This post originally appeared on 1 February 2009 on The New Republic’s The Treatment blog.
The purposes of comprehensive health reform are noble: expansion of coverage and control of costs. Yet, the latest attempt to begin to address those goals is near death. For nearly a year Democrats shepherded bills through the complex legislative process, revising and merging them to accommodate the congressional process and political realities. Ultimately two bills, similar in broad structure and differing only in detail, passed the chambers of Congress.Yet, at the brink of completion support for them has waned. What can be learned from this experience?
First, it is worthwhile appreciating how unlikely it is that policy-makers have brought health reform legislation this close to passage. It doesn’t clearly benefit all influential interest groups, a condition that normally dooms major reform. To have even pursued it was, therefore, a political risk. That Democrats, and Obama, took responsibility for attempting to solve the large and important problems of the uninsured and health care costs is laudable. In doing so they managed to mollify the concerns of major stakeholders.
One might think that support for reform would increase as more and more interest groups embraced it. That it has not has more to do with the glacial, agonizing, and ugly process of production of legislation than it has to do with its content. The spotlight hasn’t been kind to health reform. Opponents have been able to focus it on the less savory elements of legislative sausage making and on the least popular aspects of the bills, whether they exist (the individual mandate) or not (death panels).
Still, the overall structure of both the House and Senate bills is sound. The individual mandate, the low-income subsidies and other provisions are required to make the insurance reforms like the ban of pre-existing condition exclusions possible. Without the mandate people would buy coverage only when ill, increasing premiums for all. And one cannot expect low-income individuals to purchase insurance they cannot afford.
In a panicked response to the Massachusetts election, policy-makers considered chopping up the logical structure of the bills into separate legislative proposals. That’s a recipe for unworkable policy. The bills are large and complex not because policy-makers want them to be, but because they must be. It would be irresponsible to attempt to solve one component of the problem without addressing the whole. That begs the question: can comprehensive reform of the health care system or of anything else ever occur? If government controlled by one party (including a super-majority in the Senate) cannot bring about responsible reform, what can?
I wish I had an answer. We need one. I understand why reform is hard: too frequent elections, too great minority power (the filibuster), too much special interest money, among other reasons. But knowing these doesn’t lead directly to an easy fix because the process of implementing a solution is subject to the same forces that are the source of the problem. It’s a deep and difficult hole from which to legislate egress.
If health reform succeeds despite all the hurdles it will be a major accomplishment that has eluded presidents and policy-makers for decades. But if it fails (again), it will be in large part due to the challenges of governance and the imperative to win the next election. Even the best ideas face substantial risk of failure. Even for good ideas offered by responsible leaders, Congress is a graveyard.
Some say reflexively that government is not the solution to our problems. Usually proponents of markets or libertarian ideals view government as an impediment to good outcomes. The experience of health reform has revealed another sense in which government may not be the solution–because it can’t get out of its own way. That is, our government is improperly structured to solve the problems we face. It isn’t necessarily that government can’t be a solution or that government can’t propose a solution, it is that government can’t pass a solution, at least not very often. Even if health reform ultimately passes, it is clear that an historically rare level of single-party control was required to pull it off.
Unfortunately, when it comes to health care the market is not a solution either. And so we’re stuck (or may be), with a set of problems that can’t be addressed with either broad system at our disposal. It could be that the health system we have, the one resulting from a far from perfect market and a far from ideal set of government regulations, is the only one we can get. The sad consequence is that it leaves so many under-served and wastes so much of our treasure. I’m confident we can prod government into doing a little better, but without comprehensive reform, not much and not soon.
The gap between our ideals and reality is large, and even with the will and the votes the obstacles to closing it are nearly insurmountable. That’s the most troubling lesson of all.