By Harold Pollack 

So readers, what have you learned?

Congratulations to the contributors of this site for a terrific year. I’m a regular reader (and was an early contributor) because DFA writers provide that rare combination of evidence-based policy and human insight that come from working at the front lines of the nation’s troubled health care system.

When Chris Lillis asked me to contribute a posting, I quickly decided to turn the tables.

I want to ask the readers of this site a question I’ve been asking many different audiences. I’ve been involved with DFA since almost the beginning. Over the past several years, we’ve undergone an amazing number of political, economic, and legislative trials. It’s only human nature to respond by doubling down on our own prior beliefs. Whether the issue concerns legal challenges to health reform, the stimulus (on which many DFA members worked), or the 2010 election, many of us respond to whatever happened by concluding that we were even more right than we originally thought.

That’s too bad. We’ve been through some hard trials recently. I mean that in multiple senses. We’ve been tested by difficult times. We’ve also had the opportunity to see our beliefs tested through real-world experiments that should challenge our strongly-held views. Anyone active and attentive should be thinking differently about something important after having witnessed so much history being made, so quickly, on so many different fronts.

So I ask you: Have your own views changed on any basic issues of health politics and policy? I’m not so much interested in your assessment of a particular politician or specific political tactics. Rather, I’m interested in some substantive position you’ve changed in light of evidence or experience.

To open the conversation, I should say that my own views have changed in a few areas.

First, I am increasingly concerned by what Paul Starr has called the “protected publics” in the health insurance fight—constituencies who believe that their needs are met within the current system, and who are often wary about sharing social resources with other Americans who need help.

To give one concrete example, my attitudes have somewhat hardened on issues of intergenerational equity. Watching so many seniors oppose health reform and other measures to help struggling younger people, I think American society must do a better job balancing interests across the generations. And young people have to do a better job getting involved, not least showing up to vote in midterm elections. That’s one reason I’m heartened by recent figures (see below) showing that the Affordable Care Act has helped hundreds of thousands of young adults secure health coverage on their parents’ employer-based plans.

Second, I’m struck by the ways American politics increasingly mirrors wider inequalities. A growing research literature—including work by Martin Gilens and Larry Bartels –documents that our politics is overly responsive to the interests and perspectives of the affluent, educated, and politically connected. Our politics is correspondingly neglectful of the interests and perspectives of those Americans who lack the same financial, educational, or social resources.

Two problems in health reform illustrate real-world consequences of these disparities.

The first of these glitches goes under the hilariously inflated moniker, the “1099 calamity.” To raise additional revenue and to curb tax evasion, the Affordable Care Act required small businesses to submit 1099 tax forms for additional transactions engaged in by small business. For various reasons, this provision imposed too much of a paperwork and tax burden on small businesses. Small businesses were livid. The Wall Street Journal ran thundering editorials about it. Democrats tried a reasonable fix, but Republicans filibustered. This glitch was just too politically useful to allow Democrats to fix it. The entire provision was repealed this year.

The second glitch concerns the expiration of COBRA subsidies for the unemployed. Since February, 2009, the federal government has been subsidizing about two-thirds of COBRA premiums for people who wish to keep employer-based insurance after they lose their jobs. House Democrats wanted to continue COBRA subsidies in the Affordable Care Act. Scott Brown’s election, among other things, prevented this. Republicans and some moderate/conservative Democrats balk at spending the money. So the subsidy expired. As a result, hundreds of thousands of families are seeing a tripling of their health insurance premiums. This problem affects many more people than the number affected by the 1099 tax problem. Yet it’s gotten much less attention.

This pattern creates a special responsibility among DFA members to provide grass-tops support for millions of Americans. I do a lot of field work in low-income parts of the Chicago southland. A pediatrician or other health care provider is often the only highly skilled professional that a person will regularly meet. I’m especially proud of DFA’s advocacy in this area.

Third, I’m struck by the political, as well as the substantive importance of implementing good policies that visibly improves people’s lives. Low-income Americans are living through an economic catastrophe right now. Many have been waiting years for effective help. Many become jaded and politically disengaged when this help doesn’t come.

I encountered this myself recently, when I interviewed low-income residents of Chicagoland for the New York Times. At a church supper, I met a wonderful woman named Kimberly Wilk. She’s had a stroke and subsequent brain surgeries. She needs assistance walking. Her husband has heart problems and requires an implantable defibrillator. Their monthly income is less than $700. She’s exactly the kind of person who will eventually benefit from health reform, only she hasn’t followed it. Until she sees concrete evidence in her own life and in the lives of people around her, she’ll regard the Affordable Care Act as irrelevant to her situation.

This creates an enormous, strategic opportunity for opponents of social insurance. The more they can block positive action, the more they count on ordinary people to check out. This creates an enormous education and advocacy challenge.

It creates a particular challenge for the medical community to help federal and state officials implement sound policies that make a real and visible difference. Some early components of health reform have been quiet successes—insurance regulation and the widely-overlooked early-retiree reinsurance program, for example. Other components have been more troubled–the preexisting condition health plans being the most obvious examples. Clinicians and practitioners on the front lines need to help out to make these policies work.

Anyway, those were some of my thoughts. What about yours?