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Health Care Reform And The Deficit

Over the weekend, I drew some analogies between the health care reform debate and the debate over Bill Clinton's 1993 budget. In both cases, the Republicans succeeded in framing the debate. They portrayed Clinton's budget as primarily an exercise in class warfare and bigger government or even socialism -- and indeed, news stories frequently referred to the measure as Clinton's "tax bill." Likewise, Republicans have portrayed health care reform is primarily a big government welfare state measure. The Washington Post's big narrative story about how health care won, which generally follows the conventions of casting the winners in the most positive light, casually labels it a plan "to vastly expand the nation's health-care system." Likewise, Ross Douthat argues that health care reform is the final gasp of big government liberalism before the inevitable cost crunch hits:

Before the 2008 crash, it seemed like this new liberalism might be poised for a long run of domestic policy triumphs: First health care, then climate-change legislation, then card check and immigration reform and so on down the list. But in the wake of the Great Recession, our rendezvous with fiscal retrenchment has been accelerated, and the chances for a rolling series of progressive victories have diminished apace. Barring an extraordinary economic boom, the American situation will soon require the slow and painful restructuring of the welfare state that liberals have spent decades building. This environment may or may not lead to a revival of D.L.C.-style centrism among the Democrats, but at the very least it’s hard to see it proving congenial to further adventures in sweeping social legislation.
I’ve talked to liberals who seem to understand this: The reckoning is coming, they allow, and the theory of health care reform has always been to get everybody inside the barrel before it goes over the falls. (I’d lay good money that this is Peter Orszag’s view of the matter.) But seen in this light, the health care victory looks less like the dawn of a bold new era, and more like the final lurch forward before a slow retreat.

But, of course, Obama's health care reform is designed in large part as a response to that very fiscal crisis. Indeed, in the medium term, it does not "expand the nation's" health care system." It shifts the spending around, keeping the overall level about constant while shifting resources out of waste and into covering the uninsured. Here's Jonathan Cohn's ten-year graph of total health care spending:

After then first decade, the strong hope is that delivery system reforms and the excise tax will exert serious pressure on costs. This is essential, because in the long run, controlling the deficit requires more than anything else restraining the growth of health care costs. Obama's reform may fall short, but it could also succeed well beyond the hopes of its advocates. That's what happened in 1993. Clinton's budget, by the end of the debate, was almost universally seen as a big government plan, filled with phony spending cuts and likely to make at best a tiny first step in the direction of fiscal responsibility. In the light of history, it's seen as a centrist reform that combines progressive goals with significant deficit reduction. I believe health care reform will eventually be seen the same way.