is a public health policy researcher at the University of Chicago's
School of Social Service Administration, where he is faculty chair of
the Center for Health Administration Studies. He is a regular
contributor to The Treatment.
Summarizing the state of play in health reform, the Washington Post gives President Obama a middling grade. The editors rightly note that he faces a hard climb to make the budget numbers work. More surprising is their admonishment:
More disappointing was Mr. Obama’s restated commitment to a public insurance option as part of the array of available plans. A public plan is not necessary to maintain a competitive market in health insurance, but including a public plan is almost certain to doom what Mr. Obama says are his hopes for a bipartisan agreement.
The Post offers no discussion of the policy merits, no discussion of competing proposals or potential compromises. Although you wouldn’t know it from the editorial’s odd title: “A few symptoms: President Obama’s first foray into the details of health-care reform,” the jostling and negotiating have been ongoing for months now. Democrats and unaffiliated experts have proposed detailed compromises to address both the legitimate and the wholly selfish objections raised by providers, pharmaceutical and medical supply firms, and insurers. One hears conflicting reports about whether these talks are making headway. Impervious to such efforts, Newt Gingrich and other conservatives characterize the president’s incremental proposals as socialism, employing crude rhetoric reminiscent of Ronald Reagan’s opposition to Social Security and Medicare.
The Post’s editors might have asked why Republican leaders flatly reject offering Americans the option of purchasing a public health insurance plan. It appears that the main Republican tactic is to regurgitate talking points focus-grouped and crafted by pollster Frank Luntz. As occurred with Luntz’s famous repackaging of estate taxes as the “death tax,” his main contribution seems to be finding new ways to say “Washington takeover” and “bureaucrat” to spook people. An entertaining web bingo game now tracks Republicans’ metronomic invocation of Lutz’s work.
Instead of calling on Republicans to provide a more substantive and measured response, the Post’s editors accuse President Obama and the large Democratic Senate and House majorities of partisanship because they do not preemptively surrender a key plank of the 2008 campaign.
Many, probably most, experts believe that a public plan can improve the quality and the efficiency of American health care. This structure provides opportunities for standardization in IT and other logistical matters. It provides for the application of comparative effectiveness research beyond what can be accomplished solely through a system of decentralized private plans. Given the myriad opportunities for discrimination on the basis of health status, a public plan provides a valuable backstop for millions of Americans living with disabilities or chronic conditions. Contrary to the Post’s assertions, a public plan would improve competition in many cities with concentrated health insurance markets.
Perhaps for these reasons, most Americans support the public plan. An April Kaiser Family Foundation poll indicates that 67 percent of respondents support “creating a government-administered public health insurance option similar to Medicare to compete with private health insurance plans.” Such polls also indicate wide support for more radical reforms. In the eyes of millions of people, the President’s proposal that includes the public plan already represents a painful compromise. Were it not for our political system’s disproportionate tilt towards rural states and procedural rules that grant de facto veto power to 41 senators, we might now be debating a single-payer plan.
Then there is the issue of controlling medical expenditures. The Post fails to note a central irony in this debate: the refusal by self-avowed fiscal conservatives to deploy the most reliable tool to accomplish this goal: Aggressive government bargaining with providers and suppliers. Experience in the U.S. and in other wealthy democracies suggests that a strong public plan would be far more effective than our current system in constraining costs.
The Post’s fastidiousness reflects an understandable but mistaken view of bipartisanship as an end in itself in passing landmark legislation. I hope that health reform attracts moderate Republican support. I’m happy that the Obama administration is trying to achieve this. Key elements of health reform--greater emphasis on primary and preventive care, support for comparative effectiveness research, narrowing geographic variation in expenditures, and much else--certainly deserve support across partisan lines. Yet we’re reaching the limits of what compromise is likely to achieve. It sometimes seems that Democrats are negotiating with ourselves, weakening our plans in pursuit of Republican votes that may never materialize.
America has been debating health reform for decades now. We just held a big election in which health reform occupied a special place. We’ve had the experience of 1993/94, in which Republicans explicitly and publicly stonewalled to deny the last Democratic president a visible social policy victory. We’ve had the more recent experience of the stimulus bill, in which very few Republicans delivered their support.
On the technical merits, current Republican talking points are crude. Yet there is something refreshingly honest about them, too. Health reform engages real ideological differences that cannot be papered over through conversation and artful legislation. These differences concern the proper size and scope of government and, ultimately, whether and how much we should devote national resources to help low-income citizens and others with costly medical needs.
Social Security, Medicare, and the Civil Rights Act were enacted with extensive consultation with pertinent constituencies. Each was enacted with painful compromises and shortcomings. In the end, though, each was enacted by a determined majority that worked hard to recruit allies where possible, and then acted decisively to overcome determined opposition from those who held contrary views. On health reform, Democrats are reaching a similar moment to stand up and be counted—and thus to accept real accountability for the ultimate results. And you never know; once Democrats show genuine backbone, they may discover some moderate Republican friends who don’t want to be left behind.
Bipartisanship is nice, but some things are more important.