For the past year, progressives have begun to talk about health care reform as if it is inevitable. Listen to the Democratic Party’s presidential candidates, and it seems just a question of what form the health care revolution will take, how quickly it will happen, and how we’ll finance it. After all, the polls show that the majority of taxpayers, employers and even most doctors want to see a major change. Moreover, health care research shows that if we cut the waste in our system, we could fund universal coverage. What, then, is stopping us?
As regular readers know, I recently attended a Massachusetts Medical Society Leadership Forum where what I heard about the Massachusetts plan made my heart sink. While everyone in Massachusetts wants health care reform, no one wants to pay for it. Those who are receiving state subsidies to buy insurance are enthusiastic. But uninsured citizens earning more than 300% of the poverty level are expected to purchase their own insurance. The state hoped that 228,000 of its uninsured citizens would sign up; as of last month, just 15,000 had enrolled. Many have decided that they would rather pay the penalty than buy health insurance.
At the forum, Robert Blendon, professor of health policy and political analysis at Harvard’s Kennedy School of Government, talked about what Massachusetts’ experience might mean for the national health care debate: “Massachusetts is the canary in the coal mine,” Blendon, who is also a professor at Harvard’s School of Public Health, declared bluntly. “If it’s not breathing in 2009, people won’t go in that mine.” If the Massachusetts plan unravels, he suggested, Washington’s politicians will say “If they can’t do it in a liberal state like Massachusetts, how can we do it here?”
I’m not writing Massachusetts off. The state’s leaders are behind the plan and they may be able to persuade the Commonwealth’s citizens to come on board. But it won’t be easy.
In the meantime, this week I decided to ask Blendon some follow-up questions: Just what would it take, politically, to achieve national health care reform sometime in the next two to four years? How many seats would reformers have to capture in Congress? Is this likely? Some observers say that if a reform-minded president hopes to succeed, he or she will have to ram a plan through Congress sometime in 2009. But health care is complicated; wouldn’t it make more sense for a new administration to take its time and explain what it is doing to the public, while trying to create a sustainable, affordable, high quality health care system?
Finally, what are the biggest barriers to reform? If major change proves impossible, what more modest back-up plans should a new president have in mind? What other health care legislation could he or she hope to pass?
I went to Blendon with these questions because he has had extensive
experience plumbing the Mind of the American Public while conducting
polls for the Washington Post, the Henry J. Kaiser Family Foundation
and Harvard. And what he has learned is that, beneath the seemingly
uniform surface of the polls, “the public’s views on health care issues
are often more complex and conflicted” than they appear.
Moreover, while some people have immersed themselves in the intricacies
of health care policy, and others are well-versed in the intrigue of
American politics, Blendon knows both–as his cross-appointment at the
Kennedy School and the School of Public Health suggests, and when I heard him talk in Massachusetts, I was persuaded– even though
he was not saying what I wanted to hear. Blendon understands “the
political process.” And he knows that it is not rational. Democracy is
messy; success depends on winning hearts as well as minds; an emotional
appeal can trump the most logical argument. And unlike the legal
process, there is no guarantee that the political process will resolve
disputes or end in agreement.
When I talked to him this week, Blendon began by elaborating on why he
believes that in 2009, any new administration will face a “poisonous”
political climate, making compromise on health care difficult. “Whether
we decide to stick it out in Iraq, or whether we pull the troops
out—which I think we will—we’re going to go through a very painful
period, like the period that followed Vietnam. Rather than returning to
domestic politics,” Blendon predicts that the country will be mired in
a debate about “who lost the war. Whoever wins the White House, there
will be a huge split in this country about how the war ended.”
In the best-case scenario this could lead to a search for an issue that
we can agree on. Couldn’t healthcare be that issue? Maybe. “But if
the debate over SCHIP is any model,” Blendon warns, “it shows that it
is not easy to find compromises on these issues.”
If conservatives win the presidency they are likely to pursue small
changes focusing primarily on increasing tax breaks for those who save
to buy insurance, Blendon observes. Progressives, on the other hand,
are committed to doing “something large.” But even if they win, he
says, they won’t have much time to forge a grand compromise.
In an ideal world, reformers would spend the first year of a new
administration studying the problem, educating the public, and forging
alliances that lobbyists wouldn’t be able to fracture. In the past I
have written about going slow, and doing it right.
But Blendon is convincing when he argues that “there is no relationship
between how you would think, analytically, about health care reform and
how the political process works. That first year you’ll have six to
eight months to get something done. By the second year, legislators
start to worry about getting re-elected” (which makes them exceedingly
During that six-to–eight-month window, a wily president should meet
with the leaders of the major committees, Blendon advises, to see if,
behind the scenes, they can begin to strike a bargain. “Reformers need
to ask ‘what are the points that are absolutely critical to various
interest groups if we want them to find reform acceptable?’ You want
many people to feel that they have had a major say. Then they should
develop a very general plan.”
“This is what Mitt Romney did when he forged a plan for Massachusetts,”
Blendon points out. “This is what Johnson did with Medicare. Of
course, Johnson had the advantage of having grown up in the Congress.
He had a sense of everyone there, and what was most important to them.
And Johnson was pragmatic.”
It’s worth remembering how Johnson won the day. He knew that he had to
appease both the American Medical Association and the lobbyists
representing the hospitals—and to do that he would need to follow the
very expensive precedent set by the private insurers, Blue Cross and
Blue Shield. He would have to agree to pay doctors “fee-for-service”
based on whatever prices were “usual and customary” in their community,
while paying hospitals not what a service might be worth, but whatever
it cost the hospital to provide that service. Thus the most inefficient
hospitals would be paid the most and as new specialists came to a
community they would continue to raise the bar for what was “usual and
customary” in that town.
The Johnson administration’s domestic policy advisor, Joseph Califano,
later recalled the moment when the president capitulated to the doctors
and hospitals. “The key meeting, I remember vividly…we sat in President
Johnson’s little green office and he said ‘We’ve got to get this bill
out of the House Ways and Means Committee. What will it take?’
“And Larry O’Brien [then the administration’s congressional liaison]
said, ‘We have to give the doctors what they want and give the
hospitals what they want.’ Johnson said, ‘What will that cost?’ O’Brien
said ‘Half a billion dollars a year.’
“Johnson said, ‘only $5000 million a year? Give it to them. Let’s get the bill.’’’
Johnson was shrewd enough, and experienced enough, to know that before
long the tab for this compromise would climb. But Johnson wasn’t trying
to craft a perfect bill. He was trying to get something through
Congress. Later, it could be fixed.
Similarly, today, reformers should forget about finding a perfect
solution. “The very best plan for reform would be polarizing,” Blendon
warns. “Every interest group would oppose it, and it would never pass.
What reformers need to do is to decide which groups they can bargain
with. In Massachusetts they decided they could make a deal with the
insurers. But reformers will need to work quietly behind the scenes,”
he argues, finding concessions they can live with—or fix later. In
other words, the operation needs to be covert, and it needs to be quick.
The critical issue will be how many seats progressives are able to win
in Congress, Blendon adds. The votes on SCHIP suggest that very few
Republicans will vote to fund substantial reforms. And not all
Democrats will vote for a major change. “If Democrats took a dozen
seats in the Senate and 20 in the House, that could give them a
Johnson-like landslide,” says Blendon, referring to the historic
plurality Johnson enjoyed in 1964. “It would be very difficult,” he
adds. “Possible, but very difficult.”
Meanwhile, reformers need to remember that, beneath the polls saying
that everyone wants a change, “the public’s view is more complicated.
Middle-income people with insurance are risk adverse,” says Blendon.
“Legislators need to be very careful about how they try to re-arrange
coverage for the middle-class. Even if these people say they are
dissatisfied with the present system, they think they have a lot to
lose—especially if they haven’t been seriously sick and tried to
actually use their insurance.”
Blendon is convinced that if a progressive is elected, he or she will
attempt major reform. But, if that first strategy fails, a president
will need a back-up plan. Offering subsidies to states willing to experiment with reform could be
a fall-back. “In the short term, if six states could show that it can
be done, that might be a way to push the idea forward,” he suggests,
“while at the federal level, Congress could vote to cover more kids
under SCHIP and Medicaid.”
It’s easier to forge a compromise at the state level, Blendon argues,
“because the political pressure is more diffuse. State legislatures are
less politically polarized. They’re more pragmatic. In Washington, you
have a huge set of ideological barriers.”
Moreover, when Congress passes legislation, it must, by law, provide a
ten-year forecast of how it will fund the new law “In Massachusetts,
they only had to show how they would pay for it over two years.”
Congress also would have to agree on exactly what benefits a universal
plan would offer—glasses? Dentistry? One can only imagine the number of
interests groups that would be knocking on legislators’ doors.
Massachusetts was able to hand that problem over to a board to work
Still, the road to healthcare reform at the state level would be paved
with political land mines. “You would have problems with states like
Mississippi where 24% of the population doesn’t have insurance, and you
don’t have a wealthy tax base,” Blendon points out. “They would need a
huge grant from the federal government. Would Congress give them a
grant without guidelines?”
Blendon reports that in California, reform is currently “stalled” on
the question of how to pay for it. In Massachusetts, he is hopeful that
the state may be able to overcome resistance. “But it will take time.
You need targeted advertising. Young adults don’t think they need
insurance: ads should remind them that they could be in a car
accident. And you need moral suasion. You need signs in doctor’s
offices saying, ‘by this date, you are supposed to have coverage.’”
“I’m optimistic primarily because of the quality of the leadership in
Massachusetts backing the plan,” Blendon adds. “They don’t appear to
want to walk away from this bill.”
Will Washington’s politicians show as much political will?