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Obama Aide: Health Care To Be 'central Focus' In Budget

The Obama administration’s health care czar may be gone, but here is one hint that its commitment to pursuing major health care legislation in 2009 remains in place. On Sunday, a senior administration official told me that health care would be a “central focus” of Obama’s first budget proposal.

The official didn’t specify precisely what that meant: Would the administration be asking for funds to make sure every American has insurance, or just a portion? Would there be major reforms of the way medical care is delivered? But even with that ambiguity, the statement seems to signal that Obama still takes health care seriously and hopes to pass significant legislation in the next year.

Here's why. For the last month, the leaders of major liberal interest groups and some of Washington’s top health care experts have been nervous that Obama would not seek funding for major health care legislation when he unveiled his first annual budget proposal. The source of this anxiety was a rumor, circulating widely, that some Obama economic advisors were pushing him to put health care on the back burner--or at least to move very slowly on expanding insurance coverage--because of the huge cost and political risks inherent in any major reform effor

Those concerns intensified late last week, once former Senator Tom Daschle withdrew from the administration because of the controversies over his tax records and ties to the health care industry. Daschle, an outspoken champion of making health insurance a universal right and using government to reduce the cost of medical care, was supposed to spearhead the administration’s health care reform push. He was also close to Obama personally.

With Daschle out of the White House, many in Washington suspected, Obama might lose interest in the subject. And if Obama didn't put down a marker now, the thinking went, the prospects for passing major health care legislation in the near future would dwindle.

Publicly, Senators Max Baucus and Ted Kennedy, who have been working together to craft health care legislation, sent Obama a letter urging him not to give up the cause. Privately, they signed onto another letter--along with Representatives Charles Rangel, Geoge Miller, Pete Stark, and Henry Waxman. That second letter, according to several Capitol Hill sources, urged Obama to include health care in his first budget. A similar letter was sent by the reform coalition “Divided We Fail,” which represents the American Association of Retired Persons, the Business Roundtable, the National Federation of Independent Businesses, and the Service Employees International Union.

But in interviews over the past week, administration officials have said repeatedly that the dobuts about Obama’s commitment are unfounded. They say Obama himself has indicated health care is a top priority, to be pursued shortly after the debate over the economic stimulus package is over.

They also say he believes it is important to make sure everybody (or almost everybody) has insurance, because it’s not possible to control costs while so many people lack health benefits. "I've been in meetings with him and it's clear this guy is committed to getting health care and getting coverage to everybody," says one high-ranking member of the administration. "There's no question in my mind." 

And while these advisers acknowledged that the question of whether to deal with health care in the next budget had been under discussion, another senior official on Sunday indicated a decision had already been made: “Health care reform will be included--and indeed a central focus--of the budget,” this official said, while declining to offer more details. Another adviser subsequently confirmed that. (All of these sources asked not to be named.)

To be sure, the president’s budget proposal has little significance legally. Congress passes the budget entirely on its own authority. Its a joint resolution, not requiring presidential signature. And, for that matter, even the congressional budget isn’t binding per se. It merely sets guidelines for what Congress will appropriate over the course of the year.

But, historically, the White House budget has carried great influence, particularly for a chief executive like Obama who is just beginning his first term. A presidential budget proposal is far more detailed than anything candidates publish while running for office. It’s also based on numbers that come from the Office of Management and Budget. Those figures tend to be less optimistic than the figures campaigns deploy.

A president's first budget, in other words, forces him or her to make explicit the priorities and trade-offs campaign rhetoric can obscure.

Of course, even with this latest development, it’s unclear exactly how far the administration will go in its proposal. Will it seek enough funding to cover insurance for everybody within some reasonable time frame? Or will Obama’s proposal make only a heavy “down-payment” on universal coverage--perhaps in the hopes that Congress will up the ante and craft legislation that would cover everybody?

Obama has suggested that better use of information technology, efforts to cut down on unnecessary treatment, and other changes to the way American health care gets delivered could help the country spend less on health care. Those savings, in turn, are supposed help offset the cost of giving more people insurance and, eventually, to make insurance less costly for everybody. But if it takes more than a decade for those savings to appear--a very real possibility--where will Obama come up with the extra money in the meantime?

It’s also possible that, while putting forward a budget request for health care, Obama could break it out separately--or come up with some other, slightly unconventional way of accounting for government revenue and spending on health care. Clinton did with this with his health care proposal, although he waited until his second budget even to take up health care reform. (One interesting question: Might the administration seek a health care budget that looks beyond the standard ten-year window?)

But even with those admittedly big questions still unanswered, I gather--based in part on conversations with experts who follow the issue more religiously than I do--that a decision to make health care a "central focus" of the budget remains newsworthy. As the New America Foundation’s Len Nichols, an economist and longtime reform advocate, said when I reached him on Sunday, “If they put [health care] in the budget, and fully fund it, then they are demonstrating a profound commitment to health care as an integral part of the agenda. And I welcome that.”

--Jonathan Cohn