The Minimalist Case for Continuing with Health-Care Reform

A democratic congressman explains how if Obamacare is repealed, it will only result in further stalemates on how to fix the system. Returning to the status quo is clearly not an option. 


Flickr/Alex E. Proimos

Almost every economist agrees that the American health care system is unsustainable. Medical care is so expensive that it is busting all of our budgets -- government, business, and personal. Eventually, the medical price bubble will pop.

Repeal is great politics, because it ignites public hatred. It will not automatically lead to improvement, however.

What, then, are the alternatives? In 2010, the federal government started implementing a new approach that will cover virtually everyone with health insurance while encouraging doctors and hospitals to deliver care more efficiently. Health providers are getting some 30 million more paying customers in return for agreeing to waste less money.

It's called, of course, the Affordable Care Act (ACA), or Obamacare. Drafted by congressional Democrats, it bears a striking resemblance to Governor Mitt Romney's state-level reform in Massachusetts, Romneycare. Despite the popularity of most of its components, the ACA is highly controversial (constitutional issues aside) -- and also poorly understood and needlessly partisan.

I like to tell opponents of the ACA that before you criticize the law, state your preference for an alternative, because -- remember -- the status quo is not an option. Republican talk of "repeal and replace" is very heavy on "repeal" and light on "replace." Repeal is great politics, because it ignites public hatred. It will not automatically lead to improvement, however, because passing major health-care reform takes many years -- even decades, if history is any guide. Repeal will almost certainly return us to the status quo, with all of its dangers. Replacement has become virtually impossible now, after the 2012 Republican primaries, because no candidate has offered a constructive alternative.

The Supreme Court should also be wary of overturning the ACA, because, as even Justice Scalia noted, how can you surgically remove parts of a 2,700-page bill without killing the overall reform? Justices can only subtract, not add: their proper restraint in legislating from the bench prevents the construction of a coherent alternative.

So let's cool the rhetoric. As we say in Tennessee, "Any mule can kick a barn down -- it takes a carpenter to build one." Where are the carpenters in either political party?

I am the Democrat who wrote the alternative to Clintoncare (Cooper-Breaux), championed the leading alternative to Obamacare (Wyden-Bennett), and who often votes for Band-Aids that Republicans pretend are alternatives to genuine reform -- association health plans, health savings accounts, interstate insurance sales, malpractice reform, and premium support.

Almost all of these centrist and Republican proposals have failed to become law, except for a few demonstration projects, even when Republicans controlled the White House and Capitol Hill. Most of these proposals never had a chance. Nevertheless, I am proud of working hard for bipartisan health-care reform. As Jefferson said, "Great innovations should not be forced on a slender majority." This is particularly true in health-care reform, because health issues are so intimate and existential.

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I have the battle scars to prove that there are precious few plans that could conceivably pass Congress, other than the one that recently defied the odds, the ACA. To the dismay of passionate advocates, single-payer has no chance, nor does herding Americans into high-deductible plans. Ideologues on the left and right should put their dream scenarios on hold -- let's make the ACA work. America's greatest strength has always been pragmatism.

Failure to produce more workable alternatives to the ACA is probably one of the worst policy voids in American history. Like Sherlock Holmes' dog that did not bark, this dearth of alternatives is an important clue, at least to our modern political gridlock (if not our permanent decline). Why does an urgent societal problem have so few publicly offered and publicly acceptable solutions? Do we lack imagination, or is Congress unable to embrace good ideas?

Don't underestimate the staying power of the status quo. As Princeton University's Paul Starr has pointed out, the $2.6 trillion that Americans spend on health care annually exactly equals $2.6 trillion in incomes. No recipient will admit to wasting any of that money. Making 17-plus percent of the nation's economy more efficient is very, very difficult.

Most of my centrist reforms were borrowed from Alain Enthoven, the Stanford economist who invented "managed competition." (Don't confuse this with managed care.) Enthoven wants everyone to shop for health insurance the way federal employees have done for 40 years: by paying large-group rates for any private insurance plan that you pick from an annual menu. The sales pitch is "Buy health insurance like a congressman." Under managed competition, market forces hold government regulation and subsidies to a minimum.

Clintoncare proposed and Obamacare contains many elements of managed competition, but not enough to attract major Republican support. In the meantime, at the urging of the parties' more partisan elements, health care has become the main fault line in politics.

Nevertheless, despite these large and growing obstacles, people who think that bipartisanship in health care is impossible haven't tried very hard. I called my 1993 alternative "Clinton Lite" and still attracted dozens of Republican cosponsors. Before the ACA was drafted in 2009, I had recruited top liberal Democrats to lead the House version of Wyden-Bennett, along with a significant number of Republican cosponsors. Several Democrats like me have also supported Republican Band-Aid reforms. I've nearly dislocated my shoulder reaching across the aisle.

In hardball politics, however, bipartisanship is never rewarded -- it simply means that you failed to negotiate hard enough. True partisans draft legislation that gives themselves everything and their enemies nothing. They love bills that repulse and even disgust the other side. Today's politics have become an all-or-nothing, black-or-white, zero-sum game -- it's not a contact sport but a blood sport.

Bipartisanship is a necessary but not, of course, sufficient criterion for good legislation. Republicans forced the 2003 Medicare drug bill through Congress with the help of dozens of Democratic supporters, but not me. That bill added a record $7 trillion in unfunded liabilities to the national balance sheet despite being less costly than projected, making the ACA look fiscally responsible in comparison. Bipartisanship should never result in collusion to buy votes.

The ACA is like an overdue software upgrade: painful but vital. Ideal operating systems do not exist and, even if they did, could not be installed in time. The truth is that health-care reform will always be a nuisance, with version 2.0 followed by next year's 2.1. As long as it boosts productivity, it's worth it.

Remember, our old operating system is crashing. Without a feasible alternative, anyone who stands in the way of making the ACA work -- and fast -- bears an existential responsibility.