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What Would Harry Do?

A lot of people care about what happens to our health care system. But not a lot of people understand what’s actually being proposed--or even have time to figure it out. And even those who do follow the debate closely may not always know what’s important, what isn’t, and so on. (Even I get confused sometimes.)

Part of the problem is that judging reform actually requires asking several different questions. There’s the economic security issue: Will it expand insurance coverage substantially--and make sure the insurance people have is good insurance? There’s the cost question: Will it pay for itself--and will it reduce costs over the long run? And there’s the matter of quality: Will it actually make medical care better?

To help people sort this out, we’ve decided to develop a relatively straightforward scoring system. We’ve gone to some of our favorite experts and asked them to judge various reform plans on these criteria. Then, using a specially weighted composite of those numbers--more on the weighting in a moment--we compile an overall score. The scores will go from one (bad) to ten (good). And we’re calling it the Truman scale.

The name is a tribute to the president who first tried seriously to pass national health care reform: Harry Truman. Theodore Roosevelt talked about health care reform and Franklin Roosevelt thought about it, but Truman was the first who made a serious effort. He failed, of course, as did every president who’s tried since. But we’ve gotten closer each time and, as things stand, chances seem good that President Obama might actually succeed.  If so, he--and all of us--will owe Truman a debt of gratitude.

Now, about that weighting. This is where I, your friendly neighborhood health care policy wonk, get to set the priorities.  The security score will count three times, the cost question twice, and the quality once.  My thinking is that cost and quality are pretty closely related and that, together, they should count as much as security.

As for the experts, their names appear at the bottom of the score sheet. I promised to keep their individual scores confidential, although they’ve given permission to quote specific comments.

You'll note I did not attempt to assemble a group that represented the full spectrum of public opinion, or even elite opinion. On the contrary, the list includes no conservatives and nobody so far to the left that they endorse only single-payer.

This is not because I don’t respect either group. I do and, in the case of the single-payer advocates, I frequently agree with them.  But I wanted to limit this group to people who buy into the basic premise of what Obama and his allies are trying to do.

Since the Finance committee begins its markup hearings today, we’re going to start with the scores for the plan Chairman Max Baucus introduced last week. We’ll follow up shortly with ratings for the other bills--as well as for the status quo.

That last part is important. People have a tendency to compare every proposal to what they’d like best. But the real comparison is, or should be, to what will happen if we do nothing

OK, enough lead in.  Now for the scores:


Security 5.6

Cost 6.7

Quality 6.3


Synopsis and comments from the judges:

In general, judges were more impressed with the plan's fiscal elements than its coverage elements. Of the plans in committee, it's the one with the "most favorable" score from the Congressional Budget Office--that is, it not only pays for itself but actually shows savings within the ten-year window. Beyond that, it is projected to save money. On the other hand, it does so in part because it is stingier with what it gives: Fewer subsidies for people, to help them buy insurance, and less comprehensive guarantees of insurance. Plus there's no public insurnace option.

"It's the insurance company's dream plan, but a heck of a lot better than the status quo. There's plenty of room for improvement on all the Truman score elements." --Jacob Hacker

"[On security] I would give a higher rating if he hadn't limited credits and capped out of pocket help at 300 percent of the poverty line. This is a big problem in both political and policy terms. It would still be a vast improvement over status quo. [On cost] It "pays for itself," but in the wrong way--by imposing costs on people who can't afford to bear it. Long-term cost controls are reasonably weak in all bills. [On Quality] I think the QI portions of health reform are more important and valuable than people realize."--Harold Pollack

"If the Baucus plan is the floor for what health reform looks like, the system will be better off than today.  But we can, and must, have a plan more expansive than what the Chairman has proposed."--Peter Harbage

Full list of judges:

Henry Aaron, Brookings Institute

David Cutler, Harvard University

Robert Greenstein, Center on Budget and Policy Priorities

Jacob Hacker, Yale University

Peter Harbage, independent consultant

John Holahan, Urban Institute

Chris Jennings, Jennings Policy Strategies

Larry Levitt, Kaiser Family Foundation

Len Nichols, New America Foundation

Harold Pollack, University of Chicago

Sara Rosenbaum, George Washington University

Andy Stern, Service Employees International Union

Anthony Wright, Health Access California