BUFFALO, N.Y. -- Debra Street, Ph.D., associate professor of sociology at the University at Buffalo, says the history of health care reform in the U.S. is "one of lost battles" for principled approaches to creating a health care system that delivers good health care to all.

Street is a health care policy expert whose research analyzes the impact of public programs and tax policies on health and income security. She studies the unintended consequences of public policies on long-term care outcomes, and the politics and policy histories of public expenditure.

In the following Q&A, Street cites the "deliberate deception" involved in the current health care reform debate, and she tells us who is lying and why -- and who will end up "winning."

Do you think the health care reform debate is taking place in honest terms?

Street: "No. No side has the courage to tell the absolute truth because it isn't expedient to say out loud what needs to be said. Politicians lack the courage to tell the truth in the face of their re-election plans.

"Pro-reformers need to say, 'nothing but a huge amount of government intervention will change things enough to get us to the goal of universal coverage.'

"Anti-reformers need to say, 'Lack of health insurance for millions of Americans is less important to us than protecting the integrity of American self-reliance and markets and the profits of insurance shareholders.' Maybe if all sides of the issue told the truth, we could have a real, honest national conversation about what is at stake in health care reform."

In your opinion, who is blocking "real" health care reform?

Street: "If we want to understand what is blocking reform, just follow the money. Those who have the money are controlling -- or more accurately obfuscating -- the debate.

"The characters who want to block reform may change over time, but one enduring feature of this group is that it is not concerned with what is best for the health care of the nation. They are consistently and exclusively concerned with what benefits them and their shareholders financially. This is about money remaining in the hands of certain groups.

"Historically, universal access to health care was blocked by physicians through the American Medical Association and hospitals. Today, there is a new alliance of political convenience that comprises health insurance companies, the pharmaceutical industry and ancillary providers -- all of whom profit from current arrangements. This is the group that is doing its utmost to stop reform.

"There are about 45 million uninsured Americans, and out-of-control health care spending continues to increase, but this is situation is that works best for this alliance. It profits them most, it keeps power in their hands and make no mistake -- they do not want it to change.

"The longer the public can be misled and mystified about the nuts and bolts of potential reform proposals, the longer the 'winners' under current arrangements continue to 'win' and the others continue to lose."

What do we need to know about this public battle that we are not hearing through most news coverage?

Street: "First, we need to know that our health care system is not very systematic and that health care reform is very complex and difficult to fully understand, even for the experts.

"Second, we need to know that opponents of health care reform bank on our confusion. They know that it is easy to deceive and mislead the public about what the proposals entail, what they will cost, who will benefit and who will lose under different scenarios. And they use that knowledge to misrepresent the situation in ways that will benefit them.

"Third, we must recognize that no matter what health care reform is eventually enacted, whether small and incremental (the most likely kind of reform) or broader, there will be winners and losers. There are few policy changes that are win-win, and health care reform definitely isn't one of them."

You say that all parties in this debate deliberately obfuscate and mislead the public?

Street: "All sides play some of that game. Pro-reformers pitch their programs in ways that minimize cost estimates and understate the role government would have to play in meaningful reform. They shy away from saying out loud that it is the pretense that there is a 'real market' in health care in the United States that prevents us from accomplishing what every other democratic country (and some not-so-democratic ones) have achieved: routine access to high-quality health care for all.

"The anti-reform side throws out scare phrases, like 'socialized medicine' and 'euthanasia' and 'Medicare cuts' and 'government health care' and 'higher taxes' to try to intimidate the uninformed into supporting the status quo -- even though the status quo, which is a lack of health security, is against their own interests. But this is a notoriously difficult debate in which truth can emerge.

"Neither side has the courage to tell the absolute truth because it isn't expedient to say out loud what needs to be said. Our politicians lack the courage to tell the truth in the face of their plans for re-election."

Where should we be focusing our attention?

Street: "In terms of reform, we should probably be focusing our attention on pragmatic policies that build on and expand programs already in place.

"These include employment-based health insurance programs, including potential for buy-in to what federal government employees have available to them; Medicaid, SCHIPs (State Children's Health Insurance Program), Medicare. We can raise the income levels on Medicaid eligibility, for instance, sweep more kids into SCHIPs, lower the age of eligibility for Medicare to include older workers who have been downsized in this economy and who cannot get commercial health insurance.

How can individuals influence the outcome? Should we take individual action or support groups that promote our vested interests?

Street: "I wish I knew how we could influence the outcome. I really don't know. It is difficult to organize many people with little in common but a hope that someday Americans will have an irrevocable right to decent, dignified health care -- not something that comes and goes with employment, or poverty status or age, but something to which we are all entitled that contributes to the common good.

"The pockets of reformers simply will never be as deep as the anti-reformers. Health is a pretty recession-proof industry and health profits fuel a lot of noise in the system, from sophisticated ad campaigns to phony 'grassroots' anti-reform organizations that are nothing more than fronts for the organizations and industries that do well under current circumstances. It is frustrating.

"Sadly, there is not much the public can do to influence the outcome, I'm afraid. But it doesn't mean people shouldn't try."

What kind of health care reform are we likely to get after the dust settles?

Street: "We'll get what I call 'frankenreform' (no intention to besmirch our new senator, here). It will be a little bit of this, a little bit of that, a little bit of something else, stitched together, with a nut and bolt or two, then electrified at a big news conference. It will only change health care delivery at the edges. Maybe that is okay. The history of health reform in the U.S. has been one of incremental change, so to expect a revolution of the U.S. health care system isn't realistic, no matter how much we think it is needed.

"But even little bitty reforms will finally sweep some people into the health care system and make a huge difference in their lives. So I try to think of this as accepting that some good may come from these efforts, although health reforms will be hard fought, and few won."

Should we be afraid of a miserable outcome from what looks and sounds like a terrible battle among corporate interests for the public dollar?

Street: "My hunch right now is that the outcome of this health care reform won't be entirely miserable, there will be enough small changes that reformers can claim some advances and the anti-reformers can afford to concede small changes as long as current arrangements remain essentially intact.

"I doubt the reforms will be any more revolutionary than the outcomes of the Clinton-era health care reform efforts. There will be some new quality regulations, a spasm towards some kind of very limited cost controls (because these are what anti-reformers fear most), there will be some adjustments in program eligibility that will include a few more people under public programs, but the fundamental problem of health insurance insecurity when a person loses a job, or somehow doesn't quite reach the bar for eligibility in a public program, will remain.

"Those without health insurance who get sick or injured won't be covered under whatever reform package finally emerges."

Who stand to be the biggest winners and losers?

Street: "If I were a betting woman, I'd bet that this will be one of the signature political losses of an Obama administration. I think that the lack of clear and dependable information about the ramifications for health care reform is a big stumbling block, but the biggest stumbling block by far is the deep pockets of the industries that have those deep pockets because of the way health care is currently arranged. Still, the political effort to expand health care coverage to more Americans is a political battle worth pursuing. I really hope I'm wrong about who the winners and losers will be."

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