Obama's hands-off approach to health care reform looks ever more questionable. I'm getting tired of listening to speeches that state uncontroversial goals--widen coverage, curb costs, free doctors from useless paperwork, improve medical outcomes--but have little or nothing to say on how these things might actually be done. It's one thing to refrain from ramming a fully worked-out blueprint down the throat of a skeptical Congress, another entirely to step back altogether from fundamental questions of design and cost recovery.

Obama is failing even to express preferences. Aren't hard choices supposed to be his specialty? To listen to the administration, one would suppose that there are no hard choices in health care, only easy ones: for example, to curb costs, simply widen coverage. Who really believes that? It is a dream world.

Yes, he has backed the public plan option, which seems to imply a view of some kind--but what does that proposal actually mean? As this new FT column of mine argues, it is surely disingenuous to say that a public plan can be just another competitior. How can just another competitor "keep them [the private insurers] honest"? If the public plan makes a difference it will be because of its market and political power, and because of its ablity to attract subsidy--in short, because it is not just another competitor. If in turn it exerts those pressures, Obama's pledge that nothing will change for Americans who have private health insurance they like will be impossible to honor. Not even Obama can reform a system without changing it.

Incidentally, the headline on that column--"Medicare for all may be the best cure for the US"--was a little over-exuberant. The piece says that Medicare for all might be better than the current system, but that isn't saying much. In fact I think a system based on well-regulated private insurers is still the best bet. That is unlikely to be where we end up if a public option is included and empowered to make a difference. The momentum in that case would indeed be toward Medicare for all. The main point of the article is that if Obama does want to shove the US in that direction--as many other Democrats plainly do--then he, and they, should say so and start making the case.

For more on the hard choices in health care reform, here's another recent column I did on the subject for National Journal.


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