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Health Care's Year

By E.J. Dionne Jr.
Monday, April 6, 2009

Yes, this is the year Congress will finally give every American access to health insurance.

Getting there won't be pretty. But for the first time since the passage of Medicare in the 1960s, the forces favoring action on health-care reform are stronger than the forces of cynicism and obstruction.

Feel free to be skeptical. Since Bill and Hillary Clinton's reform efforts foundered in 1994, predicting the death of any comparable venture has been the safest bet in Washington.

But this conclusion misses almost everything that has been happening. It's not just that the public (including business) is frustrated with the status quo. And it has little to do with the details that policy wonks are necessarily hashing over.

What matters is that members of Congress have quietly been preparing the ground for reform since the Democrats took over two years ago. And the competing interest groups seem more inclined to get what they can out of reform than to stop the enterprise altogether.

Senate Finance Committee Chairman Max Baucus (D-Mont.) has been training (through hearings and studies) as if for a prizefight. In an interview, he said that his self-education has included time with Hillary Clinton to discuss why her initiative failed 15 years ago.

She told him that one of the things she didn't foresee was how jurisdictional battles in Congress could overwhelm all other concerns. If the heads of committees were fighting each other for influence, they were in no position to fight together for a bill.

This time, the bulls are pulling in the same direction. Baucus has been working with Sen. Edward M. Kennedy (D-Mass.), for whom health-care reform is a sacred cause, and has brought together senators in both parties who are likely to be part of a solution. He calls them a "board of directors."

Rep. Henry Waxman (D-Calif.), one of the House's resident health-care mavens, has been working closely with two other committee chairs, Reps. George Miller (D-Calif.) and Charles Rangel (D-N.Y.).

One largely unheralded change is that health-care reformers have made peace with each other. In the past, groups advocating competing proposals were more interested in establishing their dominance than in passing a bill.

"People who advocated health coverage for all Americans wanted it their way, and the second choice was nothing," Waxman told me. This time, he said, reformers want to get to universal coverage by whatever route is open.

Indeed, the reformers are broadly focused on the same set of ideas, a mixture of subsidies for those who can't afford insurance, reform of insurance markets so sick people can't be denied coverage, and serious efforts at cost containment and efficiency.

Though only some of the players will say so now, the plan will ultimately include a mandate requiring everyone to have insurance, quelling opposition from the insurance companies. They hope that having a bigger market will compensate them for whatever they might lose from regulatory changes.

In any event, business groups committed to reform will check the power of their colleagues in the insurance industry, and the pharmaceutical companies are willing to cut a deal because they know the current health-care gravy train is destined to end.

And those with coverage will be able to keep what they have and may profit from improvements in cost and quality. This time, said one influential House staffer, advocates of reform are paying far closer attention than they did 15 years ago to the views of Americans who already have insurance.

There are still obstacles: Most Democrats think that one of the options consumers should have is a government-run insurance program, but many Republicans see that as a pathway to "socialized medicine." Yet the momentum for reform is such that compromises regarding the public plan are already proliferating.

True, Congress will have to pay for all this. But a little-noticed provision in the Senate budget resolution assumes that health-care reform will cost money upfront but produce savings later. It would give the government a decade to get costs and expenditures in line, opening some fiscal space for a deal.

Oh, yes, and there happens to be a rather popular person in the White House passionately committed to the cause -- so dedicated, in fact, that he is willing to let Congress write the bill. When the Clintons created their own plan, it arrived on Capitol Hill an orphan. Obama's will have many parents.

The president has invested too much in health-care reform to lose this fight. So he won't.

ejdionne@washpost.com

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