Taking the long view on health reform

By Katrina vanden Heuvel
Wednesday, March 24, 2010

How historic is the health-care reform bill that President Obama signed into law this morning? The bill only begins the long task of taking back control of the health-care system from rapacious insurance and drug companies. We must work to include a real public option and to eliminate the insurance industry's antitrust exemption.

Just days before Congress moved to pass the most sweeping health-care legislation in decades, I was at a Moscow conference marking the 25th anniversary of perestroika, as Mikhail Gorbachev called his transformational political and economic reforms. And as I listened to the discussion, I was reminded that when assessing reforms, it's important to take the long view.

Russia has been struggling with different modes of "modernization" at least since Peter the Great. In the 1980s, Gorbachev took up the mantle of democratic modernization, introducing multi-candidate elections, ending censorship and permitting some private ownership, among other changes. He was a courageous leader willing to confront powerful opposition, entrenched interests and orthodoxy. Yet even great leaders, particularly in a democratic context, rarely complete their own historic reforms. Gorbachev could only go so far as to open doors long closed by Soviet communism and the Cold War and give his country and the world new alternatives.

Sadly, the two historic opportunities his leadership created -- one for Russia's democratization, the other for Russian-U.S. relations -- were squandered by elites in Moscow and Washington after he left power.

At the Moscow conference, a feisty Gorbachev himself presided over the debate about why his reforms, particularly democratization, had unfolded dramatically but then had been terminated, and whether they could be revived in post-Soviet Russia. Indeed, the idea of a "perestroika 2" has arisen in Moscow in connection with a public debate over the pressing need to diversify Russia's economy and modernize the country's disintegrating infrastructure.

As with most Russian political initiatives, there's a good deal of elite and popular cynicism about the debate, many viewing it as just another struggle over power and property. Even so, it is an important debate because potentially it is also a struggle over Russia's future.

Yet it will be up to other leaders and citizens to carry on the struggle for democratic modernization. Proponents of a perestroika 2 put their hopes in President Dmitri Medvedev. Advocates of Russia's traditional state-imposed "modernization from above" look to Prime Minister Vladimir Putin. And given Putin's superior power, few believe a revival of democratic modernization has much of a chance in the near term. Also standing in the way is Russia's traumatic history since the Gorbachev years. There are widespread fears, among politicians and ordinary people, that a perestroika 2 would result in the chaos -- even catastrophe in the minds of many Russians -- that perestroika led to in Soviet Russia.

"Among both the people and those in power, there's anxiety that a new round of democratic modernization will lead to instability and Russia's further collapse," Gorbachev told me. "But in politics, fear is a poor guide and we must overcome it." Nonetheless, the debate and struggle for Russia's future is at stake -- and just beginning.

In the United States, Franklin Roosevelt's New Deal began a perestroika of American capitalism, the struggle for which continues 75 years later with Obama's attempts to expand health care and regulate the crisis-prone financial system. Passage of health-care legislation, as the president said after the House vote, "answered the call of history." The bill goes a long way toward fulfilling President Truman's declaration that universal health care is a basic right. It will extend health insurance to 30 million Americans and impose tough regulations on the insurance industry, which are welcome changes.

But the legislation is only one step in a long process. And just as it is too soon to write the final chapter of the history of Roosevelt's New Deal or Gorbachev's perestroika, it is too early to judge Obama's reforms. Leaders, activist groups and citizens must continue the fight to improve the health-care legislation's protections and fix its flaws.

In urging that the struggle continue, I recall the words spoken by a Russian writer in 1986, after listening to Gorbachev express his vision of perestroika and the opposition to it: "If not now, when? If not us, who?" Those words should be our credo.

Katrina vanden Heuvel is editor and publisher of The Nation and writes a weekly column for The Post.

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