HPI associate director Tom Smith puts the Obama healthcare speech into its political and social context

Last night, US President Barack Obama delivered his most political speech since taking office. Despite positioning himself between left and right, blue and red, his prose was less purple than usual and much more political.

He will not back down on a public option for reform. Widely criticised for failing to give a lead to Congress on healthcare reform, the president made his position clear, as did the reactions of the studio audience - America’s most senior politicians.

Performing in front of a live audience
Obama walked into a room packed with Senate and House representatives. He kissed the women and high-fived the men as he made his way to his lectern. Previously, politicians had shared embraces and waved at colleagues as they gathered in room – giving the sense of a large wedding with guests that hadn’t see each other years.

The Democrats settled to the left and the Republicans to the right. All the way through the speech, they gave demonstrable reactions to the President’s arguments. Some sections received universal support. The whole house stood to applaud a commitment to reforming medical malpractice laws, aiming to reduce the costs of defensive medicine, over-testing, for example.

But when Obama defended the cost of reform as less than the wars in Iran and Afghanistan and cheaper than the tax cuts given to the wealthy (under his predecessor George W Bush), only the left hand side of the room stood to applaud.

On the more specific elements of the bill, such as including a public option, some of the left-hand side of the room failed to stand. One or two looked to floor slowly shaking their head. Pure political theatre.

Not backing down on a public option
The Washington Post and New York Times had predicted that Obama was prepared to drop his support for a public option, but the President defended the principle strongly saying it was needed to ensure universal coverage and competition for private schemes.

Despite this proclamation The Guardian this morning says that Obama hinted that he would drop the public plan, but this misunderstands that a public scheme could take more than one form.

It reflects Obama’s willingness to retreat from a federal insurance scheme, but the President was adamant he would not sign a healthcare bill without a public option, even if this took the form of public plans run by local co-operatives, a plan he said he could live with.

He said commentators “should not exaggerate what this is” – the public option was only one part of the plan. It is not socialism by stealth; but “a means to an end” to give people an alternative and pressuring improvements in the private sector.

Within four years, Obama said he would like to see Insurance Exchanges established with a public option. Until then, anyone who is being denied care because of a pre-existing condition will be offered a low-cost public scheme (an idea from John McCain that everyone applauded).

Obama said his bill would make it illegal for a company to deny care on the basis of a pre-existing condition, and would not allow the watering down of entitlement in a plan.

Making the case for a social approach to healthcare
At several points, Obama said that he wanted people to come in from the extremes of ideological debate. Neither the right-wing desire for all health plans to be purchased by individuals nor the left’s wish to adopt the Canadian system were realistic options.

He dismissed accusations of his trying to import socialism as an ideological extreme, but he did make the case for a more social approach and a greater role for government. He pointed out that the US was the only developed country in the Western world that allowed people to go without healthcare.

He reminded people that illness can come to anyone at any time and talked about individuals who suddenly lost coverage because of undeclared pre-existing conditions – in one story, a patient's failure to declare acne led a US insurance company to drop a person who was preparing for a double mastectomy. He said nobody in America should be treated that way again. He said “nobody should go broke because they get sick”, and received another standing ovation.

Obama made the point that individual purchase of insurance is three times higher than premiums sold to employers, and suggested that high fees were the result of a lack of competition faced by private insurers in many states.

He said that relying on employer insurance was stifling the labour market, as people were afraid to move jobs (known as 'job lock'). He argued that a public option could benefit from not having high overheads or the need to make profits, and at the same time could force private insurers to lower premiums.

The President told the room, “the time for bickering is over; the time for games has passed”, and everyone clapped. He said agreement could be reached acknowledging that “yes there are some problems that need to be talked through”, and everyone laughed. No, that’s not quite right: they sniggered.

For the only time in the speech, the President looked uncomfortable.

He recovered when he pointed to ideas from his opponents that he hoped would become part of the plan.

The body of an American
Obama played on the goodwill towards the recently deceased Ted Kennedy revealing that the senator had written a letter to the President back in May, which he had only just received because Kennedy left instructions for it to be delivered only after his death.

In the letter, Kennedy had describes healthcare reform as the “great unfinished business in our society”. Obama then paid tribute to the various healthcare projects that Kennedy had fulfilled, working with Republican colleagues. He said Kennedy recognised the fundamental principle of social justice in the character of our country.

In addressing the public’s fear of government involvement in healthcare, Obama acknowledged and praised America’s healthy suspicion of government - but added there were other American characteristics, such as empathy.

Ted Kennedy didn’t want healthcare reform because of rigid ideology; but because could imagine what it would be like for those who could not afford coverage and this happened to too many.

Government isn’t all bad, says Obama
Amongst the characteristics of Americans were: an ability to stand in someone else’s shoes; a recognition that we are all in this together; and a reassurance that when fortune turns against us, there will be someone there to help.

The President said that government sometime had to step in to fulfil this promise. He said that while people talked about the perils of too much government, danger also resulted from too little.

Political rather than purple prose
Obama’s speech was all the better for containing more political language than purple prose - though it still had its moments. Talking about opponents' scaremongering around his health plans, he said, “we did not come here to fear the future, we came to shape it”.

In the only purple passage, he said he wanted to change the political mood around health reform and “replace acrimony with civility”, “gridlock with progress”.

Does the speech make reform any more likely?
Barack Obama had lost control of the healthcare debate in the US, but this speech will allow him to regain the initiative with this speech. He pledged to “call out” any further scaremongering or untruths around his reform plan.

Over the next few days, his words will be picked apart but he gave every indication of remaining in the debate.

One of the key arguments in the press over the last ten days has been about whether the President should continue to seek bipartisan support or try to push through a plan. In this speech, Obama said things that could support both views.

Working across the political divide was a key theme of his speech; but the President also said he “will not waste time with those who think it is better politics to kill this plan rather than improve it”. And he said he would “not accept the status quo – not any more, not this time”. The urgency expressed by President Obama makes it clear that he will press for a vote on a bill that contains the key elements he outlined.

Some will argue that Obama has left his speech too late because over the summer, positions have become entrenched. Whether this is true will be seen over the next few weeks in the Senate, as committees try to produce a reform bill that can carry majority support.

Obama is one vote short of being able to carry a bill with all Democrat support, something which he has not been able to take for granted on this issue. But his shift towards supporting a state-based cooperative public option will bring more Democrats on side.

To ensure a bill passes, he needs the whole of his party to back the plan and he needs one (maybe two, Democrat senators' heath permitting) Republicans to support it too. To this end, there are rumours that the White House has been in negotiations with a couple of Republicans about the kind of bill that they could support.

Across the house, there are discussions with Republicans about what they could accept. The chair of the Senate finance committee Max Baucus says that he will put forward a health bill by the end of September. The vote, when it comes, will be very close. Whether the bill passes will depend upon the success of political horse-trading over the coming weeks.

This politicking will likely go on for the rest of the year, with the shape of the final bill becoming more clear in the run up to Christmas. The healthcare debate is only half-way through.