Where are we on reform? Part 2 (Hacker)
Health Reform Lessons from the Past
Jacob Hacker, PhD
National Conference on the Un and Underinsured
December 12, 2007 (Day 3)
Now I have one big point… and it is that although we are all for the most part health policy wonks, we read Health Affairs, we love to talk about the billions that will be saved doing this and the fine-tuning of mandates and the like, the bottom line is that health care reform is about politics. If real estate is about location, location, location, health care reform is about politics, politics, and politics.
So when the rhetoric heats up reformers are going to have to fight fear with fear. The fear of losing coverage against the fear of government, the fear of medical bankruptcy and debt against the fear of taxes, but they’re also going to have to be able to fight fear with hope. With a clear, simple and unthreatening vision that builds on what exists and meets public concerns head on, a vision that may lack the intellectual satisfaction of a fine-tuned policy blueprint, but which provides the political satisfaction of actually having a chance of passage. Now I think there’s some evidence the reformers have taken this message to heart, though simplicity and clarity still remain pretty elusive in the discussion.
…as we learned this morning, all the top tier Democratic candidates… would include some kind of shared financing requirement with employers either being required to pay or play, and these proposals would all, either eventually or immediately, have some kind of mandate.
Now I think this approach lacks much in terms of conceptual and policy clarity or the inspiration that David Himmelstein provided us earlier today about the sort of large scale reforms we need, but it does have some pretty big political virtues. And I should say I guess in the interests of full disclosure that I’ve been peddling an idea largely along these lines for the last few years. For one thing it means that the vast majority of people who now have private health insurance coverage through their employer would continue to have it.
This time the fight is going to take place on the scorched earth of partisan warfare and that means that we’re going to have to adopt strategies that reflect new political realities. In my view that means a much stronger clarity about ends but much greater willingness to compromise on means, a much greater attention to coalition building from the very beginning, well before a sympathetic President enters office…
http://www.kaisernetwork.org/health_cast/hcast_index.cfm?display=detail&hc=2283
Transcript (Jacob Hacker’s comments begin on page 39):
http://www.kaisernetwork.org/health_cast/uploaded_files/121207-underinsured%20part%202.pdf
Comment:
By Don McCanne, MD
The final Quote of the Day for 2007 discussed the disconnect between a new poll indicating strong support (65%) for “a universal health insurance program in which everyone is covered under a program like Medicare that is run by the government and financed by taxpayers,” and a rapidly growing movement within the progressive community to support a model based on allowing you to keep the insurance you have.
Although the policies discussed in that message were on target, the tone was quite negative and detracted from the important thrust of the policies behind the message. The message included inappropriate cynical misdirections of my obvious anger. I decided that in the first message of 2008 I should clarify and expand on the important message in my last qotd, but in a less pejorative manner.
Jacob Hacker has described very accurately the politics of health care reform. He has suggested an approach that, on surface, would appear to lead to affordable coverage for everyone, while passing the crucial test of political feasibility. His political message is very sound - in fact, so sound that the leading Democratic candidates have adopted his suggestions. He has stressed the importance of coalition building well in advance of the installation of a new government one year from now.
So what coalition activities are we seeing within the progressive community? Many respected, influential leaders state that it is time to set aside the policy debate and proceed with a political strategy that will achieve our reform goals. There is one major problem with this approach: most of the difficult policy issues have yet to be addressed. But several of these coalition leaders have told the policy community quite bluntly that the policy debate is over, and all of the activities now must be about unity. We are commanded to unify behind health care reform that promises that you can keep the insurance you have or have the option to buy into a public program.
That’s it. That’s the policy behind which we are to unify. For the sake of unity, we are not to talk about the inability of the private insurance industry to provide us with affordable health plans that are comprehensive enough to meet our health care needs. We are not to talk about a public insurance program that must provide a premium that is competitive with private plans insuring the healthy, when the public plan is weighted down with high-cost patients (adverse selection).
Even though the policy debate is swept under the table, let’s suppose that the political strategy is effective. When we have a Congress and a president who support an individual mandate with a public option, what process will be used to resolve the policy issues? How will they require the private insurance industry to provide reasonably comprehensive plans that are still affordable? How will they create an optional public program with a concentration of the most expensive patients without a massive taxpayer subsidy? What will the voter response be to a program costing far more in taxes than any of the candidates would acknowledge during the campaign?
The policy issues do matter. The politically motivated promise of an affordable individual mandate and an affordable public option cannot be met. Fundamental structural reform is essential. Unless the politicians are able to engage successfully in bait and switch strategies, the gridlock that has prevented reform will be perpetuated.
Jacob Hacker is correct when he states that we need to intensify our coalition building. But he also states that “this approach lacks much in terms of conceptual and policy clarity or the inspiration that David Himmelstein provided us earlier today about the sort of large scale reforms we need.” Also, “In my view that means a much stronger clarity about ends but much greater willingness to compromise on means.”
Those who insist on unity behind political means while suppressing clarity about policy ends will not be successful in coalition building, and clearly that is not Jacob Hacker’s intent. Those of us who insist on clarity about policy ends will be there to be certain that efforts to compromise on means will be an honest, transparent, and fully informed process.