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Health reform's vital signs

By Fred Hiatt
Sunday, November 22, 2009

Is American democracy in paralysis? That question emerged at a conference of big thinkers and experts in various fields organized last week by Foreign Policy magazine, our sister publication.

To an extent, the question reflects an America-in-decline-ism that becomes fashionable from time to time, especially when the U.S. economy is dragging. The United States always has turned out to be more resilient than the pessimists expect, while the supposed advantages of less democratic rivals (the Soviet Union in the 1960s, Japan in the 1980s) have been trumped by the rigidities of one-party rule. This decade's juggernaut -- communist China -- also faces challenges that may become more evident with time.

Yet as health-care reform sputters and lurches toward an uncertain finish line, the question is understandable. Foreigners see a Democratic Party that supposedly is alarmed by climate change, that decisively captured the White House and both houses of Congress a year ago -- and yet that will send an administration to a crucial conference in Copenhagen next month with little but hopes and promises. Now there is talk that cap-and-trade legislation will wait until not just next year but the next Congress.

Meanwhile, more than a year after his electoral triumph, President Obama has filled only 55 percent of Senate-confirmed slots in his government. He has nominated few judges, won confirmation for fewer. The principal item on the agenda of the unions that went all in for him, labor law reform, is on hold. Almost everyone agrees that America's immigration laws are broken, yet no fix is in sight. Long after the collapse of our financial system, new systems of regulation have yet to emerge. There is no discernible trade policy.

Fretting over a possible quagmire in Afghanistan, the administration appears stuck in its own bog of decision-making. Meanwhile, American power seems powerless to bend events in Iran, North Korea, the Middle East, Sudan, Congo or even tiny Honduras to our south.

Underlying all is the nation's growing debt -- to other countries and to future generations. The retirement system (Social Security) and health insurance for the elderly (Medicare) are headed for bankruptcy, with state and local pension funds and the federal pension insurance fund not far behind. Pretty much everyone understands that the government must spend less and tax more, but the system seems incapable of taking a first step in either direction.

And didn't candidate Obama promise to fix the college football Bowl Championship Series?

Many people indeed blame Obama not only for this year's lackluster football season but for all these other problems as well. Some say he went for too much, too fast, over-interpreting both his electoral mandate and the opportunity presented by the economic crisis. Others say he went for too little, allowing Congress to tangle itself up when he should have been twisting arms and dictating legislation.

Also cited at times are the divisions among Americans, which make paralysis in Washington natural and maybe even healthy. Obama, after all, was backed by only 53 percent of those who voted, who in turn represented only 64 percent of adults eligible to vote. When half the country passionately fears government intrusion and the other half is passionately ashamed that Americans may be dying for lack of health care, reform is not going to be easy.

Or maybe the country isn't all that divided -- most of us would welcome common-sense improvements in health-care delivery and insurance -- but the system feeds on and exacerbates our differences. The advent of the 60-vote rule in the Senate has magnified the already formidable checks and balances built into the Constitution, with the disproportionate blocking power it awards small and rural states. Cable television and the Internet have empowered those with the greatest intensity of feeling. The self-serving redistricting habits of the political elite, designed to protect incumbents, have left most legislators vulnerable only to primary challenges from the extremes of their respective parties.

Whichever explanation appeals to you -- and no doubt they all contain some truth -- the perception of paralysis increases the urgency of passing health-care reform. Failure would damage the Obama presidency, and it would also deepen the fear, here and abroad, that America is stuck.

Paradoxically, though, it also increases the urgency of doing health-care reform right. If Congress and the administration manage only to extend expensive new benefits, without improving the health-care system or controlling rising costs, it will be an achievement -- but not one that will long reassure anyone concerned about the U.S. ability to get things done.

fredhiatt@washpost.com

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