The stars may—just—be aligned to squeeze a national health-care bill out of Congress within the next month or two. Both houses have (barely) passed bills, and now they must cobble together a lowest-common-denominator consensus that can survive one more vote in each house. President Barack Obama is almost certain to sign anything they send him.
In its current form, the House bill is the superior offering, with more subsidies for more people, financed primarily with an income-tax increase for the top few percentages of earners. The Senate bill offers fewer subsidies and more gimmicky financing—an excise tax on high-premium plans (by itself a good idea, but elite unions hate it) and special fees on insurers and drug and device companies.
Both bills contain provisions that infuriate interest groups on all sides of the ideological canyons. Insurers are livid at the cutback of payments to Medicare HMOs, seniors detest the restraints on future Medicare spending, and all conservatives hate the new taxes and fees. Liberals are variously upset at the watering down of the public option; the exclusion of abortion services; the restrictions on care for immigrants, possibly even for legal immigrants; and/or the kid-gloves treatment of the big companies that graze in the green meadows of the medical-industrial complex.
The sheer number of warring interest groups confirms the wisdom of the administration’s strategy of staying clear of the free-for-all. Instead of pushing their own proposal, which would have drawn fire from all sides, Obama and his chief legislative honcho, Rahm Emanuel, left it to Congress to fight through the most neuralgic issues. If only from sheer exhaustion, that process has now coughed up two solution-blobs of roughly similar shapes. They’re not very pretty, but they are the kind of material that experienced conference hands can force into a single container that can survive a final vote and plausibly be labeled “National Health-Care Reform.”
That may not sound like much, but a little perspective adds a lot of glow. Over the past seventy-six years, there have been four failed attempts to pass a national health bill—one every nineteen years. Franklin Roosevelt’s bill was shot down by doctors who smelled a Communist plot. An alliance of big business and big unions defeated Harry Truman—executives wanted to keep control over benefits, and unions liked the idea of another financial issue to bargain about.
Richard Nixon made a creditable try for a broad, simply designed, national insurance program, but liberals couldn’t stomach his insistence on keeping private health insurers. The Clintons’ “Hillarycare” was sunk, of course, by its apparent complexity and the insurance industry’s caustic “Harry and Louise” TV advertising campaign. The oft-overreaching Lyndon Johnson never even made a serious attempt, focusing instead on more feasible reforms for the elderly and poor.
But note how the reform challenge keeps escalating. In FDR’s day, health care was a relatively simple matter—mostly just custodial hospital care and soothing words from general practioners. Forty years after that, the comparative elegance and clarity of the Nixon proposals were possible because health care—then only about 5 percent of GDP—was still on the brink of its leap into hypertechnology. At the outset of the Nixon presidency, heart attacks were still treated with bed rest, and cardiology was a fledgling specialty.
In the two decades between Nixon and Clinton, health care doubled its share of GDP; it became much more entwined in people’s lives, and its scientific complexity grew by orders of magnitude. The technology ratchet made another full turn between Clinton and Obama. As available therapies spiral toward infinity, grappling with knotty issues of what works and what to pay for supersedes traditional issues of coverage and cost-sharing.
Without a dramatic flattening of the health-technology curve—which seems highly unlikely—the legislative challenge will only grow in complexity. Administrations get one bite at the health-care apple, so it could be another twenty years before the window for major change opens up again. By then health care could be as much as 20 to 25 percent of GDP, and the bottom third or half of the nonaged population may have been squeezed out of the system altogether. Really high-quality care may become a prerogative of the very rich, like skiing at Courchevel.
It is a disgrace that some 50 million Americans do not have access to standard health care. The current shaggy health-care legislative beast is the best we’re likely to get, and it’s time to push it across the finish line.