Friends In the Right Places
The end result of major health care reform, if "successful," is not going to be a ten page set of principles but, of course, a thousand-plus page bill written in dense legislative language. the question is: Can President Obama get from here to there and avoid the failures of two prior Democratic presidents (Carter and Clinton) who sought comprehensive reform following LBJ's passage of Medicare and Medicaid in the 1960s?
The fundamental policy and political obstacles are little changed.
From a policy perspective, how does one make the trade-offs between the fundamental goals of reform--increased access, consistent quality and meaningful cost control--in a a sector of the economy that now accounts for 16 percent of GDP (up from eight percent 30 years ago)? How does one decide whether critical, substantive decisions should be made in legislation, in federal regulatory agencies, in states or in the private sector? And according to what standards? These complexities are, of course, compounded by an economic crisis which can play havoc with assumptions about both costs and projected cost-savings.
From a political perspective, how do reformers find a "passable" compromise between the competing interests of virtually every individual and entity in the nation--from patients to payers, governments to corporations, and taxpayers to providers--that is strong enough to do more good than harm (and not leave the hardest questions to the future) and flexible enough to deal with the inevitable unintended consequences?
But, at least two dimensions of health reform are different for President Obama.
First, he is dealing with a Congress controlled by friendly, like-minded Democrats. President Carter's reform efforts had many problems (came too late his administration, during a time of hyper inflation), but a major issue was the radically different views of reform held by conservative Senate Finance chair Russell Long and comprehensive reform advocate Ted Kennedy. President Clinton's reform efforts also had many problems (including secrecy and Rube Goldberg complexity at announcement), but a major issue was opposition from Senate Finance Chair Daniel Patrick Moynihan.
Today, the four major committee chairs (in Senate Finance, Senate Health, Education & Labor, House Ways and Means, House Energy and Commerce) are in broad agreement with the president on the direction for reform and can, presumably, work together closely to build workable majorities. Plus: the heads of the Office of Management and Budget (OMB) and the domestic policy staff are Hill veterans who can help compose Executive Branch differences and work in concerted fashion with the Hill.
Second, unlike the Carter and Clinton eras, there is broad if vague agreement among virtually all players--including corporations and providers--that the health system is too complex, too variable, too expensive and too ineffective for too many. This agreement extends beyond the broad goals of access, quality and cost restraint to a general approach, e.g. mixed public and private risk pools, a federal health board, comparative effectiveness analysis for product approvals, use of health IT to increase efficiency and the usual call for more preventive and wellness efforts. (This isn't to say that fierce opposition isn't already starting to build.)
Feeding off these changes in the Congress and among the health care players, the administration's submission of principles, if it chooses to do that, makes sense. If properly orchestrated, it can create needed momentum at the outset. But the contentious disputes about winners and losers--about who pays, whether system reforms will really work to save money--cannot be blinked away.
Like any good negotiator, this administration also needs a detailed plan, a bottom line, behind the principles if its vision of reform is to be realized, not lost, in the legislative process. The devil--and historic change--is still in the ferocious arguments to come about details.
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