Cautious Candidate, Cautious Plan

Democratic presidential hopeful Sen. Barack Obama, D-Ill., speaks during a Memorial Day reception with veterans, Monday, May 28, 2007, in Davenport, Iowa.
AP Photo/Charlie Neibergall
This column was written by Jonathan Cohn.

In Iowa on Tuesday, when Senator Barack Obama gave a speech about health care, he started by introducing Amy Chicos and telling her story. It seems that Amy and her husband, Lane, run a small business providing broadband Internet access to their small town. Twenty years ago, Lane was diagnosed with cancer — and ended up losing a lung, a leg bone, and part of his hip. He's in complete remission now, which is the good news. But, as a cancer survivor, he has sky high insurance premiums. The Chicos now pay 40 percent of their income for health insurance. They struggle to pay for the basic necessities, like food and gas. They have no savings, either — just huge credit card debt and the prospect of bankruptcy looming in the near future.

After recounting this saga, Obama suggested that "This is not who we are. And this is not who we have to be." He then proceeded to unveil a plan designed to help the Chicos and the millions of other Americans who face financial hardship because of medical bills — by reducing the cost of medicine and by helping people to pay for insurance.

Exactly how many people would he help and by how much? Is his proposed scheme the best possible way to achieve that? Those are two important questions, but before we get to them let's step back for a moment.

In the context of a primary campaign, with policy proposals flying left and right, it's easy to forget the simple message all voters should take away — particularly if Barack Obama really does end up as the Democratic nominee for president. That message is this: He thinks it's wrong that people have to go through what the Chicos have gone through. He thinks society has an obligation to fix that problem. And he's got a plan that would help accomplish this.

These are all good things — and, at least relative to whatever Republican he runs against in 2008, they more than recommend him for the job.

Still, it is not November 2008 yet. It's May 2007 — at the early stages of the presidential primaries, when we have the luxury of deciding between multiple candidates. And, while proposals like these are not the sole basis on which to make decisions about who we would like our parties to nominate, they offer us a lot of valuable insights.

Indeed, when evaluating a health care proposal like the one Obama put out on Tuesday, the plan's details matter most for what they tell us about the candidate who settled upon them. All policy decisions require making trade-offs. So what trade-offs has the candidate made? What does that reveal about his priorities and political instincts? What can we discern about his management style? And does the package as a whole suggest this is somebody who knows how to sell an idea? Here is where the verdict on Obama's plan — or, more accurately, Obama — is mixed.

The best thing you can say about his plan is that he places a great deal of emphasis on actually making medical care less expensive by eliminating waste. His initiatives for doing this — like stressing disease management, investing in information technology, and creating an independent institute to evaluate the effectiveness of treatments — are detailed and well-thought out. This reflects, among other things, the fact that Obama has surrounded himself with some of the leading experts in this field, like economist David Cutler and physician David Blumenthal.

But what about his approach to expanding coverage? From afar, it looks a lot like the plan already put forth by former Senator John Edwards. Rather than provide all Americans with basic insurance from the government — the way a single-payer system would — Obama has opted to leave current health insurance arrangements in place.

His plan assumes that most people who already have private health insurance will hold onto that coverage. As for the people who don't have insurance — or might lose it sometime in the future — Obama would offer several alternatives. Some people would qualify for coverage under expanded safety-net programs like Medicaid. Others would have the opportunity to buy coverage through a new purchasing pool that Obama would create, choosing between closely regulated private insurance plans or a new, government-run program that Obama would offer as an alternative. (Small businesses could also buy into the government-run plan.) Along the way, Obama would throw in subsidies — a lot of them, as a matter of fact — to help people who struggle with medical bills pay for their insurance.

This is all fine and good. There's an undeniable political logic to increasing coverage this way: You're telling people who don't have insurance they'll finally have a realistic chance to get it. And you're telling people who do have health insurance they don't have to feel threatened in any way — they'll get to keep what they already have, only it will be cheaper (because of all the money Obama would save through new efficiencies).

But there are some differences between what Obama and Edwards have proposed. And by far the biggest, most important one is the fact that Edwards has a "mandate" in his plan: He would require every single American to get insurance. That means his plan is truly "universal." Obama says he, too, is committed to covering everybody by 2012. And he has a mandate that all children get insurance. But there is no similar mandate on adults. There is, in other words, no requirement that every adult American have health insurance. And that means his plan is not universal — at least not in the same sense that Edwards and his advisers mean it.

Why does this matter? Obama's advisers, for what it's worth, think it doesn't. Not much, anyway. They believe that their initiative will help cover most Americans within two or three years.