The economic stimulus package just passed by the House contains much to
jump-start our economy in the next few years. And congressional moves to expand
Medicare eligibility and healthcare for children (through SCHIP) are
commendable. But these steps still leave largely unaddressed the most
fundamental long-term threat to economic security that President Barack Obama
vowed to tackle during the campaign: our crumbling framework of medical
Now is the time to fix it. The window of opportunity for comprehensive
action is open wider than at any time for decades. But without quick action, it
will close, and America's businesses, workers, and families will continue to
suffer at the hands of a healthcare nonsystem that costs far too much, leaves
far too many at economic risk, and does far too little to improve our nation's
The task is monumental, but it is not insurmountable. In fact, our current
economic crisis makes it not just more pressing, but also more possible. The
task is more pressing because the problems in job-based health benefits will
only grow worse as the recession deepens: Businesses will continue to drop
coverage and shift costs onto workers, and more and more Americans will lose their
homes and their life savings because they lack insurance or their insurance
doesn't shield them against runaway health costs.
Reform is more possible because the hastened erosion of our system is
galvanizing Americans and their leaders, and also because we must spend
aggressively now to keep our economy afloat, reducing the roadblocks to the
up-front investments needed to get to universal insurance. But the long history
of past defeats should remind us that successful reform is never assured. A
clear road map is needed to navigate the perilous political and policy terrain
ahead, and it should contain four big signposts:
1. Use the budget. There is but one high-speed train that leaves the
Capitol Hill station each year: the budget. The budget cannot be filibustered
by an obstructionist Senate minority of 41. It is how George W. Bush obtained
his massive tax cuts for the rich in 2001 and 2003. And it is how the
foundation for reform must be laid in 2009. Not everything can be done in the
budget, of course, but the key features of reform – new subsidies to help
lower- and middle-income Americans obtain coverage, and changes in existing tax
policies and health programs – can and should.
2. Move it or lose it. The history of major presidential initiatives
shows that Obama cannot afford to wait until 2010, as some suggest, to achieve
healthcare reform. To take advantage of his "honeymoon"-heightened
influence and the public desire for change that emerged during the campaign, he
should undertake the heavy lifting this year – the sooner, the better.
President Clinton delayed releasing health legislation until late 1993, almost
a year after entering office. His plan went down in flames for many reasons,
but it didn't help that members of Congress had stopped worrying about the 1991
recession and started worrying about the 1994 midterm elections.
3. Make Congress own it. Mr. Clinton's other big political mistake
was to craft his 1,342-page bill within the White House and executive agencies,
rather than move quickly to spearhead congressional action. That left members
of Congress free to grandstand and stall, and made Clinton's plan a huge bulls-eye for his
conservative critics. Mr. Obama should not make the same mistake. He should
supply the vision; Democrats in Congress should write the legislation.
4. Keep it simple. Finally, that vision should be simple and
plan had too many moving parts and too many red flags: regional purchasing
cooperatives spread across the country, efforts to encourage people to enroll
in tightly managed HMOs, caps on private premiums if they grew too fast. Obama
resisted this temptation during the campaign, and he should resist it now.
The reforms that Obama called for during the campaign had three key
elements: (1) lowering the cost of health insurance for workers who have it, so
employers continue to provide good job-based benefits, (2) creating a new
national insurance pool that allows those without such benefits to buy coverage
as good as that received by members of Congress, and (3) the creation of a new
public plan modeled after Medicare that would be offered within this pool to
provide a secure guarantee of coverage for those who now lack it and to drive
down costs while improving quality. Those are still the right elements, and
Obama should push for them quickly.
The great unanswered question is whether a public disillusioned about
politics can be brought to kindle some faith in their leaders and their
government. Nearly two-thirds of Americans say they believe in government
action to universalize health insurance, even if it means an increase in taxes.
And most (85 percent in a Pew
poll last month) say they want reform to be a "top" or
"important" priority. Similar sentiments helped bring healthcare to the
top of the agenda in the early 1990s, and reformers are on the verge of having
their moment in the sun again. If they heed the lessons of the past, they have
a real opportunity to finally seize the moment.