By Fred Hiatt
Sunday, August 16, 2009
One unusual feature of the congressional debate on health care helps explain why the August meetings with voters may be generating more heat than light: Broadly speaking, there are three sides to the debate -- and none, on first look, is obviously attractive to a majority of voters.
That means that each side has reason to obfuscate its own position or to spend more time attacking the opposition than defending its own views.
Each camp can make cogent policy arguments. Each can even argue that a majority of voters should be on its side -- that its position is in the national interest. But, oddly enough in an era when we assume politicians do nothing but pander, none of the three positions is designed to appeal to a majority of middle-class, already-insured voters.
Take the Cover Everyone Camp. These advocates of universal access, mostly liberal Democrats, can explain why everyone, even the insured, should be on their side. In the world as they would redesign it, people wouldn't have to worry about losing coverage when they lost their jobs. Their young-adult children would be covered when they left the nest. Insurance companies couldn't poke around for some concealed preexisting condition before paying up. Insurance premiums wouldn't be padded, as they are today, to pay for care for the uninsured.
But that padding isn't visible. And the primary beneficiaries of universal access would be the poor and near-poor who today are not insured (and who vote in fewer numbers). Even though the uninsured end up costing all of us money, once they were insured they would receive more health care and cost more money -- and taxpayers who are currently insured would pick up most of the tab. Universal access is, at base, an anti-poverty program, and anti-poverty programs are not usually a ticket to political success.
Then there's the Bend the Curve Camp, the Blue Dog Democrats and deficit hawks in the administration and the Senate for whom health reform is a way to control costs -- to bend their trajectory down closer to overall inflation. They, too, can explain -- and President Obama does so, eloquently -- why everyone should be on their side, how rising costs will bankrupt the government and render U.S. factories unable to compete. They can even explain that, because the U.S. system wastes so much, we could reduce costs and be none the worse for it, maybe even healthier.
But that's a complicated case, made more so by the fact that no one knows for sure how to bend the curve without harming care, though there are promising leads. So it's not surprising that people who are pretty satisfied with their care -- who feel they can see a doctor when they need to, and get whatever tests their doctor orders -- will be made nervous by talk of comparative-effectiveness research and reducing payments for unnecessary care.
Most Democrats, it should be said, would maintain that they are in both these camps; the administration certainly comprises both. There is a battle, nonetheless, between those who emphasize the moral imperative, as they see it, of universal coverage and those who fret more over deficits.
But because both are difficult sells, the administration has shifted to calling its program health insurance reform, and implying that one of its big advantages will be to pry annoying claims adjusters off everyone's back. This was never the main point, and in a world of controlling costs, those adjusters aren't going away. But it's one of the misdirections of August.
It almost gives them too much credit to put Republicans in any camp, because many of them have decided that their best strategy is to hang back and carp. But those who do put forward ideas mostly belong in the Let the Market Work Camp, the idea being that if consumers could see the true costs of their health care, they would make wiser decisions.
This, too, could have its attractions to voters, emphasizing as it does the availability of choice and the satisfaction of stuffing government bureaucrats back into their cubicles. But after a bit of reflection, it may alarm many who have insurance. If consumers are to make these wise choices, after all, it implies that many options now open to them will become suddenly expensive. That's the sort of empowerment not everyone will welcome, especially given that few laymen trust themselves to second-guess medical professionals.
Which may explain why many in the third camp prefer to talk about death panels and rationing rather than the beauties of their own health-care plans.