ISSA Proceedings 2010 – Health Care Reform And The Status Of The Public Sphere

• by: Robert C. Rowland - University of Kansas

The most important domestic policy debate in decades occurred in the United States in the first eighteen months of the Obama administration on health care reform. This debate provides a window into the functioning of the public sphere and an appropriate case for testing the degree to which American democracy remains capable of solving the grave problems facing the nation.

There is no question that the American health system was ripe for reform. Unlike every other developed nation in the world, more than 45 million Americans lacked health insurance of any kind and an estimated 25 million more were substantially underinsured, causing according to the Institute of Medicine roughly 18,000 people to die each year (“The Uninsured,” 2009, p. WK7). This situation was predicted to worsen substantially in the future (“If Reform Fails,” 2010, p. WK9; Abelson, 2010, p. WK8). The problem was not limited to those who lacked adequate insurance. Health outcomes in the United States were far below the rest of the developed world. The United States ranked 39^th in infant mortality, and 42^nd and 43^rd respectively in adult male and adult female mortality (Kristof, 2010, p. A1). Despite these failures, the United States spent roughly fifty percent more on health care in domestic product than any other nation in the world (Rubin, 2010, p.7A). The vast spending was according to health care expert Peter V. Lee “literally bankrupting the federal government and businesses and individuals across the country” (Abelson, 2010, p. WK8).

The dysfunctional nature of the system should be obvious. And yet, for roughly a century proponents of reform had failed to achieve fundamental reform. In this situation, President Barack Obama made it his top priority to pass comprehensive reform and in March of 2010 achieved that goal, signing into law what is the most important piece of social legislation passed since Medicare (Tumulty, 2009, p. 26). It is appropriate to consider what his fight for reform reveals about the functioning of the public sphere in the United States. Jonathan Cohn wrote in a comprehensive New Republic analysis of the battle for health care reform that Obama came “to view this debate as a proxy for the deepest, most systemic crises facing the country. It was a test, really: Could the country still solve its most vexing problems?” (2010, p. 15). While Obama’s victory demonstrates that at least in the face of true crisis real change is possible, a more detailed consideration is needed to assess the health of the public sphere.

1. The liberal public sphere
While the focus of most public sphere research in argumentation studies has been on the approach developed by Jürgen Habermas (1989) and extended by Goodnight (1982, 1992), Calhoun (1992, 1993), and others, that is not the most appropriate way to test the functioning of the public sphere in the health care debate. Using a broadly critical perspective, Habermas and his followers focus on access to argument, often dividing a controversy into multiple spheres or otherwise breaking the argument into parts. In relation to health care, however, a debate involving the entire nation took place. It is the functioning of the whole that is at issue here. The most appropriate way to judge this debate is by applying liberal public sphere theory (Rowland, 2003, 2005, 2006). Under this approach, the public sphere is best conceptualized not as a metaphor or a set of spheres, but as the place where the public does its business. The liberal public sphere contains all of the quite messy debate on a given topic that is found in Congress and other public bodies, the media, the internet, and the town square. It is the conceptual place where the nation confronts problems and chooses how to react to those problems.

A second reason that liberal public sphere theory is appropriate for evaluating the health care debate is that the intellectual roots of the theory are found in foundational works laying out American democracy. On this topic, James Madison (1999), the primary author of both the Constitution and the Bill of Rights and one of the two main authors of the Federalist Papers, is the most important single source. It is essential to recognize that while liberalism is widely attacked in the academy (Willard, 1996), in the larger political world, it “reigns supreme as the leading, and one might even say, overwhelming doctrine in the West” (Patterson, 1999, p. 54). It therefore is appropriate to evaluate the health care debate with an approach rooted in the perspective on which American democracy is based.

There are four primary actors in the liberal public sphere: the representatives of the public, the public, the expert community, and the media. Each of these actors plays a crucial role in the functioning of the public sphere. The representatives of the public are decision makers in the legislative, executive, and all other government agencies. For the public sphere to function effectively, they must represent the views of various groups in society and authentically state their understanding of the facts of the controversy. If all views are not presented, a vital perspective may be ignored, resulting in policy that does not represent the entire community. But if the views are inauthentic, presented not as a genuine argument based on the best information available, but instead based only on political or ideological concerns, bad policy may result because of the failure to consider the best data. It is now widely believed that the decision to invade Iraq in 2003 represents such a case.

The role of the public is to pay attention to the debate and gather enough information to make a sensible judgment. In many cases, members of the public also may participate directly in the controversy by attending demonstrations, writing letters to the editor or blogs, or other means. While such participation aids the functioning of the public sphere by ensuring that multiple voices are represented, the key role of the public is to evaluate how well their representatives carry out their responsibilities.

The expert community serves the crucial role of providing information from the technical sphere that is relevant to the debate. While Goodnight (1982), Fisher (1984), and others have decried expert domination of public debate, a certain level of reliance on experts is inevitable. In relation to health care, for example, there is considerable debate on the amount of waste in the American system (Fairfield, 2010, p. BU7). This is a crucial issue because if there is significant waste there may be ways of reforming the system without dramatically increasing cost. On this issue, reliance on experts is essential. Ordinary citizens simply lack the knowledge base to judge whether medical care was necessary or wasteful in any given case.

The final actor in the liberal public sphere is the media. Their job is to provide the public with access to the views of the expert community and all sides in the debate. The media also serve a crucial function of testing the arguments of competing actors in the dispute. Most ordinary citizens lack the time or expertise to search out all sides in a given debate. The essential role of the media is to condense the debate for the public and also test the quality of the arguments made in that debate.

It should be clear that the liberal public sphere serves two primary functions. First, it is the place where issues of public controversy are resolved through the democratic process. In a healthy public sphere, all of the primary actors present their views and the public acting through their representatives decides. But simple representation is not the only goal of the public sphere. The second goal is to produce policies that are in some sense sensible. In Federalist Number 37, Madison wrote of the importance of “combining the requisite stability and energy in government with the inviolable attention due to liberty, and to the republican form” (1999, p. 196). Here, he was concerned with product as well as process, a point that he also emphasized in the preamble of the Constitution when he justified the new form of government as designed “in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty.”

Writing at the birth of the American experiment with representative democracy, Madison recognized two primary threats to the liberal public sphere: the power of special interests and the danger of irrationality. In what is clearly the most important essay developing American liberal political theory, Federalist Number 10, he argued that problems of “unsteadiness and injustice” in government were often caused by a “factious spirit” that “tainted our public administration” (1999, pp. 160, 161). For Madison, a faction was “a number of citizens” “united and actuated by some common impulse of passion, or of interest, adverse to the rights of other citizens” (1999, p. 161). Why were factions so dangerous? The answer is that they did not base their political principles in rational deliberation, but in “some common impulse,” such as an ideology or in self-interest. The problem of faction or what we now call special interest domination was especially significant because of the danger of irrational decision making. Madison implicitly noted this problem in Federalist Number 37, when he observed that “public measures are rarely investigated with that spirit of moderation which is essential to a just estimate of their real tendency to advance or obstruct the public good” (1999, p. 194). According to Matthews, Madison believed that “individual and collective tendencies toward the irrational were . . . multifaceted and powerful” (1995, p. 23).

Madison feared that special interests might undermine democracy by taking advantage of public lack of knowledge and irrationality. And yet, he also believed that a political system that encouraged clash among competing perspectives in open debate was the best means of making good policy choices. His comment in Federalist Number 41 that “A bad cause seldom fails to betray itself” (1999, p. 230) is illustrative of his faith in reason tested through controversy. Madison was not naïve. He recognized the risk that “counterfeit” (1999, p. 501) public opinion could overwhelm the capacity of the system to make sensible policy choices. But he also believed that the only answer to this danger was still more public discussion and debate, a viewpoint based in his belief that “over the long run . . . cool and calculated rational argument would win out over passion and hyperbole” (Mathews, 1995, p. 144). His faith in the power of reason tested through controversy was obvious when he expressed his hope that we could “erect of the whole, one paramount Empire of reason” (1999, p. 500).

Liberal public sphere theory provides a means of assessing how close we have come to that “Empire of reason.” A controversy can be evaluated based on criteria (Rowland, 2003, 2005, 2006) tied to the purposes of the public sphere by considering the following questions:
(1) Were the views of all of the relevant stakeholders represented in the debate?
(2) Was the debate shaped by informed expert opinion? This question is especially relevant on issues where there is consensus.
(3) Did the media report the dispute in a way that informed the public on the issue?
(4) Did the public as a whole gather adequate information to assess the debate?
(5) Did the better arguments in some sense win out in the end? In many cases, there may be no principled way to make this judgment, but in other cases, such as on global warming, there may be a wide consensus that action is needed. In such a case, a failure to act can only be seen as a failure of the liberal public sphere.

Based on these standards, a principled evaluation of how well the liberal public sphere functioned in the health care debate can be made.

2. The health care debate
Despite the overwhelming rationale for reform, the Obama administration recognized that passing reform would be extraordinarily difficult. Enacting legislation requires passage in the House of Representatives with a simple majority and in the Senate with sixty votes to overcome a filibuster. With Democrats controlling sixty votes in the Senate, Obama needed either every Democrat and both Independents or some token Republican support (Cohn, 2010, p.18). Given unremitting Republican opposition, he knew that getting this support would be quite hard.

Throughout the debate, advocates of reform focused on three primary points. They noted that the present system failed to provide high quality care to the uninsured and the under-insured and argued that without insurance reform almost any American could suddenly lose their coverage. Second, they claimed that costs were too high both for ordinary people and for the government. Finally, they argued that reform could address both the lack of coverage and the cost problem and improve the quality of care. Although there were a number of different proposals considered, the administration and leaders in Congress quickly fixed on the combination of an individual mandate that required all Americans to have coverage, insurance reform, and subsidies for the poor and middle-class to guarantee access to coverage. The intellectual roots of these ideas were on the right not the left. In fact, the core of the reform package could be traced to conservative proposals dating to the Nixon and first Bush administration (Alonso-Zaldivar, 2010, p. 5A; Krugman, 2009b, p. A17) and was quite similar to what Massachusetts had enacted under the leadership of Republican Governor Mitt Romney (Krugman, 2009a, p. A21).

The reform process was long and involved. Three different committees worked on the legislation in the House and two more in the Senate. In this period, the White House negotiated with stakeholder groups including consumers, doctors, hospital groups, insurance associations, and drug manufacturers in the hopes of building support for reform (Cohn, 2010, pp. 18-20). Although Obama was later criticized for not being involved in shaping the legislation (Dionne, 2009), retrospective analyses (Cohn, 2010) make it clear that the administration was involved from the beginning.

In the campaign, Obama played two primary roles: educator and cheerleader. On most occasions, he focused on educating the public. For example, in the summer of 2009 he went “on a public relations offensive to persuade Americans that overhauling the nation’s health care system will benefit not only those who lack insurance, but also those who have it.” He also tried “to tamp down some of the anger and unsubstantiated rumors,” explaining that his goal was to produce a discussion “‘where we lower our voices, listen to one another and talk about differences that really exist’” (Stolberg, 2010, p. A14). This effort was continued in a number of speeches and town hall meetings, including a radio address on August 22, 2009, where he denied the charge that the legislation would result in a “government run” medical system (Obama, 2009a). In addition, the administration responded to attacks with fact sheets and other information on the White House website and on the website of the group “Organizing for America” (“Reality Check,” 2009; “Setting the Record Straight,” 2009). Obama also used a widely praised speech to a joint session of Congress (“President Obama,” 2009, p. A28; “An on-target,” 2009, p. A20; Brooks, 2009, p. A21) to both make a positive case for reform and answer objections (Obama, 2009b).

Throughout the effort, Obama was attacked for coming “across. . . as a dry technocrat” and urged to “make the moral case for reform” (Krugman, 2009c, p. A27). Charles M. Blow criticized Obama for speaking “in thesis statements,” adding that the president “sometimes seems constitutionally incapable of concision,” an approach that in his view had not worked against “a campaign of confusion and fear composed of simple sound bites” (2009c, p. A15).

However, at various points of crisis in the process, Obama did make the moral case that his critics desired, acting in the role of cheerleader. This was evident when he faced wavering support among Democrats. In a meeting with Senate Democrats in early February, 2010, “the president’s appearance took on the air of a pep rally . . . with stinging criticism of Republicans,” but he also presented “a stern reminder,” a “warning” to Democrats, “against retreating from their priorities” (Zeleny, 2010, p. A18). Similarly, before the final votes in Congress, he “struck a populist tone, setting up the health insurance industry as his main target” in order to pressure “wavering members of his party  . . . not to give into political fears” (Cooper & Herszenhorn, 2010, p. A1).

Obama’s strategy of educating first and then acting as a cheerleader reflected his faith that over time the liberal public sphere would work. Stolberg explained that Obama believed that “by listening carefully and appealing to reason he can bring people together to get results” (2010, p. A1). For most of the debate, it appeared that this approach would fail. At the end, however, even conservatives recognized that they had “underestimated” Obama who had been “tenacious” in making a case for reform (Gerson, 2010, p. A21). Obama took this approach because he knew that polling demonstrated that “opposition” was “linked to misunderstandings of health care reform” and “support for reform rises when poll respondents are read details” of the actual plan (Chait, 2009, p. 4).

In essence, there were two sets of conservative arguments against the proposed reform. Conservative policy intellectuals attacked the program as expensive, bureaucratic, not fiscally responsible, and likely to stifle innovation. Given the conservative intellectual roots of the proposal, however, some believed that a compromise could be reached (Dole, 2009, p. A20). While there was principled opposition to the proposal based on conservative small-government ideology, the dominant approach was an attempt to demonize the plan as a big-government takeover of the health care system. As part of the demonization effort, conservatives also tried to frighten seniors by claiming that the plan would produce major cuts in Medicare and in the memorable words of Sarah Palin create “death panels” that might deny care to the elderly and others (Goodman, 2009, p. 6B). From an argumentative perspective, the problem with the demonization effort was that it was largely untrue. The reform plan combined an individual mandate to purchase coverage with subsidies and insurance regulation. There was no take-over of the health care system and certainly no “death panels.” Both claims had been debunked in “an avalanche of reports” (Ruttenberg & Calmes, 2009, p. A1). This led Joe Klein to conclude that “The irrational attacks on health-care reform show what the GOP has become: a party of nihilists” (2009, p. 16). Charles M. Blow said that conservatives were “cooking up scary, outlandish claims,” and added  that “the deceptions have worked” with “76 percent of Republicans” believing “that the health care plan will lead to a government takeover of the health care system” (Blow, 2009b, p. A15).

Although the various charges were discredited again and again, there is little doubt that conservatives succeeded in misinforming the people about the proposed legislation.  On this point, it is notable that when conservative intellectual Jonah Goldberg responded to the attack that conservatives were misrepresenting the legislation, he ignored the substantive issues and focused on the fact that “Obama Care . . . has been tanking in the pool for weeks” (2009, p. A17).  For Goldberg and other conservatives, success in persuading the people that the plan was a takeover of health care trumped the fact that the plan did no such thing. Sarah Palin implicitly admitted this point when she responded to critics who pointed out that the “death panel charge” was untrue by saying, “Establishment voices dismissed that phrase, but it rang true for many Americans” (Palin, 2009; Chait, 2009, p. 4). For Palin, facts didn’t shape beliefs; rather beliefs shaped facts. Many opponents of reform had a similarly cynical worldview. Chait observed that “right-wing populism deems the existence of a widespread belief to be sufficient proof of its veracity” (2009, 4). The result was to shift “the terms of the debate, making it harder for legislators to focus on genuinely relevant issues” (Frank, 2010, p. BU5).

The debate went through several crises. Although Obama strongly supported crafting a bipartisan bill, total Republican opposition eventually forced Democrats to go it alone (Cohn, 2010, pp. 21-22). Drew noted that “Republicans had decided even before Obama was sworn in that they would use the rules to deny him success on every major issue. Such obduracy was without precedent in modern times” (2010, p. 50). This created a situation in which any Democratic senator could hold the bill hostage (Drew, 2010, p. 50). In this circumstance, it took considerable time for the reformers to resolve competing perspectives, but after significant political horse-trading, they eventually did so and the Senate passed a bill on Christmas Eve. At this point, it appeared that ultimate passage of health care reform was assured, but when unexpectedly a Republican won a special election for what had been Edward Kennedy’s Senate seat, taking away the 60^th vote that Democrats needed to pass a final version of the bill, many concluded that “health care reform was effectively dead” (Cohn, 2010, p. 24). They spoke too soon. While the election upset was initially interpreted as reflecting widespread public anger against health care reform, polling indicated that was not the case (Drew, 2010, p. 49; Washington Post, 2010).

In this situation, Obama and leaders in Congress continued to work toward passing a final bill. As part of this effort, the president led a campaign to educate the public and persuade Democrats in Congress that they should continue to fight for reform. On January 29, 2010, Obama answered questions for almost 90 minutes at a House Republican retreat, where he “gave long, confident and informed answers” that were later judged to be generally “accurate” (Baker & Hulse, 2010, p. A11; Herszenhorn, 2010, p. A11). While many critics advised him to “worry less about making arguments,” he continued to have stubborn faith that people “‘are going to gravitate towards the truth’” (Blow, 2010a, p. A19). Obama also held an all day health summit with leaders in Congress in which the President served “as moderator, M.C. and chief defender of Democratic policy prescriptions” (Stolberg & Pear, 2010, p. A1; Kaiser Health News, 2010a; Kaiser Health News, 2010b). Even some conservatives praised Obama for picking “out the core point in any comment,” and “trying to get a result” (Brooks, 2010b, p. A23). Ultimately, the result was to lead many to conclude that if Republicans were unwilling to collaborate on reform Democrats should “take the necessary steps to bring a health bill to a vote” (“We Must,” 2010, p. A10).

In the final push to pass legislation, the president focused on the impact that the current health care system was having on ordinary people and also strongly attacked the insurance industry for both denying care and raising rates to astronomical levels. He was aided by the news that one major California insurer planned to raise insurance rates by almost forty percent (Kristof, 2010, p. A21) and by the finding of the Congressional Budget Office, a non-partisan organization widely respected for its objectivity, that the reform plan would reduce the Federal budget deficit by over $130 billion in the first ten years and over a trillion dollars in the second ten years (Krugman, 2010, p. A23). At this point, many of the opponents of the legislation seemed increasingly irrational. There were several incidents of bitter name calling, racist and homophobic remarks being made, wild charges and even death threats (Hulse, 2010, p. A16) that “moved the discourse well beyond rational debate into political hysteria” (“Finally, Health Reform,” 2010,  p. A10). Frank Rich argued that in order to find a precedent for the “overheated reaction,” to “what used to be considered Republican ideas” one had to look back to the response to the 1964 Civil Rights Act (2010, p. WK10).

Despite the loss of Kennedy’s seat in the Senate, Democrats could pass the legislation if the House could be convinced to vote for the same bill that had passed the Senate. Revision of the bill could be done in the Senate through a process called budget reconciliation that only required a simple majority. This happened, resulting in “the most sweeping piece of federal legislation since Medicare” (Leonhardt, 2010, p. A1).  President Obama said on the night of final passage, “‘This is what change looks like’” (Cohn, 2010, p. 25).

3. Assessment of the debate
Using the criteria established earlier, it is possible to assess the functioning of the liberal public sphere in the debate about health reform. Initially, it is quite clear that there was ample debate on all of the significant issues involved in health care reform. At the same time, it is also clear that much of the discussion was in Madison’s terms “counterfeit” debate. The legislation was portrayed “as socialism run rampant” and “as a government ‘takeover,” while in fact it was a “fairly modest set of fixes” (Robinson, 2010, p. B7).

Was the debate informed by appropriate expert opinion? Here, there is conflicting evidence. On the one hand, the media cited expert consensus to debunk charges made against health care reform. In the case of one widely circulated anti-reform memo, two important fact checking websites researched each of the claims in the memo and concluded that they were largely false and misleading (“Vetting Claims in a Memo,” 2009, p. A16). The Congressional Budget Office also played a key role in the debate. The conclusion that the legislation would cut the budget deficit in both the short and long-term played a pivotal role in eventual passage of the legislation. At the same time that the expert community effectively commented on the legislation, it is also obvious that the expert consensus had a limited effect on public opinion. A substantial segment of the population continued to believe attacks on the bill that had been widely discredited, supporting Madison’s fear about the irrationality of the mass public.

Did the media report adequately on the legislation? At one level, the media did quite a good job. There was immense coverage of the legislation. At the same time, the focus of much of this coverage was on politics, with much less emphasis on public policy. Drew observed that “The messiness and the anger of on Capitol Hill were the story,” but “what was in the health care bill was not” (2010, p. 50). Still, there was enough policy coverage that major distortions about the legislation were uncovered. One review of the proposed legislation concluded that many of the allegations being made about health care reform have been based on misreading or misrepresentations” or simply “have no basis in the bill at all” (Bavley & Helling, 2009, p. A16).

The crux of the issue relates to the quite mixed data on whether the public gathered adequate information to make a reasoned judgment about the legislation. The unfortunate truth is that the public was terribly uninformed on many topics and frankly misinformed on others. First, it is important to recognize that public knowledge of the most basic facts relating to public policy is astonishingly low. For example, polling found that “only 1 person in 4” understood that “60 voters are needed in the senate to break a filibuster” (Blow, 2010b, p.A17).  Second, the public was woefully uninformed about the details of the legislation. Karen Tumulty noted that “The more the public hears, the less it seems to understand” (2009, p. 26). A CBS poll found that “Just 42 percent said they had a good understanding of its likely impact” (2010).

In addition, a large segment of the public came to believe things that were not true. Drew observed that “through repetition and lies, the Republicans were winning the propaganda debate” (2010, p. 51). On this point, The New York Times editorialized that “Republicans have scared many older Americans into believing that their medical treatment would suffer” under the reform, a claim that the Times rejected based on a careful review of the legislation (“Medicare Scare-Mongering,” 2009, p. WK11). Charles Blow cited an Indiana University Poll that found that by mid-summer 2009, the “obviously false and widely discredited” attacks had shaped public opinion to the point that “most Americans now believe that if health care reforms pass, health care services will be rationed and taxpayers will be required to pay for abortions” (2009a, p. A17). In addition, strident attacks on the legislation combined with what David Brooks labeled “a corrosive cynicism about public action” to produce a number of angry protests, name calling and in a few cases threats of violence (2010a, p. A23).

At the same time, polling indicates that “Americans closely tracked the final stages of the long-running debate over health care reform” and that they were quite critical of the job the media had done in reporting the debate, with 75 percent saying the media had “done only a fair or poor job of explaining the details of the proposals” (Pew Research Center, 2010a). This would seem to indicate a desire for more coverage of policy, but it also may reflect the public’s unwillingness to take steps to seek out material on the complex policy issues at stake.

By late summer 2009, the public had turned against the health care proposals with a majority disapproving of Obama’s job performance on health care and a plurality opposing the legislation (Fram, 2009, p. 6A). Public opinion changed little until ultimate passage (Rasmussen, 2010). In May 2010, a Kaiser Foundation poll found that public opposition had lessened and that the gap between those with a favorable and unfavorable view of the legislation was only 3 percent net unfavorable (Kaiser Family Foundation, 2010b). While over the course of debate on health reform, public support lessened, polling also consistently found support for both the need for health reform and for many of the elements found in the reform package (Kaiser Family Foundation, 2010a, pp. 1, 5). These polls found especially strong support for the creation of an insurance exchange, expanding Medicaid, subsidies to assist people in buying coverage, insurance reform, and a public option. Each of these elements drew more than 50 percent of the sample stating that they made them more likely to support the proposal (Kaiser Family Foundation, 2010a, p. 5). The elements of the legislation receiving the least support included the individual mandate, the almost $900 billion cost of the program, the specification of a basic benefits package and the proposed tax on high-cost insurance plans. These results strongly suggest broad support for the overall outlines of the policy passed by Congress. They also indicate a fundamental immaturity on the part of the American people. The public favored those items that added to their coverage or made it easier to obtain, but opposed efforts to rein in cost or require people to purchase coverage, policies that were needed to make the program function. Polling also indicated that only 18 percent of the American people favored Congress leaving the present system as it is (Pew Research Center, 2010b,).

The public opinion information indicates that the public as a whole strongly favored reform as long they that reform didn’t cost them much. The polling also indicates that much of the opposition to the legislation was based on misinformation. This suggests a basic problem in American democracy. On any issue that is complex, it is easier to scare the people about the dangers of change than it is to inform them about the benefits of that change. Madison and the other Founders were profoundly worried about the dangers of majority tyranny and as a consequence built a number of checks into the system that made legislation difficult. What Madison did not recognize was that the inability of the public to process complex policy disputes might threaten the capacity of the liberal public sphere to confront problems that threatened the nation’s wellbeing.  Given the inherent complexity involved in confronting global warming, nuclear proliferation, financial reform, and so forth, the results of the health care debate are not reassuring.

At the same time, American democracy is representative in nature and the failure to persuade a majority of the public to support a given piece of legislation does not necessarily indicate a failure in the liberal public sphere. President Obama and Democrats in Congress were able to generate enough support for reform in the 2008 election that they ultimately had the votes to pass comprehensive reform. Because of that success, the misinformation campaign that began in mid-summer 2009 did not derail health care reform.

The final question – did the better argument in some sense win out? – may seem inherently partisan.  Given the contested nature of the health care debate, it might seem that there is no way of answering the question in a principled fashion. At the same time, while the Obama health care plan remains a contested issue, on two points there is universal agreement. A health care system that cost 50 percent more than any other in the world and still didn’t cover 1/6^th of the American people cannot be considered a well-designed system. The present system was unsustainable. Ultimately, what may have pushed reform over the finish line was that the failures in the present system left little option but reform. The opponents of reform persuaded a narrow majority that the Obama plan was dangerous, but overwhelmingly the American people still believed in reform. In that sense, the advocates of reform and the better argument won out and the Democrats in Congress carried out their responsibility to “represent” the American people by passing comprehensive legislation that according to  Drew was “the greatest advance in health care coverage for Americans in decades, if not ever” (2010, p. 49).

4. Conclusion
In the health care debate, the liberal public sphere both failed and worked. Misinformation almost overwhelmed the debate at several points. The public showed little appetite for searching out the details of public policy and little ability to process complex arguments. It is telling that Obama was derided when he tried to calmly explain the rationale behind reform. Commentators clearly thought an effort to educate the people about the issues, an effort that implicitly treated them as citizens capable of rational deliberation, was naïve. In the end, a reform, the main elements of which the public favored, passed although a small plurality of the public opposed the legislation, in many cases because of misinformation about what was in it. Over time, support for the effort grew and by November 2010 a small majority favored the legislation (Thomma, 2010, p. All).

This result was by no means inevitable. Health reform had failed on several other occasions despite similarly strong arguments. The political skill of Democratic leaders in Congress and the administration, along with Democratic control of the House, Senate, and presidency undoubtedly played a role. At the same time, Obama’s enlightenment commitment to reason also was clearly important. Obama believed that in the end the stronger position would win out if he remained committed to educating the people about the better arguments. Like Madison and Lincoln, he believed that sweet reason ultimately would be decisive. At many points in the debate, his faith in reason almost seemed quaint, but ultimately his faith was justified, if only barely. As he demonstrated in the end game in the meeting with House Republicans and in the health care summit, there is power in mastery of argument. Rod Dreher noted that “Traditional belief in the effectiveness of reason, however imperfectly realized, has long been a stabilizing force in our liberal democracy.  If that faith is slipping into irrelevance, we are going to lose more than our minds” (2009, p. 8A).  Perhaps the ultimate lesson of the fight for health care reform is that at least as enacted by President Obama, faith in public reason has not yet slipped into irrelevance.

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