The pundits are busy filing their reports on how President Obama blew it on health care reform. And while the health care fight is far from over--I remain convinced the Democrats will pass a bill, maybe even a good one--the pundits have a point. Obama surely has made mistakes, among them focusing so heavily on how reform would reduce the cost of medicine. Had he spent more time reminding voters that reform would provide them with the security they now lack--security from financial ruin and medical catastrophe, the type private insurance too rarely provides--he probably would have been better off.
But I'm not so sure this was obvious a few months ago, when Obama kicked off his campaign for health reform. On the contrary, I seem to remember quite a few writers and television commentators gushing over Obama and his advisors' aggressive approach to the cost problem. Remember, these were the days when Washington feted Budget Director Peter Orszag as a celebrity and turned "bend the curve" into a bumper sticker. And while you can--and should--write some of that off to typical Beltway mood swings, there were, at the time, plenty of reasons to think that Obama's approach made sense.
First and foremost, it made sense substantively. Like a lot of longtime universal health care advocates, I've long focused on the need to give people economic security. Although improving the quality and reducing the cost of medical care seemed like worthy endeavors, those imperatives struck me as secondary. Very secondary.
But the evidence of unnecessary, even harmful medical care--compiled most famously by researchers at Dartmouth College and conveyed in books like Shannon Brownlee's Overtreated--has simply become overwhelming. And the argument that health care is a threat to our long-term fiscal health--as advanced, most memorably, by Orszag before he joined the administration--has become impossible to ignore.
As a society, we can theoretically spend as much as we want on our health. Twenty percent of GDP, thirty percent, there's no law of economics forbidding that. But the money spent on medicine is money not spent elsewhere--it's government dollars that didn't go into schools or public housing; it's employer dollars that didn't go into wages or other benefits. And don't forget that, as health care gets increasingly expensive, it becomes harder for people to buy insurance--thus exacerbating the economic security problem.
Of course, the right policy isn't always the easiest policy to sell. This is where political judgment comes in. Just because Obama was determined to make cost cutting a serious priority doesn't mean that he had to sell it that way. But here, again, it's easier to make the right call in hindsight. Americans still remain skeptical of government. And, particularly among political independents, government spending remains a proxy for waste. Making a big deal about how reform might curb health care spending--and, thus, ease the long-term burden on the federal budget--seemed like a perfectly plausible way to reach these voters.
No less important than the predispositions of voters was the predisposition of senators. For better or worse--and I would certainly argue worse--the makeup of the Senate means that small, relatively conservative states are represented. Throw in the filibuster, which can stall debate indefinitely until 60 senators vote to break it, and it becomes almost impossible for Democrats to pass legislation without convincing at least a few of their centrist members to go along. These centrists have turned balancing the budget into a fetish (although, it's worth noting, they frequently make exceptions when it comes to helping out local constituencies or campaign financiers). Again, showing seriousness on cost control seemed like the best way to keep these senators in line.
The trouble for Obama is that, in getting serious about cost, he gave critics lots of fat, juicy targets. Obama proposed to tie payments to quality; Betsy McCaughey said he would be giving doctors money for pulling the plug on grandma. Obama proposed to put a board of experts, using clinical evidence, to set Medicare payment rates; Sarah Palin interpreted that as creating a "death panel" that would declare the sick and disabled unworthy of treatment. The great irony is that by trying earnestly to craft a plan that could control costs, as well as expand coverage, Obama has provoked a political backlash that will make cost control harder in the future. He's tried to tackle health care like a grown-up and, at the moment, he's suffering for it politically.
Should he have seen this coming? Should his advisors? Maybe. But plenty of other people missed the signals. And, speaking as one of them, I can easily see why.
By Jonathan Cohn:
Reprinted with permission from The New Republic.