Obama's Speech Promises Much, But Delivers Few Details

Last Updated Sep 9, 2009 10:17 PM EDT

Early in President Obama's speech on healthcare reform to a joint session of Congress, he said, "I am not the first President to take up this cause, but I am determined to be the last." Like much of Obama's rhetoric, this remark had a certain ring of inevitability to it. But, even if the plan he outlined passes Congress, it's likely that future Presidents-or even Obama himself, if he wins a second term-will have to revisit the subject.

Overall, the tone of the President's speech was moderate. While supporting a public option, for example, the President made clear that it would be only one method of lowering insurance costs as part of an insurance exchange for uninsured individuals and small firms. Pointing out less than 5 percent of consumers would be expected to enroll in such a plan, he appealed to Democrats and Republicans not to turn it into a political football (which it already is). He also made bipartisan gestures such as proposing reform of malpractice laws-a longtime Republican goal. But although the Republicans stood and applauded that line, they clearly have no intention of supporting the Democratic health reform agenda.

The President called for a mandate that individuals buy insurance, and he also said that employers above a certain size should offer insurance to their employees or "chip in to cover the cost of their workers." That was reassuring, although it's not clear whether companies that don't insure their employees will get off with a slap on the wrist, as in Massachusetts and the Senate Finance Committee bill.

Of course, universal coverage will require government subsidies and the expansion of existing government programs. Obama said that the cost of his proposal would be $900 billion over 10 years, but would not increase the federal deficit. "Reducing the waste and inefficiency in Medicare and Medicaid will pay for most of this plan," he said.

This is the point at which many Americans-myself included-would have liked to hear some more details. But, rather than get bogged down in a wonkish exposition, the President contented himself with a vague allusion to the great work being done at large, integrated delivery systems like Intermountain and Geisinger. Somehow, he suggested, "an independent commission of doctors and medical experts" would come up with ideas for spreading the magical quality and efficiency of these organizations to the mostly unorganized, fragmented mess that is American healthcare today.

When Obama promised that the forthcoming legislation would include a clause requiring future spending cuts if the promised savings did not materialize, thunderous applause erupted in the audience. But the areas in which savings are expected-such as health IT and better preventive and chronic care-will not cut cost growth in the near term, according to experts. So this provision guarantees that the legislation would have to be revisited to avoid severe Medicare cuts.

More seriously, the lack of real cost control measures in any of the current measures before Congress means that people who can afford to buy health insurance this year won't be able to afford it next year, and that government subsidies will keep rising until Uncle Sam runs out of money.

I'm as much in favor of reform as the President is, and I hope he succeeds in getting a bill that will move us toward universal coverage. But I'm also virtually certain that this is only the first act in what will probably be a decade-long drama.

  • Ken Terry

    Ken Terry, a former senior editor at Medical Economics Magazine, is the author of the book Rx For Health Care Reform.