Why Health Care Reform Is So Troubled

The commenters in Mark Thoma's threads seem to think that the administration erred in trying to modify the plan in order to buy votes in Congress.  I take this as symptomatic of how the debate played out on progressive blogs, magazines, and columns; Paul Krugman is exhibit A.  People were led to expect that Obama could pass a plan through mere force of will, "cracking heads" and bulldozing Congress into something close to the left-wing technocratic version of health care reform.

This was never, ever going to happen.   The Democratic conventional wisdom, true or not, is that Bill Clinton lost because the overwhelming majority of folks who have insurance, and are basically satisfied with their health care, freaked out when they realized that their coverage was going to change.  The Clinton administration argued to no avail that it would change for the better; people are risk averse, and too many of them simply didn't trust the government with their own health care.  So the kind of massive grotting around with the innards of the health care system that progressives envisioned was DOA.  And so was the best hope for cost control.

The commenters also believe that the Blue Dog fascination with budget deficits is ridiculous, since it's a small part of the overall budget for the 10 year period.  This ignores the fact that this "small" deficit persists even after the Democrats have used their most politically popular arsenal.  A surtax that will bring the total tax increase on very high incomes to 10%, plus smaller increases below that.  And this assumes that all the cost savings planned will materialize.  Much has been made of the government's ability to batter down prices.  But in fact Congress has a history of passing health care cuts and then undoing them.  Cat care is one example.  There's also the automatic cuts in physician reimbursement, which are ritually repealed in an annual kabuki ritual, because physicians say that they will stop taking Medicare, and/or voting for politicians who support the reimbursement cuts.  What happens if cost growth exceeds projections, the way it has in Massachussetts, and AFAIK, every Federal health care program ever?  Where do we get more money?

A lot of people seem to have thought they were going to get a bill designed by wonks, instead of an ugly and self-interested political process.  Obama's tried to avoid Clinton's fate by staying out of the fray, which has only made the bill even worse.  If Democrats want national health care, they need fewer wonks, and more Lyndon B. Johnsons.