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August 14, 2009

BILL MOYERS: Welcome to the JOURNAL.

I'm okay with protest. Sometimes I wish I'd done more of it myself when I was young.

But it's hard to reason with someone who's packing a gun. That's why I found so menacing that photograph of the fellow standing outside President Obama's town hall meeting on health care in New Hampshire this week with a 9mm pistol strapped to his thigh and a sign quoting Thomas Jefferson on watering the tree of liberty with the blood of tyrants and patriots.

Knowing from his MySpace profile that he admires white supremacists, it made me queasy to see that man standing there, pistol at his side. Of course he's exercising his Second Amendment rights under the Constitution and he has a carry permit. But still…

The protesters I admire are those unarmed men and women who put themselves in danger for Civil Rights. And the Suffragettes, marching for the right to vote. And the veterans of the Bonus Army who camped out in Washington after the first World War when the government defaulted on its obligations to them. And those who spoke out against the Vietnam War. I've been haunted for years by the image of the pacifist who doused his clothing in kerosene and burned himself to death beneath Robert McNamara's Pentagon window in 1965, soon after I'd had a meeting in that very office. Some said he was delusional, but his wife said he was expressing "His concern over the great loss of life and human suffering caused by the war in Vietnam." Over the years I came to better understand the deeply moral grounding of his anguished martyrdom.

PROTESTORS: No more Obamacare. Just say no! Just say no!

BILL MOYERS: So you can see, perhaps, why it's hard even to describe as protests what's happening today -- the raucous disruption of town meetings that deny others their right to free speech. The cries of tyranny, the analogies to Hitler on the signs and in postings on the internet. That's not conscience at work; it's the product of colicky, cranky unconscionable anger, fueled by lies.

Here's Newt Gingrich dissembling on health care. Yes, the same Newt Gingrich, once disgraced, now back on the Sunday talk shows like Napoleon returning from Elba.

NEWT GINGRICH: You're asking us to trust turning power over to the government when there clearly are people in America who believe in establishing euthanasia including selective standards.

BILL MOYERS: Remember, this is from the man who told the New York Times in 1994 that he would use opposition to Clinton's health care reform as "…a springboard to win Republican control of the House." That's exactly what he did - and hopes to do again.

Oh, I forgot Sarah Palin, who, like Gingrich, is also vying to speak for the extreme right of their party. She noted on her Facebook page that, quote, "The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama's 'death panel'… Such a system is downright evil." She said.

Death panel? We have nothing to fear but fear mongering itself.

Even in the hallowed halls of Congress, the cuckoo flu seems to have reached epidemic proportions:

REP. PAUL BROUN: This program of government option that's being touted as being this panacea, the savior of allowing people to have quality health care at an affordable price, is going to kill people.

BILL MOYERS: Throughout our history, there's a thin line between hot-headed, partisanship and deeply ingrained paranoia. Yet what are we really talking about? Nothing less -- or more -- than trying to do a civilized thing -- stem the exorbitant costs of a health care system that routinely victimizes those without the wherewithal to check into a hospital when they're sick.

How to make sense of all this? I put out an SOS for my two guests. They're just what the doctor ordered.

You'll recognize Kathleen Hall Jamieson instantly -- she's been at this table often, making sense of politics and the press. She is director of the Annenberg Public Policy Center at the University of Pennsylvania, which runs, a non-partisan research organization that tests the accuracy of our political discourse. Among her many books is my favorite, UNSPUN: FINDING FACTS IN A WORLD OF DISINFORMATION.

Drew Altman is President and CEO of the Henry J. Kaiser Family Foundation, widely respected for its independent research and information on American health care. The foundation runs a superb, impartial website that looks at the health care reform advertising blitz and measures claims against the truth -- check it out via our website at

Welcome to you both. You're just in time.

Thank you.


BILL MOYERS: We're seeing this debate take a really ugly turn. Let's take a look at how ugly.

CROWD: No more Obamacare! No more Obamacare! No more Obamacare!

PROTESTOR MALE: Tell me what page it's on. What page is it on?

REP. JOHN D. DINGELL: It is in the bill.


REP. JOHN D. DINGELL: Go and sit down.

PROTESTOR MALE: You want to talk about conspiracies? I'll tell you about conspiracies!

PROTESTOR MALE: One day God's going to stand before you and he's going to judge you.

CROWD: Kill the bill! Kill the bill! Kill the bill!

PROTESTOR FEMALE: I want to know if it's coming out of my paycheck? Yes or no!

REP. JOHN D. DINGELL: Your employer supports the bill.

PROTESTOR FEMALE: I want an answer to the question!

BILL MOYERS: Kathleen, what's playing out here?

KATHLEEN HALL JAMIESON: People who are angry and frustrated and not necessarily well informed in part driven by people who are on the other side of the reform effort. And it's driving into news evocative visuals that are leading the public, I think, to overgeneralize the extent to which there is principal, reasoned dissent from health care reform.

It's part of our democracy, but I think it's actually kind of sad because the left, doesn't like this legislation a lot. They're not really enthusiastic about it. They would prefer a single-payer approach with more government. And on the conservative side, they're not crazy about it either. They would like a market approach, people getting vouches or a tax credit and just shop in the marketplace. This is down-the-middle legislation. And yet we see these fears and concerns as if this were a radical approach. It's not a radical approach. It's just a down-the-middle approach.

KATHLEEN HALL JAMIESON: But you're also seeing something else. In your clip you see a woman who says, "Is it coming out of my paycheck?" She's raising a legitimate question. But when people are shouting at each other, the answer doesn't get through. And when you're impugning the integrity of the person who's answering the questions, the member of Congress, that person's response isn't going to be believed if it is able to be articulated and isn't simply shouted down.

And so it's not creating context in which misinformation on both sides can be corrected. And that's the problem. We don't have a deliberative process here taking place in public to inform public opinion.

Instead, we're potentially distorting it.

But I think what also happens is, the concerns of most Americans, of average Americans, just get lost in this process. This whole debate began because of the real problems and worries that average people are having paying their health care bills. And what we really have here are the strong concerns and fears-- and you don't want to minimize them; it's part of our democracy-- that some people have about this legislation.

But the worries that average people have that we see in our polls about paying their bills get lost. And in instead we're debating other things, fears that people have that really aren't there in the legislation.

BILL MOYERS: How do we decide who these people represent? I mean, are they just a fringe element that are like honey to the cameras of the press? Or is there something else going on that's difficult at this moment to measure?

KATHLEEN HALL JAMIESON: I'm not sure that we should be trying to measure it. I worry about public opinion polls coming into this environment and asking questions that may actually distort our understanding of what the public knows. Unless you start by asking the public in a poll what they know, what the baseline level of knowledge is, it doesn't matter what the public thinks ultimately about a piece of legislation or not because you can be reflecting uninformed public opinion.

But the nature of public opinion it's expressed in "USA Today" in-- at a front-page piece that appeared on Thursday of this week which says "Protests Tilt Views on Health Care Bill." Now that's reflecting the results of a poll that asked about people's response not to the health care bill but to the protests about the health care bill.

But the headline leads you to think it's about the health care bill itself. And it suggests that public opinion is now shifting dramatically away from the Obama health care reform efforts.

BILL MOYERS: So the protests seem to be making some people more sympathetic to the protesters?

KATHLEEN HALL JAMIESON: And potentially the press then picks that up, polls, finds that sympathy, creates a structure that suggests that health care reform initiatives are losing support. Now polls have driven press coverage which says "Obama on the defensive. Obama struggling to explain. Obama trying," when, in fact, the dynamic under that has been created by a news structure that decided to cover this in a certain way, to do polling in a certain way. And those two things played into the process to make it more difficult for the discussion to actually happen about the substance of what's going on.

So it's exactly right. So we have the protests, the media coverage, especially the 24-hour news cycle, follows the protests and the town meetings. Then the polls poll about the media coverage of the protests. And we create almost an alternative reality about what is occurring out there.

When you look at the real polls about where the public actually is, what you see is there's been a little bit of a tick down in public support and people are getting a little anxious as they follow the media coverage. But still the majority of the American people are for moving forward with this.

And we have seen more people begin to say, "Gee, I'm not so sure that this is good for me and my family," but it's still a small number. It's only 20, 22 percent who say, "I'm a little bit worried about this." And a much bigger number say, "I still think this is good for me and my family." And then you've got a group in the middle who's not so sure. And everyone's fighting for that group on both sides.

KATHLEEN HALL JAMIESON: And imagine if you're trying now as just a person who's sitting in your home and you do all sorts of other things, you have a job, you have children, you know, you have all sorts of concerns. And what you get of this debate is what comes through news. The pictures that you're seeing are-- because the news is focusing on conflict and attack, are a very angry people shouting at representatives.

First, no substantive information. But secondly, what aren't you seeing? Well, you aren't seeing something that actually was featured on the front page of "The New York Times" this week. "Free health care draws thousands. Thousands of people came to the forum in Englewood, California, for free dental care and free medical and vision services." People at protests-- people protesting health care reform shouting at legislators as opposed to people waiting for free health care and dental care--

Who can't afford it otherwise.

KATHLEEN HALL JAMIESON: Who can't afford it otherwise.


KATHLEEN HALL JAMIESON: Now suppose we saw more of these pictures and fewer of those or just a balance of the two. You'd have a completely different sense of what's at play in the debate. Pictures matter. Evocative visuals lead us to generalize to what's important to the framing of the debate, how we should see this discussion. And also they help shape the answers to those public opinion polls. More pictures of people dissenting, more sense that maybe we should hold back a little in our support. More pictures of people in need of care, people just like us who don't have it, greater sense that maybe there's a social concern here. And then the question might I, the insured, at some point be in that situation?

And you really got to feel bad for just the American people who, from the beginning, have just been trying to answer one question. Will this help me with my health care bills? That's the question they're trying to answer.

And so they're turning on the television and they're seeing a debate about whether this is Russia or it isn't Russia and whether there are death panels and whether it's a government take over of the health care system. And they just want to know "my premiums are going up $1 thousand every five years. And is this going to help me with that 'cause I can't pay my rent or my mortgage? I'm having trouble paying for my food because of my health care bills." That's really the question they want answered.

BILL MOYERS: Some of it depends upon how well the member of Congress handles the protest. I saw one this week in which Senator McCaskill of Missouri did quite well. Take a look.

SEN. CLAIRE MCCASKILL: We will not get a single-payer bill, nationalized health care system out of Congress. It's not even on the table… I don't understand this rudeness. What is this? I don't get it. I honestly don't get it. Do you all think that you are persuading people when you shout out like that? Beg your pardon? You don't trust me.

BILL MOYERS: Some of those protesters, some of the loudest protesters, were advocates of a single-payer nationalized plan that-- which she said is not going to happen. So what do you think about how she handled that?

KATHLEEN HALL JAMIESON: Well, first, there is a way to structure these encounters in which you increase the likelihood that the person who is there to speak for the Congress, in this case Senator McCaskill, actually is able to control the microphone.

And in part in this structure in the rooms of some of these members as they talk to audiences is set up for confrontation because the member is standing there in the same environment, looking face to face with all these individuals. And once you get into that range and cameras come in, you can hear the shouting out at the same moment you hear the member's voice. And as a result, the member doesn't control the environment. She's controlling the environment.

But more importantly, she, across the last week, has held a number of forums in which she's had a chance to explain in depth at longer-- in longer periods than this the substance of the various pieces of legislation and debunk misinformation. That's the way democracy should work. And that the attacks are coming from both the left and the right is an important realization. There's been a tendency in news to feature those that are coming from the right without indicating there's substantial dissatisfaction from some on the left about the fact that this isn't single-payer at the time which those on the right that, yes, it is; it's Canadian style socialized medicine. That is going to produce all sorts of bad outcomes that, in fact, don't occur in Canada or Great Britain, in fact.

It's revealing that in this clip, the single-payer advocates were so upset with the Senator because it just makes the point that both the folks further on the left and on the far right are equally dissatisfied with this legislation.

I'd like to make just one other point about this bill, which is that they're all doing town meetings. And these town meetings, of course, bring out folks who are most interested in the issue on the right and on the left.

And that leaves the President alone as the national communicator about health reform. And it might have been helpful if some of these members in the Congress who are putting this legislation together also played a role as national explainers of what's going on with health reform because, again, the President is by himself as the national explainer of this issue.

BILL MOYERS: But how do you explain that he has lost control of the message? I mean, he's got the biggest pulpit of all. And yet he's not determining this narrative right now, right? How did he drop the ball?

KATHLEEN HALL JAMIESON: He's lost the message in news. He didn't lose the message in his town hall earlier this week when he spent much of the time in the town hall explaining the legislation and arguing that the status quo is scarier. If we don't change, it's scarier than if we do change.

And he did it in detail and he did it very effectively. News then comes in and plays that town hall as Obama on the defensive, trying to explain his message.

And so what happens is the few who watch the town hall get the whole context. That was an effective town hall for President Obama. He made one serious error when he suggested AARP had certified the legislation, that the legislation would not produce cuts in Medicare, when in fact it has not endorsed any legislation.

That also then is featured in news. But those who watched the whole town hall I think reasonably would have concluded a strong case was made that keeping the status quo, not putting change in place, was scarier. What was going to happen in the future is scarier for those with insurance than it would be if we made the change.

I think, in addition, what happened is for a time the experts' agenda and the policy makers' agenda on Capitol Hill hijacked the public's agenda.

BILL MOYERS: What do you mean?

Because the focus became about bending the curve and health information technology and the policy makers' understandable interest in reducing the federal deficit in the future.

And now, as you may have noticed, they brought the discussion back to the concerns of the people, which brought us this debate in the first place. And so the language has changed. It's now about health insurance reform and not about health reform.

BILL MOYERS: Take a look at this montage.

PRESIDENT BARACK OBAMA: And that's why we are going to pass health insurance reform in 2009[…] Now when we pass health care reform, insurance companies will no longer be able to place some arbitrary cap on the amount of coverage you can receive, in a given a year or a lifetime[…] we are closer to achieving health insurance reform than we have ever been[…]every time we come close to passing health insurance reform, the special interests fight back with everything they've got.

BILL MOYERS: Health insurance reform. Not health care reform. What's the strategy behind that?

KATHLEEN HALL JAMIESON: People like their health care. They don't want their health care reform. The problem is one of access and cost. And they mis-framed this debate in 1993, '94 by talking about health care reform. Early in this debate--

BILL MOYERS: The Clintons?

KATHLEEN HALL JAMIESON: Yes. Early in this debate, talked about health care reform brought up all the wrong associations. If it's health insurance reform, then who's potentially the enemy? The insurance industry. Who's rationing care? It's the insurance industry. Who should we be concerned about bringing under control? The insurance industry. They're the ones who stand between you and your doctor.

Obama's coming in to interdict that. He's going to get this under control. It's a very important reframing.

I think this is really critical because this wasn't the debate drifted for a while and the message drifted for a while. It wasn't defined in terms that average people could understand. So they couldn't answer--

BILL MOYERS: You're including me in that. I'm serious about that.

And maybe I--

KATHLEEN HALL JAMIESON: I think you're including all of us in that.


So people just couldn't answer the question, "What does this mean for me and my family?" And so they didn't know what they had to lose if this didn't happen. But more importantly, that left the field open for the critics and the opposition to define it the way they wanted to and even to scare people a little bit that this might be a government takeover of the health care system. Or a bureaucrat might get between you and your doctor.

People couldn't say, "No, I want to fight for this because I know what I'm going to get. I'm going to get some help with my bills." Or "I'm going to get-- the insurance system is going to change. And if I get sick or if I have cancer or heart disease, I'm going to be able to get health insurance and they can't drop me. Or I can change jobs and I'll still have health insurance coverage."

They didn't know what they would get. They didn't know what they might lose if this didn't pass. And that now is changing. In a sense, what happened was the media and the debate focused on the issues which were in contention on Capitol Hill, that they were debating on Capitol Hill, because media coverage follows the controversies instead of the people issues that brought us this debate in the first place.

BILL MOYERS: Let me show you the ad that the liberal group is running-- taking on the insurance industry in the vein of what-- Obama was saying in Portsmouth, New Hampshire this week. Take a look.

ADVERTISEMENT: They are enormous and powerful. They prey on our weaknesses, trying to separate the healthy from the sick. Their strategy is to confuse and exhaust their victims. And they kill people each year by denying coverage while profiting billions. During shark week, let's take on the real predators: health insurance companies. Call Congress, tell them: don't put insurance profits before health care. Support a real public option.

KATHLEEN HALL JAMIESON: It's an evocative image, the idea that the health insurance industry is a shark about to devour you. But what-- as it plays with you beforehand, it's certainly one that's memorable. I don't think it's fair to suggest that they're killing people. There is a process in place, however, in which if the public option is robust in this health insurance plan, it does dramatically change what they are able to do.

And we could come out of this reform scenario with a world in which things are much better for the insurance industry but don't necessarily accomplish the objectives that President Obama has if the public option is taken down by arguments that it's government takeover or socialized medicine or whatever.

I think the public option is an important piece in cost control and in insuring long term that the insurance industry, which has many positive aspects, but that the insurance industry is as competitive as it ought to be but also to treat people fairly

You know, one side says it's a government takeover of the health care system. And the other side says, "Well, then you'll just be left at the mercy of the sharks in the health insurance industry." That's messaging. It's standard health reform messaging. Whether there is or isn't a public option in this legislation, it would fundamentally change how private health insurance works in a way that would be better for people. That's the substance of the legislation.

BILL MOYERS: How do you explain the disinformation and the misinformation? You had Representative John Mica this week saying that Obama's plan creates a new cottage industry of death counselors. You've got Sarah Palin, Newt Gingrich talking about euthanasia. What-- how do you account for that? And how does the press break through and the average citizen break through to understand that that's a lie?

KATHLEEN HALL JAMIESON: That's one of those claims generated because a provision in the bill has meant-- a provision of one of the bills has been seriously distorted. But in this case, news organizations have actually done a very good job debunking the claim. If you just simply count up the number of news organizations that have taken that on, gone to the provision, said, "It's not there; here's what this is," you'd say news has done a pretty good job.

Why is there still misinformation out there? Because you have in these news accounts of the town halls people still shouting about death counsels or death panels. And as a result, it's still getting through in news despite news's own debunking of it.

BILL MOYERS: So it's an effective strategy?

KATHLEEN HALL JAMIESON: Any strategy which takes the White House off message and puts the President in the position of having to deny the death panels are in a bill is an effective strategy for the opposition. It takes something which is a tiny, tiny, tiny misleading piece of one piece of potential legislation and blows it up into being, in effect, the intent of the bill, killing grandmother.

But there's a deeper issue, I think, which is not just debunking the myths and doing the fact checking, which is critically important. But it is how much and how often you cover the town hall meetings and spend time debunking the myths and doing the fact checking because the more you cover it, the more the focus becomes the ads and the town hall meetings. Even if you're fact checking and even if you're providing the facts, you create unease among the American people that there is something wrong here, that there is a debate that there may not actually be about these facts. And that unease grows. And we see that in our polling. We do a tracking poll every month on this. And you can just see that anxiety growing in the American people.

BILL MOYERS: So the fear mongering is working?

I believe that this will turn, as much as anything, on the media coverage of this. And it has in the past. And the media has a set of important decisions to make not just about getting to the facts as opposed to covering "he said this and she said that," but how much they cover the town hall meetings, how much they cover the ads, as opposed to looking at the legislation and also covering what's in it, what it means for people.

BILL MOYERS: Well, there's not any legislation yet, as you have--

Well, we have five bills and we'll--


--maybe get to two and then to one. But we'll see.

KATHLEEN HALL JAMIESON: And I predict end-of-life voluntary private counseling I bet is not going to be in the final legislation.

BILL MOYERS: Euthanasia?

KATHLEEN HALL JAMIESON: And I bet the word "euthanasia" is not ever going to appear in a piece of legislation.

Somebody may make a decision that having voluntary counseling just isn't worth it.

BILL MOYERS: I don't know why they included that in the bill.

DREW ALTMAN: It was a Republican…

BILL MOYERS: Yeah, yeah, exactly. Now he's backing away.

KATHLEEN HALL JAMIESON: You know, I know why. The-- everyone who has worked with elderly parents or foresees a point at which they are going to have to be making these kinds of decisions has thought about end-of-life issues.

BILL MOYERS: I had my mother when she was dying, you know? I had to face that. You--

KATHLEEN HALL JAMIESON: Well, and we-- we've all been in this kind of a situation. And we're going to be personally affected by this at some point. And wouldn't you like to have at that point the-- the ability to say that-- that that discussion you'd like to have with your doctor about what the options look like? Do you want to stay on a ventilator under these kinds of circumstances? You know, what kind of heroic means do you want in case, you know, you were in critical life support failure? How much resuscitation do you want? Do you want a do-not-resuscitate order or not?

Do you want that encounter with your physician, when the physician's explaining what that means paid for or not? I can see someone sitting in a room saying, "Why would we want to deny people the opportunity to take advantage of that medical exchange and have it covered?" Why wouldn't you want people to know about hospice, which is a--

Yeah, they--

KATHLEEN HALL JAMIESON: --a wonderful movement in this country that has done more--

They genuinely thought it would be helpful.

BILL MOYERS: Yeah, okay.

KATHLEEN HALL JAMIESON: And I don't think they heard the possibility that this well-intentioned and I think completely appropriate move would be translated into killing grandmother. And I'm interested, by the way, in which no one's hypothesizing killing grandfather.

BILL MOYERS: Well, I think there are too many grandfathers in Congress in control of the legislation. I mean, but the truth of the matter is no good deed goes unpunished, right?

Well, I don't think we anticipated. In the past, these debates were about health care's legendary interest groups and raw politics. But, you know, there is a deep strain in our country. There was a debate once about fluoridation, just fluoridating the water supply. And it became a debate about this being a Communist plot. And I think the people at these town meetings--

BILL MOYERS: Ah, democracy--

--believe these things. This is our country.

BILL MOYERS: What do you think when you hear protesters standing up at these town hall meetings say, "Keep your cotton-picking government hands off my Medicare?" What's going on there?

KATHLEEN HALL JAMIESON: I love the fact that those people love their Medicare because it provides the basis ultimately for a turn in this argument to explain how similar part of these proposals to their Medicare. It actually is reassuring to me, not that they're misinformed and don't realize that Medicare is government based but that the Medicare model is, in fact, the model under the public option essentially.

You know, facts are useful here. While this legislation does involve a significant expansion of government financing for coverage for people, it's useful to point out that the lion's share of the coverage is private coverage, which is why many people think the private insurance industry is supporting this legislation and they are because they get more paying customers.

And while there is a debate about the public option in this legislation, one, it isn't clear that a public option will materialize in the final legislation 'cause many people are against it. And the Congressional Budget Office has actually estimated looking at the House bill that if there is a public option under the rules and I won't go through the details of how it will work, potentially by 2019, which is a ways off, maybe nine or ten million people might enroll in that public option. So that could hardly be construed as a government takeover of the health care system.

BILL MOYERS: Yes, Drew, but what people on the left say, liberals and people even further left, say that what this legislation threatens to do is to require citizens to subscribe to insurance under the insurance company. And without a public option, the insurance company has a captive constituent.

One the reasons for that is in order to do the reforms of the health insurance system, how health insurance works, which everyone benefits from. It's the one part of this legislation that helps everyone. So you can't be turned away if you get cancer or heart disease or if you're sick. You'd have to have a big pool, so you spread the risk that way so that those of us who are healthy are subsidizing those of us who are sick because we, too, may get sick some day. So that's the reason for the requirement that everyone's in.

BILL MOYERS: Is it a legitimate concern that if I'm required by government to have insurance and the only people selling that insurance are insurance companies, then I'm their captive?

Well, what it really means then is we have to be-- I think this is the next shoe to drop in this debate, once we get past five bills and we can focus on what are the details of health reform, health insurance reform sorry, legislation is, there'll be a set of rules about what are the minimum benefits that need to be provided so people are adequately protected? What's the basic plan that people will get? What are the subsidies that people are going to get? And will the subsidies that people get be adequate so that now they're going to be required to have health insurance coverage, they can actually afford that coverage?

And when we see the details of the legislation, when we get to a House bill and a Senate bill and a final bill, I believe everyone will be focused on that question because something on the order of 30 million people-- it could be more or less depending on the details-- will be in these so-called exchanges buying mostly private health insurance policies and will be able to look at that. And another maybe 11 million people will be getting their coverage through expansions of the Medicaid program. So there'll be a lot of people who are affected by that.

KATHLEEN HALL JAMIESON: But there's one other issue. It's not simply going to be will individuals be able to afford it under a mandate, but will government be able to afford it? Will we collectively, as the taxpayers, be able to afford? And one of the things that is legitimate underlying the protests in these encounters with members of Congress is a concern about the cost. Can the government continue to carry these gigantic deficits? Will the--

BILL MOYERS: A legitimate question.

KATHLEEN HALL JAMIESON: And those are very important questions. And it-- when the CBO has scored--

BILL MOYERS: Congressional Budget Office.

KATHLEEN HALL JAMIESON: --existing legislation, it has suggested that some of the projections were overly optimistic. And as a result, that we may not yet be in a situation in which Obama, President Obama, can deliver on his promise that this will be deficit neutral over ten years. And then it's possible that they get to being deficit neutral over ten years. What about the out years? What about the years beyond ten years?

We're in a situation that we wouldn't have been in were it not for many of the decisions of the Bush administration. But the deficit now is a serious issue with real economic consequences in the long term. And when you hear individuals in these exchanges with members of Congress saying, first, we had the big bailout. Then we had the big stimulus. Then we had cash for clunkers. How are we going to afford that? What are you passing on to my children and grandchildren? And what's it going to cost me as a taxpayer? Those individuals are asking legitimate important questions and as are the Republicans who are concerned about how this is going to be paid for long term. That's helping to restrain the process to increase the likelihood that everybody is going to be honest when they look at the CBO numbers, the final piece of legislation, to see what the effect is on deficit and debt long term.

And it needs to be said that there are legitimate reasons why conservatives, be they Republicans or blue dog Democrats or any conservative could be against this legislation. It's just not death panels or government takeover, but there are legitimate reasons they could be against it. The policy makers who are putting this together are absolutely committed to doing this in a deficit neutral way.


Meaning that they will pay for it through a combination of savings measures and new revenues.

BILL MOYERS: It will not contribute to the increased deficit?

KATHLEEN HALL JAMIESON: Over the first ten years.

But there's a bit of a catch here. First, though, that's the biggest challenge they face. Of all the challenges they face, the toughest one is financing, financing, financing. It is coming up with that list of savings measures and new revenues that really is the toughest nut to crack. And that's what they're working away at.

KATHLEEN HALL JAMIESON: I think that you've got a real problem with cost shifting in this country. It's not as large as the administration has made it out to be. But when people come into hospitals without insurance and they are helped in the process, as they should be, that cost goes somewhere and it comes off into the people who are insured through some mechanism. I think we ought to be concerned about what that does economically in the long term, also what it does to the well being of those who come in without insurance and, as a result, get care later with a worse prognosis.

We ought to be concerned about that because we're moral human beings. But when Obama, President Obama, makes the big argument which says our economic future is dependent on fixing this, if he could make that single case, he could justify putting this through even if he couldn't in the process guarantee deficit neutrality across a period beyond ten years. He hasn't persuasively made the case. But imagine if he could persuade you that we've got another kind of economic meltdown coming because we're not fixing this piece of our own economy. And he makes the case to you, we could forestall that. Or if it were to happen, it wouldn't be as bad if we fixed this. Wouldn't you find that a persuasive argument? I think there's a case to be made, and I think it's a challenge to him to make it.

BILL MOYERS: What will each of you be looking for as Congress comes back into session on this issue?

I would look for-- I think two things. One, obviously, have they weathered this storm during the recess? Does it unravel or does it move forward still? I'm certain it'll move forward. I'm pretty confident it will move forward. Let me put it that way.

And then secondly, when they put the legislation together, have they found a way to pay for it? And what is the tradeoff between lowering the price tag of paying for it, which they're trying to do, and the benefits people get? And when we look at that, does it still meet the expectations of the American people for the help they're looking for with their health care bills?

KATHLEEN HALL JAMIESON: I'm not looking for what Congress does, but I'm looking for the signals that are sent to the public by groups the public trusts. If the final legislation comes forward and the AARP has actually endorsed it, then you have a powerful signal to seniors that there's nothing here that's going to hurt you.

If a Concord Coalition, which cares a lot about deficits, has said this final legislation has gotten the cost drivers under control and hence long-term costs under control, that in fact this will help address the problem of rising costs, and if the AMA and the nursing associations are also on board, then I think you'll have reassurance that you've got two important groups in the health care equation saying, "We don't think that our relationship with our patients is going to be hurt by that or our ability to do our job." I'm going to look for those four signals that they've got a good piece of legislation. And I think if you've got those four signals, much of the details can fall to the side because you've got a lot of reassurance going out to the public that it's not as scary as the extremes on either side would argue.

BILL MOYERS: Drew Altman, Kathleen Hall Jamieson, thank you for being with me on the Journal.

Thank you, Bill.


MAN: I want everybody to be as courteous and as civil to everybody else as possible.

CROWD: We won't go, we won't go! Angry Mob! Angry Mob!

BILL MOYERS: I was looking at the website the other day and was stopped by the question: What if we win the health care fight? What happens then?

The writer, David Frum, went on to warn his fellow conservatives to be careful what they wish for. David Frum is with me now. He's the Canadian-born journalist who became a speechwriter to President George W. Bush, the first insider to write about that administration. This is his book: THE RIGHT MAN: THE SURPRISE PRESIDENCY OF GEORGE W. BUSH.

Now a resident fellow at the American Enterprise Institute, David Frum edits, which is "dedicated to the modernization and renewal of the Republican Party and the conservative movement."


DAVID FRUM: Thank you, Bill.

BILL MOYERS: What did you mean conservatives should be careful what they wish for?

DAVID FRUM: Well, let me invite you, just for a minute, to imagine yourself a conservative Republican and looking back on the history of the past decade. And as you look back at it, you know, what was one of the greatest points of vulnerability of the Republican record as they went into the 2008 election cycle? It was the stagnation of wages that occurred between 2000 and 2008.

Basically, the typical American worker was making no more money in the year 2007, before the crisis, than in the year 2000. Why not? It's not that employers weren't paying more for labor. They're paying a lot more for labor, about 25 percent more.

All of that increase in the wage fund was consumed by the cost of benefits. So Republicans went to the country with a very dismal economic record in large part because of the explosion of health care costs. Let me give you another thing to think about from a Republican point of view.

We believe in tax cuts. Conservatives want to lower taxes. Yet the Bush tax cuts are slated to phase out in 2010 and 2011, whatever the Democrats do. It's just automatic. Why was the tax cut written that way? It was the rules of Congress to make sure there wasn't an explosion of the deficit, require the tax cut to be phased out because of the remorseless rise in the cost of programs like Medicare and Medicaid. If those programs don't stop increasing in costs, there will never be another tax cut. And we are going to be faced with government taking an ever-larger share of the nation's economy.

BILL MOYERS: So if the Republicans win this health care fight, by that I think you mean if they just simply defeat whatever the Democrats propose, right?

DAVID FRUM: Republicans-- there are many Republicans who fantasize about a repeat of 1994, when the Clintons' plan was defeated and Republicans went on to win back both houses of Congress, forgetting that 1994 was the end of a very long period, more than 40 years in the case of the House, of Democratic rule, that that was a very weak majority anyway. This is a young and strong Democratic majority. And they also remember 1994.

They're going to pass something. So the question for Republicans is what do you want that to be? You have an interest here, too. You would like to see the rise in health care costs slow. And you would like to see more room in the federal budget for tax cuts in the future. There are some mistakes in the way that President Obama has presented his case that have made him vulnerable.

You know, he's made it very clear why his health care reform will be good for the federal budget. He's not made it so clear why it would be good for the typical person. That's a point of vulnerability. But if the Republicans win, this is not going to be a great victory for individual liberty. It's going to be a victory for the status quo. The people who are angriest in those town halls are people who have an excellent deal on Medicare who are determined to protect it.

You can't blame them. People are very attached to what they have. But understand the message the political system will take if Obama is defeated is not let's have a lot more free market individualism. The message the political system will take is never tamper with Medicare again unless it is to make it more generous. From a conservative point of view, from a Republican point of view, is that a good message?

BILL MOYERS: You mentioned the Bush tax cuts. You were in the White House at the time those were implemented. And they are due to lapse next year. Isn't that lapse a good thing because we need more revenue to pay for the health care system that even you want to reform?

DAVID FRUM: I would like to see those tax cuts continued. Especially the tax cuts on capital gains and on dividends. Those are, I think, really important to the future growth of the American economy. And it is precisely in order to protect, the rising costs of health care have to be restrained. If health care costs continue to grow as they have been growing, there will never be another tax cut ever. And the level of taxation to the economy is bound to rise and rise and rise.

The thing that is so hilariously grimly ironic about this debate, whatever you think of the Obama plan-- and I don't-- well, there isn't an Obama plan.

BILL MOYERS: The five plans on the Hill right now.

DAVID FRUM: The House plan, which I don't much like. Which is the most finished plan we have. When the President talks about it, he talks about that plan using arguments that I think ought to resonate with conservatives and Republicans. He talks about the federal budget. He talks about the cost to employers and to small business. And those are real concerns, even if you reject his solution, which I hope will happen. There are other parts of the Congress, like the Senate Finance Committee, that can produce responses that reply to the valid concerns the President is raising, concerns, by the way, tormented Republican presidents before him.

BILL MOYERS: So what's the plan you would like to see the Republicans put on the table?

DAVID FRUM: Well, let's start by focusing on what do you think is the problem? You can't solve a problem unless you agree on what you're trying to achieve. The Republicans are not the party of equality. They're the party of liberty and they're the party of efficiency.

BILL MOYERS: And liberty leads to inequality.

DAVID FRUM: Liberty leads to inequality just as attempts to reduce equality lead to adoption of liberty. And it is that tradeoff that is why you have two parties so that the country can come to its balance. Especially in this health care debate, we are talking a lot about efficiencies.

Why is the American health system so crazy? Why do Americans spend so much more than anybody else for outcomes that aren't a lot better? Well, we talk about the health market. We don't have a health market. We have 50 state markets.

And although there are many, many insurers, in many states there are only one or two who are active. So what we need to do, first of all, is create a national market. I would like to see the responsibility for regulating health care removed from the states entirely and put in the hands of the federal government.

We don't regulate banking at state level anymore because it doesn't make sense. That should be true with insurance as well. The federal government should set rules. Here are the requirements for what a health plan should look like.

BILL MOYERS: Now you've just lost some of your conservative allies--

DAVID FRUM: But the state--

BILL MOYERS: --because you're calling for more regulation.

DAVID FRUM: No. Different locus. The states regulate it right now. And they regulate it in incredibly detailed ways. They say in some states that infertility must be covered if anything is and other states not. In some cases, if a woman has a mastectomy, the plan must cover reconstructive surgery. In other states, not.

In some cases, there's community rating. Everybody must be charged the same price. In other states, there are different systems. So from an insurer's point of view, they have to write a completely different set of offerings for Maryland from Oregon, from New York, from New Mexico. And the result is that you have these segmented little markets. It's a case for free trade to say let's begin by opening up a national market.

BILL MOYERS: If you eliminate regulation at the level of 50 states, aren't you giving the insurance industry more clout at the national level?

DAVID FRUM: It's a downside risk that you would have much more regulation at the national level. But just think about it. If we had 50 different mileage standards in this country, if we had 50 different sets of rules to describe what could and couldn't go into toothpaste, we would just collapse the national market. The reason almost every product is cheaper and better and more convenient in the United States than it is in other places is because of the size of the national market. No surprise that when the national market is cut up for one product, that is the product that is the most troublesome.

A second immediate thing, if you're self-employed, the way more and more people are-- and you want to go buy a plan, you'll have to play with after-tax dollars. Employers buy with before-tax dollars. If you're a small business, you get a much worse deal than big businesses. We need to regulate, level this field. One of the ideas that originates with the Heritage Foundation that was adopted by Republican Governor Mitt Romney are these health insurance exchanges that allow individuals and small business to buy on more equal terms. Again, that can be nationalized and made-- that's, by the way, in the Obama plan.

BILL MOYERS: Right. Health exchange.

DAVID FRUM: Health exchange. We need to begin to sever the link between employment and insurance. It is just-- it's a holdover irrationality that you get your insurance through the place where you work, that discourages people from leaving. People who get ill, when they're at a job are then indentured because they can't-- so long as they can work at the old company, they are covered under the old plan. If they move, they can't get a new one. And there-- and that is an artifact of the tax code. And we need to correct the elements for the tax code that do that.

Breaking the link between employment and coverage. We have a terrible problem right now with the cost of Medicaid are divided between the federal government and the states. This is a formula, always, for irresponsibility because the people who are not only-- are states spending 50 cent dollars or in some cases less, but worse, when it comes time to cut budgets, a state, especially a state that gets a lot of money from the federal government, says, "If we take dollar out of Medicaid, we buy a dollar's worth of political pain. And yet we only get 40 cents of budgetary benefits." So that makes no sense. And so Medicaid ratchets endlessly upwards with no one really in control of it. We need, I think, to have to locate Medicaid either with the states or with the federal government, not continue to divide them.

BILL MOYERS: What about a public option that would provide a government competition to the health insurers? It would not end private insurance, but it would provide competition, which, of course, conservatives believe in because they believe competition reduces prices.

DAVID FRUM: This is going to be a line in the sand and one of those--

BILL MOYERS: Deal breaker?

DAVID FRUM: No, on which -- a lot of politics is about political muscle. What do you bring to the party? Party A has this view. Party B has that view. And they put their shoulders against each other in rugby style, see who can push the other over the line. For Republicans, it's absolutely unacceptable. For a lot of Democrats, it's secretly unacceptable.

BILL MOYERS: What do you mean?

DAVID FRUM: Well, I think there are a lot of things that Democrats from conservative states pretend to be in favor of to keep in good order with the national party while counting on the Republicans to make it impossible to happen. When they have Democratic majorities, they then quietly defect because they don't believe in it either.

BILL MOYERS: So you're saying a public option is not politically feasible?

DAVID FRUM: No, I'm saying it's not acceptable to conservatives.

BILL MOYERS: What about you?

BILL MOYERS: You've broken with conservatism in this respect.

DAVID FRUM: I am not an unorthodox conservative. I think I'm a calm conservative. Right now I think a lot of -- their blood is up. They want to win this fight.

BILL MOYERS: Is that why we're seeing these protests, these loud, raucous protests?

DAVID FRUM: Well, let's distinguish between the people who are in those halls, who I think are many-- who, as I say, are people who have a good government plan in Medicare and are anxious because they know that President Obama wants to take a lot of money out of Medicare. That's how he's going to finance his plan.

BILL MOYERS: He says not.

DAVID FRUM: No, he acknowledges he's going to take money out. He just says it's going to make no difference. Because they're going to find so many efficiencies. So there are people who are a little skeptical about it. And they're kind of worried. Those are the voices. Now, that's different from what you're hearing on the radio. That's different from what you're going to be seeing in television advertising. Those people have more ideological motives. But what I am concerned about is in the desire to defeat President Obama, the Republicans are going to fossilize a status quo that is more unacceptable to them.

BILL MOYERS: You mean an unworkable health care system.

DAVID FRUM: Right. Because from the point-- Think about this, if you're a Democrat and you're confronted with ever-escalating health care costs and especially ever-escalating health care costs in the public sector, oh, well. You raise taxes to pay for it. It's not the worst thing in the world.

And if health care grows and if government grows with it, you know, you're not as upset by government as Republicans are. If you want to hold the line on the growth of government over the next two decades, this system has to be reformed.

BILL MOYERS: That's what Kathleen Hall Jamieson says. She said that in order to fix the long-term deficits, which are a concern to conservatives, we need to fix health care. Is that what you're saying?

DAVID FRUM: Yeah, if you see President Obama saying, "I volunteer to go into the beehive and put my hand inside the beehive and fix it," good luck, buddy. Better you than us. Like, why aren't Republicans saying, here's some things you can do that we'll like. Here are our red lines. If you do the public option, no. Surtaxes, no. Higher taxes on capital gains, no.

But if you have an idea as to how to slow the growth in Medicare, if you want to do things like this health exchanges, making it easier to afford to make it easier to buy across state lines, well, good luck to you. That sounds pretty good. And if you're prepared to take the political heat, again-- you know, good luck to you.

BILL MOYERS: I'm reminded that you grew up in Canada.


BILL MOYERS: Couldn't the conservative, a calm conservative make a case for that kind of national insurance plan in this country?

DAVID FRUM: Look, where those plans have grown up, as in Britain, for example, you've seen conservatives make their peace with them, as the British conservatives have done. And once something is integrated into the status quo of your country, it gets conservative. There are I think a lot of reasons not to regard it as a preferable system.

It stifles the possibility of innovation and diversity. It means that ideas that get into the minds of people in Washington are very difficult to get out. And it creates a -- it also creates this tremendous problem where every malfunction in the system becomes the fault of the politicians.

BILL MOYERS: You describe yourself as a calm conservative. But you have certainly aroused those to your right in the Republican Party. You know, talk show hosts like Mark Levin have come after you saying you're kneecapping your own. What about that?

DAVID FRUM: Look, a lot of the conservative movement in this country is conducting itself in a way that is tremendously destructive. Both of the basic constitutional compact of the requirements of good faith and of their own good sense. I mean, when you were going on the air and calling the President of the United States a Nazi as Rush Limbaugh has repeatedly done. When Mark Levin -- you mentioned him -- he said the President of the United States is literally at war with the American people.

And then people begin, unsurprisingly, showing up at rallies with guns. Well, obviously, if the President were-- I mean, folks, if I believed the President of the United States were a Nazi, were planning a Fascist takeover, it would be contemptibly cowardly of me not to do everything in my power, including contemplating violence, to resist such a thing. Every decent person should do that.

That's why you don't say it when it's not true. And I mean, one of the ways that the constitutional system works is with some understanding that the people on the other side have slightly different priorities but they share your constitutional values. They have invested in the same system. The problems they've got are hard problems. And even if you don't like their answers, you have to have some restraint in the way you talk about them, as you would hope they would have about you.

And I think it's just outrageous. It is dangerous. It's dangerous for the whole constitutional system. Now, I'm absolutely prepared to fight with them. And by the way, it's dangerous to conservatives because the effect of the talk of people like Levin and Rush Limbaugh is to kill our cause with voters who are under 65.

You make that man the face and you say let us contrast him to Barack Obama who is maybe too expensive but who seems calm and judicious? That's an ugly comparison.

BILL MOYERS: For this appearance alone, your website,, is going to be besieged by some of those folks, right?

DAVID FRUM: We have been besieged but this is a fight worth doing. And I have to say I'm thinking of changing our slogan. I'm adapting something from the old Panasonic folks, our new motto's going to be "just slightly ahead of our time." I know the conservatives of this country are not with me on these issues today. But I know equally well they will be with me on these issues in the future. They are just going to learn it, unfortunately, a harder way.

BILL MOYERS: The book is COMEBACK: CONSERVATISM THAT CAN WIN AGAIN. David Frum, thanks for being with me on the JOURNAL.

DAVID FRUM: Thank you.

VIRGINIA FOXX: Republicans have a better solution that won't put the government in charge of people's health care that will make sure we bring down the cost of health care for all Americans. And that ensures affordable access for all Americans, and is pro life because it will not put seniors in a position of being put to death by their government.

BILL MOYERS: That's it for the Journal. Your letters and e-mails are telling us what you think of our continuing coverage of the health care debate. We'll be staying with this story for as long as it takes, and it's useful for us to read your comments, both pro and con, about our work. We read everything that you post.

Over the next two weeks we're presenting two important documentaries on health care. First up is a film from the producer Roger Weisberg that tells the story of what happens to average Americans who fall seriously ill without insurance. It's called "Critical Condition."

DALE: A lot of people are dying, and they are dying because they don't have health care.

KAREN: Medical care is definitely a right. Nobody should be turned away.

CARLOS: The big issue is your money or your life.

DALE: You spend most of your life working, but once you don't have health insurance, every thing you work for your whole life will just go.

KAREN: It shouldn't matter if you got a $20 thousand a year job. Your life is just as important as somebody else's that makes a lot of money.

BILL MOYERS: That's next week on the JOURNAL. In the meantime, you can learn much more about the health care debate by logging onto our website at Just click on "Bill Moyers Journal." There you'll be able to fact check all sides of the health care reform ad blitz. You'll also get a side-by-side comparison of the different Health Care Reform bills currently circling Capitol Hill. I'm Bill Moyers. See you next time.

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