said, ``We have to think about the future. We are going to start land 
grant universities. We are going to give them.'' And every State has 
one. I am sure Georgia has one, I am sure Minnesota has one. We have 
got one. Washington State University was created, the idea was created 
in the middle of the war. The National Science Foundation was created 
by Abraham Lincoln in the middle of the war.
  In these times of the deepest darkest stuff, you have to make long-
term investments and think about where we are going in the future. And 
this bill is filled with it in terms of the health care and in terms of 
the alternative energy things. Those are changes that are not going to 
be on the table next Wednesday; they are going to be affecting us in 2 
or 3 or 4 or 5 years, but our kids are going to be better off and our 
country will be better off because we got back up on the road and 
started thinking long term.
  Mr. JOHNSON of Georgia. I think we have got to be broad-minded as we 
look for solutions to this difficulty that we face that was caused by 
the conservative movement, the trickled-down economic theories, a 
failed policy, miserably, a miserably failed policy. And it is causing 
so much misery to the 90 percent of the people who were working and did 
not participate in the accumulation of wealth over the last 8 years.
  So I am glad that Congressman Ellison and the Progressive Caucus is 
taking the lead in ushering in change in the United States Congress. 
And I will say that I think that the House version of the American 
Recovery and Reinvestment Act; I don't like the way that the plan is 
shaping up on the Senate side, it seems like they are wanting to cut 
things that are important for a changing economy. They want to cut, 
things like $400 million has been removed for HIV/AIDS prevention and 
treatment and also STD prevention. Our schools, our middle schools, 
junior high schools, high schools are rife with persons who are either 
infected or at risk for being infected by these illnesses. And to the 
extent that we can prevent these kinds of developments, which are so 
costly to treat, we are going to actually have a savings when we look 
at it holistically.
  Mr. ELLISON. Well, Congressman, I know you and I join together in 
thanking Congressman McDermott, who did such a great job. But on your 
point, I just want to say that it is too bad that the Senate proposed 
to cut the provisions on HIV and STD treatment, because it is 
stimulative. We would be hiring people who would go out to these 
schools and talk to young people about the importance of proper sexual 
health, of respecting their bodies and respecting other people, 
understanding the medical situation that arises when you are 
irresponsible, when you are unlucky enough to be infected with these 
horrendous diseases, which are preventable if you know what you are 
talking about, if you are well armed with good information. It is 
really too bad. And that is one of the reasons we

[[Page 2739]]

have to come here, because we are not here as an extension of the Obama 
administration. We love the fact that he signed SCHIP today. Go for it, 
President Obama. But if it ever comes a time when we don't agree, we 
will be here saying that.
  So it is critical today that you bring out differences that we have 
with the Senate package, because it is our job to project a progressive 
vision. And if you want to know and if folks want to know how to reach 
us with their progressive vision, they can send their ideas to this e-
mail at the bottom of this document here.
  I didn't really want to interrupt you, but I just thought it would be 
an important time to say, don't expect the Progressive Caucus to come 
to the House floor saying thumbs up to everybody. Expect the 
Progressive Caucus to say that we agree with some things, we don't 
agree with others. We are projecting a progressive vision that includes 
all Americans, that says all Americans should have health, all 
Americans should have civil rights, all Americans should have a shared 
economic prosperity.
  So forgive me for that interruption, but you inspired me for a 
moment.
  Mr. JOHNSON of Georgia. It is important to note that in addition to 
promoting policies that led us into this economic downturn in previous 
House sessions under the control of my friends on the other side, in 
addition to them willingly going along with certain things that they 
should have known were going to result in problems for the middle-class 
people of this country, there was also just simply being a rubber stamp 
and letting things go by without caring about the impact just to be 
team players. That kind of situation destroyed the check and balance 
system between the President, the executive branch, and the legislative 
branch. So we are now charged with the responsibility and the 
obligation to be, as much as we really like the new President and the 
new administration and the new policies and that kind of thing, we have 
got to remain diligent that we move with haste and with all deliberate 
speed on certain things.
  The American people voted for change. They voted for change in this 
body, they voted for change in the executive branch, and change we must 
fight for. And so when we have those who would take us back, it is our 
duty and our obligation to speak out against them. And that is why I 
support our courageous Speaker of the House, Nancy Pelosi. She gets a 
bad rap on radio and sometimes in print with people demonizing her.

                              {time}  1915

  But there is a reason why you want to reach out and kill the head of 
a movement. And it is because that person is being very effective. And 
so I think that for the most part, we should stand tall with the House 
version and stand behind our House leadership as they fight for the 
things that we've worked so carefully for and got into the American 
Recovery and Reinvestment Act that the Senate threatens now to take 
away because of wanting to compromise and getting some Republican 
votes.
  Mr. ELLISON. Will the gentleman yield? If you don't mind, if you have 
a few other facts and figures at your disposal, would you mind 
detailing for us tonight some of the other things that you believe we 
need to stick with and not compromise away? Do you have a list of those 
kinds of things?
  Mr. JOHNSON of Georgia. Yes. I would say one of the things would be 
the extension of the unemployment benefits. And another thing would be 
the increase in public assistance money, food stamps, and the like that 
serve as a safety net. It is just obscene in this country that we would 
allow people to be living under bridges and we don't even have enough 
homeless shelters for people. And many of the people are suffering from 
some kind of health ailment that has been neglected chronically. And so 
that is important.
  I think it is very important that we make a strong investment in our 
public transportation system. And that money, that pot of money has 
been decimated by the Senate. And it doesn't take us well into the 
future. We have to think more in terms of clean and efficient energy 
that is environmentally safe, that starts contributing to the global 
warming, because that threatens to take us all out, all the people on 
Earth. It changes our entire way of living. And so there are certain 
things we must address and we must address them now. And it is for the 
long-term benefit of America and the world.
  Mr. ELLISON. Will the gentleman yield?
  Mr. JOHNSON of Georgia. I will.
  Mr. ELLISON. One of the things that I think is important to bear in 
mind is that as we look at the American Recovery and Reinvestment Act, 
it is not only stimulus. We keep talking stimulus, stimulus, stimulus. 
That is not really the right way to describe what we're doing. It is 
for long-term investment. It is to deal with an emergency issue, but it 
is also to invest in the long-term health of our Nation. So it is not 
just stimulus. It is important for the American people to know that.
  But I do like this chart because a conservative economist named Mark 
Zandi did it. And he got his computers out, did some readings and 
figured out what is going to stimulate the economy the most, what is 
going to give the economy the most punch. And he found that one of the 
lowest things on his chart was make the income tax cuts expiring in 
2010 permanent. That is like .9 percent. That is pretty low. But the 
big ones, the big ones that he found were things like temporary 
increase in food stamps. That is 1.73. That is the highest one on here. 
That is going to jack up and get people, that is going to help 
stimulate the economy, things like extend unemployment compensation 
benefits, 1.64 percent, things you mentioned just a moment ago, that we 
have to stick with the House version and hold up. Increasing 
infrastructure spending, 1.59. These are things that are really going 
to stimulate the economy. And I think it is important that as we really 
focus on stimulating the economy, we don't give in to ideological 
matters.
  One thing I will say regarding the Obama administration, and you know 
I'm a big fan, is that President Obama reached out to the Republican 
Caucus, came to talk to them and tried to work with them. And they 
completely rebuffed him. And they told him just nothing doing. And here 
he is reaching across the aisle, trying to move us to this post-
partisan place. And not one of them, even though they got their tax 
cuts, voted for the stimulus package. So in my opinion, I think we 
should not try to, we should put all the weight on stimulating the 
economy. We get the economy moving.
  We have proved to the American people that conservatives are bad in 
economics. They don't understand economics very well. When the 
Democratic President left office in the year 2000, we had a $288 
billion surplus. It didn't take long for the Republican President to 
mess it all up. And the reason was because they are bad at economics. 
They don't understand economics. Actually they like economics where the 
rich people get and the poor people don't. If I may, they don't quite 
understand that a rising tide lifts all boats. You have to make sure 
that everyone is part of the economic life of the country in order to 
have a strong, robust economy. You can't just have tax cuts for the 
rich people. By definition, being rich means you don't need the money. 
You just stick that money in your back pocket. Maybe it can just sit in 
an account. But when you give moneys to the poor for things like 
unemployment insurance, things like food stamps, when you invest in the 
Nation's infrastructure, then you are really building the economy. Then 
you're really stimulating the economy.
  In my view, I will say with all due respect to our President, who I 
believe is a great leader, that he has tried to work with them on the 
other side of the aisle. They have rejected and rebuffed his overture. 
So skip their tax cuts. Let's get to some real stimulative stuff.
  And I yield back.
  Mr. JOHNSON of Georgia. Thank you, Congressman. That whole process

[[Page 2740]]

of trying to get bipartisan support here in the House I guess was 
probably doomed to failure from the outset because there was no good-
faith being exercised by my friends on the other side. It was just 
politics as usual. Let's play ``gotcha'' politics, and let's use our 
control over the media to get our message out and to undercut public 
support for the change that Americans voted for in November.
  And I think that the fact that no Republican bucked their leadership 
to vote in favor of this plan despite the fact that President Obama 
made significant concessions to my friends on the other side of the 
aisle, they kept moving the goalposts. If you do this, then they want 
something down here.
  Mr. ELLISON. Do you remember Charlie Brown, whenever he tried to kick 
the ball, Lucy always picks the ball up. And they picked the ball up on 
the President, even though they said they were going to hold it down.
  I yield back.
  Mr. JOHNSON of Georgia. A tremendous analogy. And so we have seen 
what happened in the House of Representatives. The Senate is supposed 
to be a more thoughtful and deliberative body. But isn't that the place 
where all of the earmarks come from? And it is politics up there, too, 
even though the Senators are elected for 6 years as opposed to the 2 
years that Representatives are elected for. And we simply cannot afford 
to cede our constitutional obligations to the Senate with respect to 
this reinvestment plan.
  Mr. ELLISON. So Congressman, we're going to begin to wrap up our hour 
at this time. We're going to allow somebody else to offer their views 
to the American people. But as we get ready to wrap up, I wonder if you 
have any remarks you would like to share before we hand it over.
  Mr. JOHNSON of Georgia. Yes. My friends on the other side have become 
what they call ``fiscally conservative'' once they lost the majority in 
the House. And the reason why they lost the majority is because people 
did not like this idea of increasing spending while at the same time 
cutting revenues by giving a tax break to the top 10 percent of 
wealthiest individuals who didn't need it. And so I find it ironic that 
we hear the voices of those same proponents of failed policy wanting to 
dictate how we get out of this and what policies we should have. And I 
just think that now is the time for change. Now is the time for Members 
of the Progressive Caucus and all the other caucuses to insist that our 
carefully structured recovery and reinvestment package is not 
eviscerated by the Senate and then is crammed down our throat in 
conference committee. I just really want us to stand tall on this one. 
And I do believe that our Speaker is going to lead that effort. And for 
that I want to thank her and let her know that we will be right there 
for her.
  Mr. ELLISON. And if the gentleman yields back, you can bet I will be 
right there with you standing behind our great Speaker, Nancy Pelosi, a 
leader for all America, a transformative leader, a leader with energy. 
The fact that she has children the same age as you and I, Congressman, 
doesn't undermine her energy level. She is energetic. She is powerful. 
She is visionary. She is progressive. And you and I are here today 
talking about the Progressive Caucus.
  We're here talking about a progressive vision for our Nation. We're 
making an obvious observation. In the Progressive Caucus you say, look, 
if you don't like government, if you believe government is the problem, 
as Ronald Reagan famously said, ``government is the problem,'' it 
stands to reason you might not be good at it. If you think government 
is not a good idea to begin with, you might not invest the time, energy 
and resources necessary to be good at it. And therefore it should be no 
surprise to anyone that the government, that the Republicans and the 
conservatives are bad at economics. They are just not good at it. And 
so it is not surprising to me that they would think that you could 
increase spending around a war, cut taxes, and then think that things 
are going to go well economically--they didn't go well economically--
and then deregulate everything, and then neglect the infrastructure.
  Well, we're back to offer a progressive vision, to say to America 
that it is time to have an inclusive economy, to have civil rights, to 
have environmental protection and to make a better way forward for all 
Americans. This has been Congressman Keith Ellison with the Progressive 
Caucus with Congressman Johnson. Thank you, sir. Congressman McDermott 
joined us and we are very proud to be here representing the Progressive 
Caucus with the progressive message.

                  [From The New Yorker, Jan. 26, 2009]

            Annals of Public Policy: Getting There From Here


                  How should Obama reform health care?

                           (By Atul Gawande)

       In every industrialized nation, the movement to reform 
     health care has begun with stories about cruelty. The 
     Canadians had stories like the 1946 Toronto Globe and Mail 
     report of a woman in labor who was refused help by three 
     successive physicians, apparently because of her inability to 
     pay. In Australia, a 1954 letter published in the Sydney 
     Morning Herald sought help for a young woman who had lung 
     disease. She couldn't afford to refill her oxygen tank, and 
     had been forced to ration her intake ``to a point where she 
     is on the borderline of death.'' In Britain, George Bernard 
     Shaw was at a London hospital visiting an eminent physician 
     when an assistant came in to report that a sick man had 
     arrived requesting treatment. ``Is he worth it?'' the 
     physician asked. It was the normality of the question that 
     shocked Shaw and prompted his scathing and influential 1906 
     play, ``The Doctor's Dilemma.'' The British health system, he 
     charged, was ``a conspiracy to exploit popular credulity and 
     human suffering.''
       In the United States, our stories are like the one that 
     appeared in the Times before Christmas. Starla Darling, 
     pregnant and due for delivery, had just taken maternity leave 
     from her factory job at Archway & Mother's Cookie Company, in 
     Ashland, Ohio, when she received a letter informing her that 
     the company was going out of business. In three days, the 
     letter said, she and almost three hundred co-workers would be 
     laid off, and would lose their health-insurance coverage. The 
     company was self-insured, so the employees didn't have the 
     option of paying for the insurance themselves--their 
     insurance plan was being terminated.
       ``When I heard that I was losing my insurance, I was 
     scared,'' Darling told the Times. Her husband had been laid 
     off from his job, too. ``I remember that the bill for my 
     son's delivery in 2005 was about $9,000, and I knew I would 
     never be able to pay that by myself.'' So she prevailed on 
     her midwife to induce labor while she still had insurance 
     coverage. During labor, Darling began bleeding profusely, and 
     needed a Cesarean section. Mother and baby pulled through. 
     But the insurer denied Darling's claim for coverage. The 
     couple ended up owing more than seventeen thousand dollars.
       The stories become unconscionable in any society that 
     purports to serve the needs of ordinary people, and, at some 
     alchemical point, they combine with opportunity and 
     leadership to produce change. Britain reached this point and 
     enacted universal health-care coverage in 1945, Canada in 
     1966, Australia in 1974. The United States may finally be 
     there now. In 2007, fifty-seven million Americans had 
     difficulty paying their medical bills, up fourteen million 
     from 2003. On average, they had two thousand dollars in 
     medical debt and had been contacted by a collection agency at 
     least once. Because, in part, of underpayment, half of 
     American hospitals operated at a loss in 2007. Today, large 
     numbers of employers are limiting or dropping insurance 
     coverage in order to stay afloat, or simply going under--even 
     hospitals themselves.
       Yet wherever the prospect of universal health insurance has 
     been considered, it has been widely attacked as a Bolshevik 
     fantasy--a coercive system to be imposed upon people by 
     benighted socialist master planners. People fear the 
     unintended consequences of drastic change, the blunt force of 
     government. However terrible the system may seem, we all know 
     that it could be worse--especially for those who already have 
     dependable coverage and access to good doctors and hospitals.
       Many would-be reformers hold that ``true'' reform must 
     simply override those fears. They believe that a new system 
     will be far better for most people, and that those who would 
     hang on to the old do so out of either lack of imagination or 
     narrow self-interest. On the left, then, single-payer 
     enthusiasts argue that the only coherent solution is to end 
     private health insurance and replace it with a national 
     insurance program. And, on the right, the free marketeers 
     argue that the only coherent solution is to end public 
     insurance and employer-controlled health benefits so that we 
     can all buy our own coverage and put market forces to work.
       Neither side can stand the other. But both reserve special 
     contempt for the pragmatists, who would build around the mess 
     we have. The country has this one chance, the

[[Page 2741]]

     idealist maintains, to sweep away our inhumane, wasteful 
     patchwork system and replace it with something new and more 
     rational. So we should prepare for a bold overhaul, just as 
     every other Western democracy has. True reform requires 
     transformation at a stroke. But is this really the way it has 
     occurred in other countries? The answer is no. And the 
     reality of how health reform has come about elsewhere is both 
     surprising and instructive.
       No example is more striking than that of Great Britain, 
     which has the most socialized health system in the 
     industrialized world. Established on July 5, 1948, the 
     National Health Service owns the vast majority of the 
     country's hospitals, blood banks, and ambulance operations, 
     employs most specialist physicians as salaried government 
     workers, and has made medical care available to every 
     resident for free. The system is so thoroughly government-
     controlled that, across the Atlantic, we imagine it had to 
     have been imposed by fiat, by the coercion of ideological 
     planners bending the system to their will.
       But look at the news report in the Times of London on July 
     6, 1948, headlined ``FIRST DAY OF HEALTH SERVICE.'' You might 
     expect descriptions of bureaucratic shock troops walking into 
     hospitals, insurance-company executives and doctors 
     protesting in the streets, patients standing outside chemist 
     shops worrying about whether they can get their prescriptions 
     filled. Instead, there was only a four-paragraph notice 
     between an item on the King and Queen's return from a holiday 
     in Scotland and one on currency problems in Germany.
       The beginning of the new national health service ``was 
     taking place smoothly,'' the report said. No major problems 
     were noted by the 2,751 hospitals involved or by patients 
     arriving to see their family doctors. Ninety per cent of the 
     British Medical Association's members signed up with the 
     program voluntarily--and found that they had a larger and 
     steadier income by doing so. The greatest difficulty, it 
     turned out, was the unexpected pent-up demand for everything 
     from basic dental care to pediatric visits for hundreds of 
     thousands of people who had been going without.
       The program proved successful and lasting, historians say, 
     precisely because it was not the result of an ideologue's 
     master plan. Instead, the N.H.S. was a pragmatic outgrowth of 
     circumstances peculiar to Britain immediately after the 
     Second World War. The single most important moment that 
     determined what Britain's health-care system would look like 
     was not any policymaker's meeting in 1945 but the country's 
     declaration of war on Germany, on September 3, 1939.
       As tensions between the two countries mounted, Britain's 
     ministers realized that they would have to prepare not only 
     for land and sea combat but also for air attacks on cities on 
     an unprecedented scale. And so, in the days before war was 
     declared, the British government oversaw an immense 
     evacuation; three and a half million people moved out of the 
     cities and into the countryside. The government had to 
     arrange transport and lodging for those in need, along with 
     supervision, food, and schooling for hundreds of thousands of 
     children whose parents had stayed behind to join in the war 
     effort. It also had to insure that medical services were in 
     place--both in the receiving regions, whose populations had 
     exploded, and in the cities, where up to two million war-
     injured civilians and returning servicemen were anticipated.
       As a matter of wartime necessity, the government began a 
     national Emergency Medical Service to supplement the local 
     services. Within a period of months, sometimes weeks, it 
     built or expanded hundreds of hospitals. It conducted a 
     survey of the existing hospitals and discovered that 
     essential services were either missing or severely 
     inadequate--laboratories, X-ray facilities, ambulances, care 
     for fractures and burns and head injuries. The Ministry of 
     Health was forced to upgrade and, ultimately, to operate 
     these services itself.
       The war compelled the government to provide free hospital 
     treatment for civilian casualties, as well as for combatants. 
     In London and other cities, the government asked local 
     hospitals to transfer some of the sick to private hospitals 
     in the outer suburbs in order to make room for victims of the 
     war. As a result, the government wound up paying for a large 
     fraction of the private hospitals' costs. Likewise, doctors 
     received government salaries for the portion of their time 
     that was devoted to the new wartime medical service. When the 
     Blitz came, in September, 1940, vast numbers of private 
     hospitals and clinics were destroyed, further increasing the 
     government's share of medical costs. The private hospitals 
     and doctors whose doors were still open had far fewer paying 
     patients and were close to financial ruin.
       Churchill's government intended the program to be 
     temporary. But the war destroyed the status quo for patients, 
     doctors, and hospitals alike. Moreover, the new system proved 
     better than the old. Despite the ravages of war, the health 
     of the population had improved. The medical and social 
     services had reduced infant and adult mortality rates. Even 
     the dental care was better. By the end of 1944, when the 
     wartime medical service began to demobilize, the country's 
     citizens did not want to see it go. The private hospitals 
     didn't, either; they had come to depend on those government 
     payments.
       By 1945, when the National Health Service was proposed, it 
     had become evident that a national system of health coverage 
     was not only necessary but also largely already in place--
     with nationally run hospitals, salaried doctors, and free 
     care for everyone. So, while the ideal of universal coverage 
     was spurred by those horror stories, the particular system 
     that emerged in Britain was not the product of socialist 
     ideology or a deliberate policy process in which all the 
     theoretical options were weighed. It was, instead, an almost 
     conservative creation: a program that built on a tested, 
     practical means of providing adequate health care for 
     everyone, while protecting the existing services that people 
     depended upon every day. No other major country has adopted 
     the British system--not because it didn't work but because 
     other countries came to universalize health care under 
     entirely different circumstances.
       In France, in the winter of 1945, President de Gaulle was 
     likewise weighing how to insure that his nation's population 
     had decent health care after the devastation of war. But the 
     system that he inherited upon liberation had no significant 
     public insurance or hospital sector. Seventy-five per cent of 
     the population paid cash for private medical care, and many 
     people had become too destitute to afford heat, let alone 
     medications or hospital visits.
       Long before the war, large manufacturers and unions had 
     organized collective insurance funds for their employees, 
     financed through a self-imposed payroll tax, rather than a 
     set premium. This was virtually the only insurance system in 
     place, and it became the scaffolding for French health care. 
     With, an almost impossible range of crises on its hands--food 
     shortages, destroyed power plants, a quarter of the 
     population living as refugees--the de Gaulle government had 
     neither the time nor the capacity to create an entirely new 
     health-care system. So it built on what it had, expanding the 
     existing payroll-tax-funded, private insurance system to 
     cover all wage earners, their families, and retirees. The 
     self-employed were added in the nineteen-sixties. And the 
     remainder of uninsured residents were finally included in 
     2000.
       Today, Securite Sociale provides payroll-tax-financed 
     insurance to all French residents, primarily through a 
     hundred and forty-four independent, not-for-profit, local 
     insurance funds. The French health-care system has among the 
     highest public-satisfaction levels of any major Western 
     country; and, compared with Americans, the French have a 
     higher life expectancy, lower infant mortality, more 
     physicians, and lower costs. In 2000, the World Health 
     Organization ranked it the best health-care system in the 
     world. (The United States was ranked thirty-seventh.)
       Switzerland, because of its wartime neutrality, escaped the 
     damage that drove health-care reform elsewhere. Instead, most 
     of its citizens came to rely on private commercial health-
     insurance coverage. When problems with coverage gaps and 
     inconsistencies finally led the nation to pass its universal-
     coverage law, in 1994, it had no experience with public 
     insurance. So the country--you get the picture now--built on 
     what it already had. It required every resident to purchase 
     private health insurance and provided subsidies to limit the 
     cost to no more than about ten per cent of an individual's 
     income.
       Every industrialized nation in the world except the United 
     States has a national system that guarantees affordable 
     health care for all its citizens. Nearly all have been 
     popular and successful. But each has taken a drastically 
     different form, and the reason has rarely been ideology. 
     Rather, each country has built on its own history, however 
     imperfect, unusual, and untidy. Social scientists have a name 
     for this pattern of evolution based on past experience. They 
     call it ``path-dependence.'' In the battles between Betamax 
     and VHS video recorders, Mac and P.C. computers, the QWERTY 
     typewriter keyboard and alternative designs, they found that 
     small, early events played a far more critical role in the 
     market outcome than did the question of which design was 
     better. Paul Krugman received a Nobel Prize in Economics in 
     part for showing that trade patterns and the geographic 
     location of industrial production are also path-dependent. 
     The first firms to get established in a given industry, he 
     pointed out, attract suppliers, skilled labor, specialized 
     financing, and physical infrastructure. This entrenches local 
     advantages that lead other firms producing similar goods to 
     set up business in the same area--even if prices, taxes, and 
     competition are stiffer. ``The long shadow cast by history 
     over location is apparent at all scales, from the smallest to 
     the largest--from the cluster of costume jewelry firms in 
     Providence to the concentration of 60 million people in the 
     Northeast Corridor,'' Krugman wrote in 1991.
       With path-dependent processes, the outcome is unpredictable 
     at the start. Small, often random events early in the process 
     are ``remembered,'' continuing to have influence later. And, 
     as you go along, the range of future possibilities gets 
     narrower. It becomes more and more unlikely that you can 
     simply

[[Page 2742]]

     shift from one path to another, even if you are locked in on 
     a path that has a lower payoff than an alternate one.
       The political scientist Paul Pierson observed that this 
     sounds a lot like politics, and not just economics. When a 
     social policy entails major setup costs and large numbers of 
     people who must devote time and resources to developing 
     expertise, early choices become difficult to reverse. And if 
     the choices involve what economists call ``increasing 
     returns''--where the benefits of a policy increase as more 
     people organize their activities around it--those early 
     decisions become self-reinforcing. America's transportation 
     system developed this way. The century-old decision to base 
     it on gasoline-powered automobiles led to a gigantic 
     manufacturing capacity, along with roads, repair facilities, 
     and fuelling stations that now make it exceedingly difficult 
     to do things differently.
       There's a similar explanation for our employment-based 
     health-care system. Like Switzerland, America made it through 
     the war without damage to its domestic infrastructure. Unlike 
     Switzerland, we sent much of our workforce abroad to fight. 
     This led the Roosevelt Administration to impose national wage 
     controls to prevent inflationary increases in labor costs. 
     Employers who wanted to compete for workers could, however, 
     offer commercial health insurance. That spurred our 
     distinctive reliance on private insurance obtained through 
     one's place of employment--a source of troubles (for 
     employers and the unemployed alike) that we've struggled with 
     for six decades.
       Some people regard the path-dependence of our policies as 
     evidence of weak leadership; we have, they charge, allowed 
     our choices to be constrained by history and by vested 
     interests. But that's too simple. The reality is that leaders 
     are held responsible for the hazards of change as well as for 
     the benefits. And the history of master-planned 
     transformation isn't exactly inspiring. The familiar horror 
     story is Mao's Great Leap Forward, where the collectivization 
     of farming caused some thirty million deaths from famine. 
     But, to take an example from our own era, consider Defense 
     Secretary Donald Rumsfeld's disastrous reinvention of modern 
     military operations for the 2003 invasion of Iraq, in which 
     he insisted on deploying far fewer ground troops than were 
     needed. Or consider a health-care example: the 2003 
     prescription-drug program for America's elderly.
       This legislation aimed to expand the Medicare insurance 
     program in order to provide drug coverage for some ten 
     million elderly Americans who lacked it, averaging fifteen 
     hundred dollars per person annually. The White House, 
     congressional Republicans, and the pharmaceutical industry 
     opposed providing this coverage through the existing Medicare 
     public-insurance program. Instead, they created an entirely 
     new, market-oriented program that offered the elderly an 
     online choice of competing, partially subsidized commercial 
     drug-insurance plans. It was, in theory, a reasonable 
     approach. But it meant that twenty-five million Americans got 
     new drug plans, and that all sixty thousand retail pharmacies 
     in the United States had to establish contracts and billing 
     systems for those plans.
       On January 1, 2006, the program went into effect 
     nationwide. The result was chaos. There had been little 
     realistic consideration of how millions of elderly people 
     with cognitive difficulties, chronic illness, or limited 
     English would manage to select the right plan for themselves. 
     Even the savviest struggled to figure out how to navigate the 
     choices: insurance companies offered 1,429 prescription-drug 
     plans across the country. People arrived at their pharmacy 
     only to discover that they needed an insurance card that 
     hadn't come, or that they hadn't received pre-authorization 
     for their drugs, or had switched to a plan that didn't cover 
     the drugs they took. Tens of thousands were unable to get 
     their prescriptions filled, many for essential drugs like 
     insulin, inhalers, and blood-pressure medications. The result 
     was a public-health crisis in thirty-seven states, which had 
     to provide emergency pharmacy payments for the frail. We will 
     never know how many were harmed, but it is likely that the 
     program killed people.
       This is the trouble with the lure of the ideal. Over and 
     over in the health-reform debate, one hears serious policy 
     analysts say that the only genuine solution is to replace our 
     health-care system (with a single-payer system, a free-market 
     system, or whatever); anything else is a missed opportunity. 
     But this is a siren song.
       Yes, American health care is an appallingly patched-
     together ship, with rotting timbers, water leaking in, 
     mercenaries on board, and fifteen per cent of the passengers 
     thrown over the rails just to keep it afloat. But hundreds of 
     millions of people depend on it. The system provides more 
     than thirty-five million hospital stays a year, sixty-four 
     million surgical procedures, nine hundred million office 
     visits, three and a half billion prescriptions. It represents 
     a sixth of our economy. There is no dry-docking health care 
     for a few months, or even for an afternoon, while we rebuild 
     it. Grand plans admit no possibility of mistakes or failures, 
     or the chance to learn from them. If we get things wrong, 
     people will die. This doesn't mean that ambitious reform is 
     beyond us. But we have to start with what we have.
       That kind of constraint isn't unique to the health-care 
     system. A century ago, the modern phone system was built on a 
     structure that came to be called the P.S.T.N., the Public 
     Switched Telephone Network. This automated system connects 
     our phone calls twenty-four hours a day, and over time it has 
     had to be upgraded. But you can't turn off the phone system 
     and do a reboot. It's too critical to too many. So engineers 
     have had to add on one patch after another.
       The P.S.T.N. is probably the shaggiest, most convoluted 
     system around; it contains tens of millions of lines of 
     software code. Given a chance for a do-over, no self-
     respecting engineer would create anything remotely like it. 
     Yet this jerry-rigged system has provided us with 911 
     emergency service, voice mail, instant global connectivity, 
     mobile-phone lines, and the transformation from analog to 
     digital communication. It has also been fantastically 
     reliable, designed to have as little as two hours of total 
     downtime every forty years. As a system that can't be turned 
     off, the P.S.T.N. may be the ultimate in path-dependence. But 
     that hasn't prevented dramatic change. The structure may not 
     have undergone revolution; the way it functions has. The 
     P.S.T.N. has made the twenty-first century possible.
       So accepting the path-dependent nature of our health-care 
     system--recognizing that we had better build on what we've 
     got--doesn't mean that we have to curtail our ambitions. The 
     overarching goal of health-care reform is to establish a 
     system that has three basic attributes. It should leave no 
     one uncovered--medical debt must disappear as a cause of 
     personal bankruptcy in America. It should no longer be an 
     economic catastrophe for employers. And it should hold 
     doctors, nurses, hospitals, drug and device companies, and 
     insurers collectively responsible for making care better, 
     safer, and less costly.
       We cannot swap out our old system for a new one that will 
     accomplish all this. But we can build a new system on the old 
     one. On the start date for our new health-care system--on, 
     say, January 1, 2011--there need be no noticeable change for 
     the vast majority of Americans who have dependable coverage 
     and decent health care. But we can construct a kind of 
     lifeboat alongside it for those who have been left out or 
     dumped out, a rescue program for people like Starla Darling.
       In designing this program, we'll inevitably want to build 
     on the institutions we already have. That precept sounds as 
     if it would severely limit our choices. But our health-care 
     system has been a hodgepodge for so long that we actually 
     have experience with all kinds of systems. The truth is that 
     American health care has been more flotilla than ship. Our 
     veterans' health-care system is a program of twelve hundred 
     government-run hospitals and other medical facilities all 
     across the country (just like Britain's). We could open it up 
     to other people. We could give people a chance to join 
     Medicare, our government insurance program (much like 
     Canada's). Or we could provide people with coverage through 
     the benefits program that federal workers already have, a 
     system of private-insurance choices (like Switzerland's).
       These are all established programs, each with advantages 
     and disadvantages. The veterans' system has low costs, one of 
     the nation's best information-technology systems for health 
     care, and quality of care that (despite what you've heard) 
     has, in recent years, come to exceed the private sector's on 
     numerous measures. But it has a tightly limited choice of 
     clinicians--you can't go to see any doctor you want, and the 
     nearest facility may be far away from where you live. 
     Medicare allows you to go to almost any private doctor or 
     hospital you like, and has been enormously popular among its 
     beneficiaries, but it costs about a third more per person and 
     has had a hard time getting doctors and hospitals to improve 
     the quality and safety of their care. Federal workers are 
     entitled to a range of subsidized private-insurance choices, 
     but insurance companies have done even less than Medicare to 
     contain costs and most have done little to improve health 
     care (although there are some striking exceptions).

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