One of the points made by President Obama in his speech to the joint session of Congress to advocate health care reform was that he would be receptive to good and constructive ideas from any source, including Republicans who oppose nearly everything he does. It was a fine speech, and it succeeded in raising the prospects of enacting some kind of significant health care reform. If he really meant what he said about considering good ideas from the political opposition, he should make that more clear.
Without a doubt, health care reform is a very difficult challenge. As the saying goes, if it was easy, it would have been done long ago. Obama’s allies in Congress (the Democrats) have major differences among themselves, regarding the merits of different aspects of reform. The Republicans are almost 100% united in opposition, both for sincere ideological reasons and for pure political motives. Obama would like to have a bipartisan bill, but (with very few possible exceptions) congressional Republicans will refuse to back any bill, even if it contains several provisions to their liking. By temperament and political background, Obama has always tried to build a consensus, but neither party in Congress is in the mood. What is a president to do?
In apparent opposition to all conventional wisdom, I still believe that the best solution – both for policy and politics – would be a moderate health care reform bill that uses some of the better ideas from both parties. For the reforms to work, they will have to expand access and reduce overall health care costs, regardless of how payment of those costs is distributed. Reforms that focus on one of these issues while ignoring the other will ultimately fail.
With my usual disclaimer about not being an expert on this or any other subject, the best health care reform at this time would have the following characteristics:
1) No legal resident of the U.S. can have his/her coverage denied or revoked due to personal health issues. [The issue regarding illegal residents is trickier. My inclination is to believe that illegal residents should be included, but I would not insist on it as a condition to support an otherwise good bill.]
2) All persons eligible for coverage must be covered. There can be no “opt out” for individuals or families. Tax credits or similar assistance should be available for those who are too poor to afford coverage, but they have to get the coverage. If insurance companies must accept all applicants and all preexisting conditions, then it makes no sense to allow healthy Americans to stay out of the system before the need for insurance becomes obvious.
3) The tax favored treatment for employer-sponsored insurance should be ended, or at least sharply reduced. People who cannot get health insurance through work should not be disadvantaged the way they are now.
4) Individuals and small groups should be able to join large risk pools, in order to remove cost distortions due to underwriting.
5) Sensible tort reform is necessary. This includes caps on non-economic damages and an effective distinction between ordinary and gross negligence. In return for setting limits, the medical profession must do a better job of policing its members. The current practical necessities of defensive medicine and huge malpractice premiums greatly add to overall health care costs, while doing very little for patient well being.
6) End the interstate prohibition on selling medical insurance. Most states need more effective competition among its potential health insurers. Allowing the sale of insurance across state lines would be a big help.
7) Emphasis on prevention, as opposed to treatment and cure, needs to be a component of health care reform. There needs to be financial incentives for people to participate in wellness programs and annual physical exams.
8) For all the talk about “death panels,” the fact is that a large chunk of health care costs take place in the last six months of the patient’s life. I am not about write off somebody for being terminally ill, but there needs to be more honest discussion about the costs associated with extraordinary measures to keep somebody breathing for a few extra months, or weeks, or days. I don’t know what the appropriate answer is, but this is a big element of the national health care bill, and the issue must be faced with more honesty than it has had so far.
9) The public option is not as great an idea as its advocates suggest. This is especially true if there is an “opt out” provision for each individual state. It would likely have the effect of denying coverage for many vulnerable Americans. It will do nothing to contain actual costs, and the notion that it will “save” money by paying doctors at Medicare (or Medicaid) rates makes no sense. Doctors and hospitals can presently treat Medicare as a loss leader item, pushing up the costs to everybody else. They cannot do that if there is no everybody else. The public option either works like Medicare, providing a short term illusion of cost saving, or it works like a private insurance company, with no saving. The “trigger” provision suggested by Olympia Snowe and some other senators, where the public option would be created something like five years in the future if demonstrated to necessary by conditions at that time, might make sense.
Anyway, the status quo cannot continue indefinitely. We need to have some sensible health care reform, but we need to get something that can pass both the House and Senate. Passing a feel good measure that passes only one house of Congress is useless. I believe that a health care reform bill with the characteristics outlined above would be good public policy, and can pass Congress if President Obama makes clear that this is something he supports. It may seem to be too much of half-hearted reform for the liking of Nancy Pelosi and Harry Reid, but even a half-hearted reform now leaves open further reforms in the near future, if those are believed to be needed. The reverse is not true. Failure to pass something now will almost guarantee a very long delay in passing any reform. It will also seriously weaken Obama’s presidency. I do not want that to happen.
