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Today’s
political
conventional
wisdom
assumes that
proposals to
address the
chronic
problems of
U.S. health
care will
regain the
domestic
policy
spotlight in
the 2008
presidential
campaign.
Steadily rising
costs of health
care services,
growing gaps in
access to care,
and mounting
strains on the
predominantly
employer-based
system of
private
insurance
coverage are not
necessarily
“new” problems.
However, they
appear to have
stimulated a new
round of more
intensive
political
responses.
Several dozen
states are
experimenting
with various
stages of health
reform plans.
Multi-interest
coalitions of
business, labor,
and advocacy
groups are
probing and
repositioning to
gain the high
ground in the
developing
health care
debate.
Accordingly, a
number of the
leading presidential
candidates are
staking out
their policy
priorities and
perspectives, if
not concrete
solutions.
Are we in the
early stages of
a replay of
1992, the last
presidential
campaign to set
the stage for a
comprehensive
health reform
debate?
Not exactly.
In any case,
will it be
followed by
another whimper
(like the
unraveling of
Clinton Care in
1994), or a big
bang that
transforms U.S.
health care?
Neither one, but
expect some
grudgingly
modest progress
–
eventually.
Current
similarities to
the dynamics of
the campaign
trail fifteen
years ago are
limited. This
time, a war in
the Gulf has not
gone as well.
Unlike its
predecessor, it
continues to
dominate the
overall
political
landscape. The
economy is
somewhat
healthier,
though not a
political plus.
Another
incumbent named
Bush has low job
approval rating,
but he cannot
seek re-election
this time.
Control of
Congress
switched to the
opposition party
last fall.
The common
element that the
1992 and 2007
share is the
electorate’s
unease, if not
discontent, with
the workings of
the existing
health care
system. In each
case, the
increasingly
less affordable
cost of
insurance
coverage raised
anxieties about
its current
stability and
future
availability.
No single
triggering
political event
like the 1991
Pennsylvania
Senate race
(when Harris
Wofford upset
Dick Thornburgh,
relying on a
health reform
platform) stands
out today that
would make
nervous
incumbents
scramble to
address
perceptions of a
swiftly changing
landscape.
However, the
cumulative
effects of a
widening gap in
recent years
between the
price of health
coverage and
what many
Americans are
willing or able
to pay for it,
either
individually or
collectively,
once again has
reinvigorated
political
impulses to “do
something.” As
always, deeper
disagreements
over the degree
of change needed
and the
problematic
details of
implementation
remain. But
some of the
early parameters
of today’s “soft
consensus” for
health policy
reform seem more
clearly defined
than the fuzzier
concept of
“managed
competition”
tentatively
voiced by the
1992-vintage
Clinton
campaign.
In one form or
another, most of
the leading 2008
Democratic
presidential
aspirants favor
moving more
aggressively
toward universal
coverage within
the context of a
mixed
public/private
system. John
Edwards would do
so most
comprehensively,
by conspicuously
endorsing higher
taxes and
imposing more
binding coverage
mandates on
employers.
Barack Obama
pledges
generically to
achieve
universal
coverage within
four years.
Hillary Clinton,
reflecting the
hard-earned
lessons of
overreaching
hubris in her
first White
House tour,
suggests now
that it might
take her
“second” term as
president to
finish the job
with a
step-by-step
strategy.
The Democratic
frontrunners
also support
creation of
large
public/private
pooling
mechanisms to
supplement, if
not replace,
employer-group
coverage, along
with expansion
of more
traditional
public insurance
coverage through
Medicaid and
S-CHIP.
Similar to their
Republican
competitors,
they would also
place faith in
the as-yet
unproven virtues
of information
technology,
electronic
medical records,
and preventive
care to lower
costs and
improve
quality.
At this stage of
the presidential
campaign, health
care issues have
figured much
more prominently
in Democratic
candidates’
appeals to
potential
primary
voters.
Republican
presidential
frontrunners
Rudy Giuliani
and John McCain
have been less
vocal, let alone
detailed, thus
far in
addressing
health care
reform (compared
to national
security issues
such as
terrorism).
Nevertheless,
one might
predict their
preferences:
favoring
tax-based
subsidies more
than increased
public spending
to expand access
to insurance,
bolstering
private forms of
insurance
coverage, and
limiting the
expansion of
publicly
administered
health
programs. They
would not make
universal
coverage per se
their foremost
health policy
goal. Although
Mitt Romney may
share the
private market
emphasis of his
Republican, the
former governor
is more heavily
invested in the
future success
of his
Massachusetts
model, which
combines an
individual
mandate,
income-based
subsidies, and a
“connector”
insurance
purchasing
mechanism to aim
for
near-universal
insurance
coverage.
The traditional
cut and thrust
of presidential
politics
suggests that
less is often
more on the
campaign trail.
One should not
expect more
detailed
blueprints of a
health system
overhaul until
the winner
answers the
question, “What
do we do next,”
in mid- to
late-2009.
Substantial
evidence of a
successfully
implemented
state-level
health reform
would make a
difference, but
don’t hold your
breath waiting
for it. The
recurring cycles
of our health
reform debates
usually peak
with broad
agreement on
what we do not
like, or wish
could be
different, but
break down over
what settling
for second-best
compromises
might entail.
The
gravitational
pull of
universal
coverage
nostrums and
stylized bipolar
disputes between
national health
insurance and
free market
medicine tends
to distract our
national
political debate
from confronting
more serious
matters that
need greater
attention. The
unfunded future
liabilities of
both Medicare
and Medicaid
pose more
pressing fiscal
threats to the
national
economy’s
balance sheet
today than they
did in 1992.
Although
Republican
candidates can
point to some
promising
inroads in
delivering new
drug benefits to
seniors through
private plan
choices, neither
party’s standard
bearers are
likely to
highlight the
need for
significant
belt-tightening
or restructuring
of health care
entitlement
programs before
the inevitable
becomes
inescapable.
Whereas more
observers have
questioned the
proposition that
U.S. health care
is the best in
the world, the
bedrock belief
of middle-class
voters that they
should continue
to have their
own opportunity
to consume
American-style
health care a la
carte, as long
as they don’t
see the full
price tag
directly, helped
sink an earlier
Clinton plan for
universal
coverage and
health security,
and it remains
quite resilient
today.
Hence, the
unexploited
opportunity thus
far to transform
the national
health care
debate involves
offering voters
new mechanisms
to gain access
to higher-value
care and improve
their overall
health. It
doesn’t mean
promising the
illusion of as
much as you
want, whenever
you want it,
from whomever
you choose to
provide it, at
less cost, based
on magical
assumptions. It
would start with
leveling a bit
more with voters
that we will
need to develop
and disseminate
better measures
of the
effectiveness
and efficiency
of more
accountable
health care
providers,
provide stronger
incentives and
tools for
consumers to
make smarter
choices, promote
healthier
behavior away
from the
doctor’s office,
target public
subsidies more
narrowly on the
basis of income
and health
status –
regardless of
age, and
acknowledge it’s
time to
reconcile better
the limits of
public resources
with needs, not
wants.
Defining better
choices in the
gray zone
between “you get
what you pay
for” and “you’ll
get what we
decide to pay
for,” might not
fit within a
60-second
campaign spot or
the paragraph of
a stump speech,
but it could
begin to move us
past the dead
end of 1992 and
beyond the
initial teases
of 2008.
--###--
Tom Miller is a
resident fellow
at the American
Enterprise
Institute. |
