There are two basic points about health care reform that President Obama wants to convey. The first is that, as he put it in an ABC special in June, "the status quo is untenable." Our health care system is rife with "skewed incentives." It gives us "a whole bunch of care" that "may not be making us healthier." It generates too many specialists and not enough primary-care physicians. It is "bankrupting families," "bankrupting businesses" and "bankrupting our government at the state and federal level. So we know things are going to have to change."
Obama's second major point is that to quote from the same broadcast "if you are happy with your plan and you are happy with your doctor, then we don't want you to have to change ... So what we're saying is, If you are happy with your plan and your doctor, you stick with it."
So the system is an unsustainable disaster, but you can keep your piece of it if you want. And the Democrats wonder why selling health care reform to the public has been so hard?
Again and again, their effort has brought us into a land of paradoxes. Public skepticism is warranted when the President promises to cut costs while simultaneously providing coverage to nearly 50 million uninsured people. It is even more warranted when his congressional allies seek to raise taxes to pay for all the new spending that this cost-cutting entails. We aren't talking about short-term spending either; this isn't a trillion-dollar investment in a new system that will ultimately save money. The Congressional Budget Office says the leading health care reform proposals will increase health care spending and make the budget harder to balance in the long run. Yet saving money is the President's principal stated rationale for reform.
Health care reformers send out mixed messages on the uninsured as well. The moral imperative of improving their health care is what drives the passion of most liberal activists for reform. But when you read the liberal policy analysts, it quickly becomes clear that getting young and healthy people to pay more in premiums than they will spend on medical expenses is the point of forcing them to buy insurance. Which is it? In aggregate, are we trying to rescue the uninsured or bilk them? Is reform something we are doing for them or to them?
The reformers' speed belies their words as well. If health care reform is so critically important, as they keep insisting, why not take the time to get it right? Hard as it is to believe, at one point Obama was urging the House and Senate to pass legislation by three weeks after they began debating it.
One final contradiction may lie beneath all the others. Democrats, particularly those involved in health policy, were scarred by President Clinton's failure to achieve reform in 1994. They are determined to avoid a similar debacle. So on every procedural question, they have done the reverse of what he did.
Everything is different this time everything, that is, except the plan. The Democrats are seeking mostly the same policies they sought 15 years ago: mandates, regulations on insurance companies, new government-managed markets. The major difference is that this time they also want a "public option," an insurance program open to everyone and run by the government. Obamacare is Clintoncare with a little more liberalism.
The Democrats have apparently concluded that it was tactical blunders that sank Clinton. It wasn't. It was his plan. Like today's plans, it had too many conflicting goals.
Stanley Greenberg, who was polling for Clinton back then, recently reminded Democrats that the insured public in the early '90s just could not be persuaded that the President was going to cut its costs by expanding coverage for others. No amount of clever strategizing is going to make the sales job easier this time. Instead, the President is in a series of double binds. The more he emphasizes how much has to change, for example, the more people are going to doubt his pledge that they can keep their doctor.
Congress may yet pass the health legislation Obama wants. If it does, that success will reflect the Democrats' numbers in Congress and their determination, not public enthusiasm. This time there is no barrage of Harry and Louise ads to blame. It is health care reform's own contradictions that are causing it to sink.