Who Killed Obama's Health Care Reform?

Is health care reform best left to the capitalists, or to the government? These are not appealing choices. They might have been when we still naively believed that both were competent.
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President Obama's health care initiative isn't dead yet. It's not even on life support. It is, however, in grave danger as long as either the approval or rejection of legislation in Congress rests in the domain of political ideologues and their media lapdogs.

Americans want meaningful changes in the way health care is managed and distributed. They want fair and equitable (mutually exclusive terms?) universal insurance coverage and an intelligent way to pay for it. They want all their elected representatives to understand how the "new and improved" health care system would work and then they want those representatives to come home and explain it to them. If they cannot, they will surely be voted out of office this coming election. Americans really don't understand the granular issues of medical rationing and single payer systems. They are demanding that their representatives do, and that their trust in Congress not be misplaced this time.

More and more, Americans are rejecting the pundits, left and right, and their tired polemic. Limbaugh's claim that the current health care reform proposal is tantamount to gang rape and O'Reilly's framing of coverage for the poor as extra-Constitutional are simply devices to exercise their constituents. Matthews' demand for passage of a coverage bill on moral grounds is as specious as Krugman's exhortation to Congressmen that approving any Obama-based legislation without detailed cost benefit analysis is the mark of a true Democrat.

Americans want a bi-partisan effort on health care reform. They want Republicans and Democrats to keep this from becoming a European soccer match with partisan crazies loathing the opposing team and those wearing its colors. More and more I hear from colleagues in the broad center trying to marginalize the fringe. I am listening for respectful appreciation of opposing views from die hard members' political forums and finding that "yellow and blue dogs" and "grand old party" members are looking for compromise. Hopefully that attitude will push upward from the grass roots to Congress.

The current debate on how to fix health care is over thirty-five years old. In 1974, then-President Nixon introduced the Comprehensive Health Insurance Act that mandated health insurance, costs to be paid for by employers and employees. The Act was coupled with an optional federal health care plan paid for by individual contributions based on income levels. At that time, there were 25 million uninsured Americans. There were opposing bills, including one sponsored by Senator Kennedy and founded on the belief that "only the federal government could operate health insurance that is in the best interest of all the people." The genesis of the political differences in approach to health care lies in the underlying question of who should best care for the interest of the populace. Is health care reform best left to the capitalists, or to the government?

These are not appealing choices. They might have been when we still naively believed that both were competent. With apologies to the few good folks who work in these institutions, Americans are more and more afraid that either Wall Street or the DMV will manage their health care choices.

In 1986, then-President Reagan championed the Tax Reform Act, which was intended to be revenue neutral, meaning that as some revenues were added (new taxes) others were reduced (judicious lowering of taxes). In fact, "revenue neutral," is a theory only, and is so dependent upon future estimates of potential revenues based on projected income growth rates that it becomes an immeasurable concept. There is a lesson for health care reform in the concept.

I propose a different approach. Cost neutral. Like balancing the budget, for every new dollar of health care costs the federal government assumes, an equal dollar of health care cost savings must be found. It is impractical to presume that this zero-sum-game cost approach could be implemented ratably during the first few years of any bill, but a time line based on reasonable savings estimates can be crafted if there is the will to have reform linked to a cost neutral proposition. The added benefit to a longer term approach is that fluctuations based on inaccuracies can be smoothed out in future years.

We then need to address issues of profit motivation in the distribution of our services at the insurer level, the drug company level, the hospital level, and the doctor level. Every one of these groups drive up the cost of the service we receive. Americans do not want to eliminate the profit motive in medicine but they do want it managed.

We need to look at the way we educate doctors. We need to open more medical schools, educate more of them at a more reasonable cost, and break the hold that medical societies have on the acceptances and entrance requirements. We don't need tort reform that caps awards; Americans want to be able to sue their doctor or hospital or even their drug company. We could limit the amount of fees their attorneys get but that won't pass muster with so many lawyers in Congress. We do need to do something about the spiraling cost of malpractice insurance which is driving doctors away from some specialties and some out of the profession altogether. We can create low cost government backed malpractice insurance (and therein regulate attorney litigation costs), not unlike flood insurance. We need to have rational discussions about the cost of care for lifestyle illnesses. Should we require people who smoke to pay for private cancer and lung disease insurance? Is the public really served by allowing drug advertising on television? Should we use our emergency rooms for only true emergency care? And finally, what do we do with the millions of people living in America who have come here illegally and now demand health care service without paying for it. It is decidedly un-American to turn these people away. It is decidedly un-American not to demand some form of compensation. But we now have 47 million people without proper insurance in our system.

All these issues and the many like them are not Republican or Democratic. They are American. And it is up to Americans to demand that our representatives address them as they work toward intelligent health care reform that will not bankrupt our country. That will take a truly bi-partisan approach. And that will keep the Obama Health Care Reform agenda alive.

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