Health Reform: Diagnosis, Cure, In Progress

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That nyaaaaaaaah you heard yesterday was the sound of Republicans realizing that Democrats are pressing ahead with comprehensive health care reform a lot more quickly than they had previously anticipated. The frenzy of lawmaking has made it difficult for Republicans to try and frame the issue, and they're late to the game. We have a pretty good idea, at this point, of what the national health insurance picture will look like post-reform. And privately, Republicans are pessimistic that that they can gin up enough public anxiety to prevent a major transformation that reflects, in general, the Democratic Party's principals.

President Obama makes the broad case today, attempting to further kindle a sense of urgency (as if there wasn't enough already!), in a major, programmatic speech. And on Monday, Obama brings his case to the most ornery and important of constituencies: the American Medical Association... the doctors... (the AMA's members tend to be more skeptical than the average doc)... the folks whose decisions influence the system more than any other actors.

Here's a brief sketch of the state of play, as of today. Consider it a clip-and-save of what you'd need to know if you were asked to give a cocktail party encapsulation of the reform efforts.

1. The White House's apparent flexibility on such items as the oomph given to a "public plan" and the way to pay for reform is... actually very real. There is a consensus among Obama advisers about what they'd like to see, but there is also a consensus that what emerges from Congress will be good enough.  What would Obama like to see? My guess is that they like the idea that Sen. Olympia Snowe is proposing. Snowe would allow a robust "public plan" (see below) to kick in if and only if the insurance industry can't come up with a way to reduce health care costs, cover everyone and raise the general level or care. Time horizons differ, as do penalties.

2. For a "public plan" -- that is, a government-run health insurance plan -- to do what reformers want it to do, it needs to be financed with something other than the premiums that individuals or employers pay into it. So far, only the House of Representatives' health care bill contains a "public plan" that is remotely like an additional entitlement. And even in the House, it's not clear whether the plan is big enough to do what reformers really want it to do: pressure health insurance companies to forfeit in a few years because the government's plan is so manifestly better than the private options.

3. Sen. Max Baucus seems to have delineated the boundaries of what type of public plan he'd accept. He could possibly accept a plan that bypasses government altogether; Sen. Kent Conrad has thought about regional non-profit plans that are "public" in the sense that they aren't subject to profit motives but not government-run in the sense that bureaucrats won't make decisions.  Or, Baucus could accept a non-robust public option, run by the government, that nonetheless is a real but limited competitor to private plans.

4. Don't pay too much attention to the debate about public plans; there doesn't seem to be enough support for a robust plan that would transform the system into single-payer.  Pay more attention instead to the debate about financing. Right now, the most conservative estimates of what universal health care will cost the government over 10 years would require an infusion of about $200 billion to $300 billion more dollars than is currently budgeted.  Either premiums will have to rise, the government will have end the exclusion on taxing health care premiums (similar to an idea that John McCain supported as a presidential candidate and one that may test the limits of the White House's vow not to raise taxes on those earning less than $250,000 a year), benefits will have to be reduced; care will have to be rationed; or administrative costs have to be strangled.  Obama has endorsed a few measures to avoid tax hikes; he'd give a Medicare evaluation panel the power to set prices subject to a congressional veto.  But the question is far from settled, and there are major political considerations to bear in mind, like regional variations in the cost of health care.  The current tax-free nature of health benefits is a sop to the middle class at the expense of those without insurance, and it will probably find its way into the dustbin.

5.  In the long-term, what makes universal health care affordable is its universal-ness. Healthy individuals pay, in essence, for the chronic care of sicker individuals. The trick is to figure out how to force healthy people who pay for health care out of pocket to buy insurance. They account for roughly half of the uninsured population. Requiring them to buy insurance would solve the problem, but figuring out how to penalize people who refused is politically tricky.  White House officials want universal, universal coverage, but they're open to plans that phase in a mandate; these plans would start with children and work their way up to healthy adults.

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Marc Ambinder is an Atlantic contributing editor. He is also a senior contributor at Defense One, a contributing editor at GQ, and a regular contributor at The Week.

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