By Jonathan Oberlander, Ph.D.
The New England Journal of Medicine
October 25, 2007
The Clinton administration’s misadventure carries several broader lessons about the politics of health care reform. First, no matter how much momentum it seems to have, no matter how many signs point to change, there is nothing inevitable about health care reform in the United States. In U.S. health policy, the status quo is deeply entrenched and, despite all its failings, the system is remarkably resistant to change, in part because many constituencies profit from it. Thus, although everyone decries the amount of money spent on health care, the political reality is that national health care expenditures represent income to health industry stakeholders, whose interests lie in ensuring even greater spending.
Second, many Americans are satisfied with their own health care arrangements, so reforms that threaten to unsettle those arrangements risk running afoul of the voting public. Health care reformers must thread the needle by persuading the anxious insured that reform is in their best interest and that the uninsured can be covered without disturbing (and ideally, while enhancing) their coverage.
Third, expanding government authority over a health care system that accounts for more than $2 trillion and one sixth of the economy in a country that is ambivalent about public power is an inherently controversial exercise. No universal coverage plan, no matter how clever, can evade that ideological debate.
Fourth, paying for health care reform remains a formidable challenge. The Clinton plan collapsed largely because the administration could not secure congressional support for an employer mandate, but no obvious financing alternatives have emerged in the ensuing years, and persistent antitax politics and federal deficits constrain the options for reform.
Fifth, U.S. political institutions limit presidential power, foster divisions in Congress, create opportunities for those with vested interests to block change, and generally complicate the adoption of health care reform.
Finally, the window for enacting a comprehensive plan for health care reform never stays open for long, so failure comes at a high price — namely, the loss of political will to do anything meaningful about the uninsured for some time to come.
NEJM Audio Interview with Jonathan Oberlander:
I really believe that for health reform to pass things have to get worse, and they have to get much worse for the middle class. As long as this is an issue about people on the other side of the tracks, it’s not going to pass. It has to be a case where the president and members of Congress are really hearing that their middle class constituents who, after all are the ones who are voting, are hurting, and I’m afraid actually that’s exactly where we’re headed.
http://content.nejm.org/cgi/content/full/357/17/1677
Comment:
By Don McCanne, MD
It would be a shame to see so much more suffering occur before we could achieve reform. What would the healthy want to hear now, before their personal finances are threatened by medical costs, that would make them want to change to a public program ?
They need to be convinced that the coverage would be superior to what they have, with greater benefits, fewer out-of-pocket costs, and free choice of their health care professionals.
Perhaps even more persuasive would be the assurance of permanent health security. No longer would individuals potentially be one paycheck away from losing their insurance merely because of loss of employment or the desire for early retirement. A public program would be there for them for their entire lives.
So we should ask Americans whether they want to wait for the pain, or prevent the pain. If they want to prevent it, they need to let Congress and the president know.