Urban healthcare crisis, rural reform

One of the weird ironies of the current health care reform debate is that most Americans want substantial reform — and most favor a public option.

Here’s a poll from June 2009:

A clear majority of Americans — 72 percent — support a government-sponsored health care plan to compete with private insurers, a new CBS News/New York Times poll finds. Most also think the government would do a better job than private industry at keeping down costs and believe that the government should guarantee health care for all Americans.

In modern American politics, 72 percent is a landslide. That’s slam-dunk territory, especially for a Democratic Party with filibuster-proof minorities.

So why are we stuck? And why does so much of the debate center around red herring issues (socialism! death panels!) rather than pragmatic hurdles (pushing down costs, improving preventative care, etc.)?

A big part of the answer lies in the structure of the U.S. Senate, where health care is being reformed.

The Senate is a profoundly non-democratic institution, in the sense that it redistributes massive amounts of political power away from the states where people live and into states with passingly small populations.

A Senator in North Dakota enjoys roughly 72 times more voting clout, per constituent, than a Senator from California.

And because America has a lot of low-population rural states, those “homelander” Senators hold enormous sway.

Consider this astonishing fact:

The four U.S. Senators with the most influence over the reform debate currently are Democrats Harry Reid and Max Baucus and Republicans Olympia Snowe and Charles Grassley.

Together, they represent states with about eight million people. That’s a fair chunk shy of the population of New York City.

What’s more, they represent states with passingly small populations of minorities and urbanites. Those are the people hardest hit by our health coverage crisis.

Yes, there are a few progressive rural states, but most are home to people who hew to traditions about self-reliance and small government.

Ironically, all of these rural states are net drains on the Federal treasury. That means big urban states like New York pay hefty income taxes that are then spent in small rural states like Montana.

What’s more, far more rural citizens per capita — government workers and retirees, the elderly, ex-military, etc. — are already covered by some kind of public option.

It’s a troubling disconnect.

This is one of those cases where the redistribution of power in the Senate skews the way America wrestles with its most pressing problems.

At the end of the day, it appears likely that white rural lawmakers will approve a plan that leaves tens of millions of urban blacks and Hispanics out in the cold.