The Real Issue
Health care reform has eluded many presidents, notably Nixon and Clinton, whose approaches reflected the two ends of the leadership spectrum. Nixon proposed broad principles and Clinton's very detailed legislation was the product of a task force led by Hilary Clinton. Both initiatives failed. For different reasons, the stakeholder stars did not align.
The problems with health care in the U.S.---rising costs, large numbers of uninsured, and an opaque, fragmented system---remain entrenched and get worse with time.
The voices of the public seem to get lost in the negotiation process. Public opinion research discussed in a series of town hall meetings across the U.S. in 2008 (co-hosted by the Council for Excellence in Government and the Institute of Medicine) provided insights into the public's agenda. People, including the insured, are most concerned about the rising cost of health care. A majority favors covering the uninsured but a majority would not be willing to pay more in taxes for this purpose. Portability, transparency about providers' performance and the cost of their services, electronic health records, and larger insurance pools (competition across state lines) are also high on the public's agenda.
A framework of broad principles, as President Obama has proposed, is good but the real issue is the willingness of stakeholders to address the toughest trade-off--containing costs versus expanding coverage by giving up something. This will be a test of leadership, at the top, among stakeholders and of the American people.
Remaking the health care market, with cost-sensitive choices, accountability for performance and coverage for the uninsured requires everyone and every organized interest group to give up something for the greater good.
Such a commitment from competing stakeholders and the public is the critical determinant of success.
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