Medical Miracle

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SEPTEMBER 10, 2007

Medical Miracle

The gathering took place in late May, at a conference center some 80
miles north of Salt Lake City. To the casual observer, it would have
seemed like a rather ordinary businessmen's meeting. Inside a
windowless room with handsome wood paneling, about 300 people sat
at round tables, sipping juice and finishing off eggs from the hot
breakfast buffet. Up on the stage, a tall, gangly figure worked his
way through a rudimentary PowerPoint presentation. He spoke crisply
but in a relative monotone; with the lights dimmed, a few audience
members nodded off. But those who stayed awake saw a remarkable
speech- -and, potentially, an important one. That's because the
man at the podium was Bob Bennett, the Republican senator from
Utah. And he was there to champion his new favorite cause:
universal health insurance.Step by step, he made the same statistical case for action that
Democrats have been making for years. More and more people were
losing their health insurance; even those who had it were
struggling to pay their bills. Employers who gave their workers
coverage were in trouble, too. Bennett assured the audience, a
typically conservative slice of Utah's small-business community,
that he shared their disdain for the familiar liberal solution of
having government insure everybody through a so-called single-payer
system. But, he explained, there was an alternative based on
free-market principles. It was a bill proposed by one of his
Democratic colleagues, Senator Ron Wyden of Oregon. Everybody would
have insurance, but, Bennett promised, it would be private coverage
rather than a new government program. Competition, not government
edicts, would hold down costs. The Wyden bill wasn't perfect,
Bennett said, but it was an awfully good start--so much so that,
just a few weeks before, he had agreed to co-sponsor the measure.

The audience responded positively to Bennett's message, just as two
of his Republican Senate colleagues-- Lamar Alexander of Tennessee
and Judd Gregg of New Hampshire--have done in the last month. And,
while that's a total of just three co-sponsors out of a Republican
delegation numbering 49, it's a significant development all the
same. For most of recent memory, Republican lawmakers in Washington
have followed a dictum first issued by Bill Kristol during the 1994
Clintoncare fight: Oppose universal health insurance "sight
unseen." But now the right's political outlook seems to be changing.
The rising cost of health insurance has rattled some
Republican-leaning interest groups, mainly large employers seeking
relief from skyrocketing employee health premiums. Two prominent
Republican governors, Mitt Romney in Massachusetts and Arnold
Schwarzenegger in California, have embraced universal coverage
schemes for their states. Given Bennett's standing in the
party--he's widely respected and known to be close to Senate
Minority Leader Mitch McConnell--it seems likely he'll win more
converts soon.

But then what? Bennett's stated reservations about elements of the
Wyden proposal aren't exactly surprising, given that Wyden is one
of the Senate's most liberal members and Bennett is a bona fide
conservative. And those objections seem mild when compared to what
the other co-sponsors have said. When Gregg announced his support
for the bill, known formally as the "Healthy Americans Act," he
issued so many caveats that it was fair to wonder what, exactly, he
had agreed to endorse. In 1994, Republican support for compromise
health care reforms eventually proved hollow; then-Senate Minority
Leader Robert Dole ended up disavowing not one but two universal
coverage bills he had previously co-sponsored. Bennett's enthusiasm
is encouraging, to be sure, but is there reason to think that
he--or his party--will act differently this time?

Bennett's own history on health care traces back to the battle over
the Clinton plan, when--as a junior senator in his second year--he
served as one of several Republican henchmen charged with blocking
the initiative. As Bennett explained to me during an interview, the
Senate GOP leadership set up a working group with about a
half-dozen senators, assigning each one part of the Clinton
plan--with orders to research it and develop convincing arguments
against it. They met twice daily and, eventually, honed an
effective strategy for derailing reform: seize on a controversial
provision, develop a stinging critique, and then take that message
to the public. By summer, when then-Majority Leader George Mitchell
had ditched the politically unviable Clinton plan and substituted
his own alternative, the work became easy--since, according to
Bennett, the hastily drafted scheme was full of ill-conceived
provisions. "Whichever senator got today's clunker would go after
Mitchell--and then [Mitchell] would have to admit that this was
really bad, have an amendment to take it out, and then the next day
it would come down," Bennett recalls. "Eventually, he had to pull
the whole bill down."

Today, Bennett says he watched the demise of Clintoncare with more
sadness than anger. And, as a former businessman who recalls his
own frustrations dealing with employee health insurance, he says he
hoped to revisit the issue in 1995, once Republicans took over
Congress. Dole agreed to let Bennett lead the Republican task force
on health care--a group that the late Rhode Island Senator John
Chafee had led during the Clintoncare fight and that had nearly
devised a successful compromise plan. But Bennett says the "moment
of exhilaration ... lasted until the first meeting," once it became
apparent that a lowly task force would have no power now that
Republicans controlled their own committees. And, while those
committees would enact some modest health care reform measures,
like the State Children's Health Insurance Program, universal
coverage vanished from the congressional agenda.

That's how things remained until the past fall, when Democrats won
back Congress and, seizing the opportunity, Wyden first introduced
the Healthy Americans Act. Although Wyden had not been a pivotal
player on health care like, say, Ted Kennedy or Jay Rockefeller,
his plan was noteworthy for its ambition. Eschewing the incremental
approach of recent years, Wyden wanted to insure every single
American. At the same time, Wyden knew that passing a bill meant
overcoming the inevitable filibuster from opponents, which meant
getting 60 votes, which in turn meant winning over at least some
Republicans. So, rather than call for creating a new government
insurance program or expanding existing ones--non-starters on the
right--Wyden proposed creating a marketplace through which
everybody could buy private insurance. The insurance would have to
have generous benefits, which meant offering something like what
members of Congress get; it would have to be affordable, which
meant providing lower-income Americans with subsidies; and it would
have to be available to everybody, which meant forcing the
insurance companies to sell to all comers, regardless of pre-
existing medical conditions. But it would still be private
insurance. And, since people would be shopping around for coverage,
insurance companies would theoretically have to compete for their
business based on price and quality-- unleashing the kind of market
forces in which conservatives have faith.

As Wyden went door to door, making his pitch, Republican colleagues
were friendly but skeptical--Bennett among them. "I said the
standard thing any senator says: 'Well, I'll have a look at it,'"
Bennett remembers. "That's as firm a 'no' as you're going to get."
But, when he dispatched a staffer to review the Wyden plan, the
response surprised him: There seemed to be a lot of common ground.
Like many conservatives, Bennett had come to believe the
fundamental problem with health insurance was the fact that most
working people get coverage through their employers, who select the
type of coverage and pay a large share of the premiums
directly--thereby taking away employees' choice and insulating them
from the real cost of their medical care. The Healthy Americans Act
essentially eliminated the employer system altogether. Bennett, like
many of his GOP colleagues, had also become very concerned about
the unhealthy lifestyles of many Americans--and the way those
habits contributed to rising health care costs. Wyden's bill
proposed to address this problem, too, by offering financial
incentives for enrolling in wellness programs. After checking with
McConnell to make sure he wouldn't run afoul of the party
leadership, Bennett agreed to hold formal conversations with Wyden.
(Wyden sought, and received, the same blessing from Senate Majority
Leader Harry Reid. ) Eventually, he signed on, with the caveat that
he was endorsing the general approach but not every specific
feature.

How big a deal was this? Under the Healthy Americans Act, the
federal government would discourage insurance companies from
competing to avoid medically risky beneficiaries--the way they do
now--by prohibiting insurers from discriminating based on
pre-existing conditions. That's a whole lot of regulation. People
with high incomes and generous health benefits would end up losing
some of their existing tax breaks--which is to say, they would pay
(slightly) higher taxes. Some conservatives are sure to attack that.
And, of course, it would achieve universal coverage--the
traditional Republican bugaboo. But Bennett has signed on to these
features and, on more than one occasion, defended them. At a recent
event co-sponsored by the Heritage Foundation and the New America
Foundation, a questioner asked Bennett what he would tell a critic
who called the plan a tax hike. Bennett retorted that such a critic
is "incapable of reading a piece of legislation," since the plan
simply makes explicit--and redistributes more equitably--the hidden
payments people already make for the nation's health care bill.

Still, there are sticking points. Early on, Bennett objected to
Wyden's promise that all Americans would have insurance "as good
as" the coverage members of Congress get. Bennett thought that
promised too much; the federal employee system (through which
members get their coverage) offers a menu of choices, with higher
prices for more generous plans, and he saw no reason to promise the
high-end plans for which most members of Congress presumably opt.
And, while that issue was easy to finesse--Bennett just talks about
giving all Americans the "same choices" that members have--it's
fair to wonder how many other Republicans would go as far as
Bennett has. Among the "serious concerns" Judd Gregg enumerated in
his endorsement was "the imposition of mandates." But it's the
mandates--on individuals to buy insurance, on businesses to help
pay for it, and on insurers to provide it in a fair and equitable
way--that make the plan work. Without them, the Healthy Americans
Act would quite literally fall apart.

Not that Gregg's reticence is surprising. All the mandates and
regulation in the Healthy Americans Act really are pretty
antithetical to modern conservatism- -more, perhaps, than Bennett
wants to admit. It may not be government-run insurance, but it's
still more government-- a lot more, as a matter of fact. At one
point during our interview, I noted that new state agencies would
get heavily involved in the business of buying and selling health
insurance-- screening private insurance companies to enforce
standards for pricing and benefits and acting as a conduit through
which people would actually select their coverage. In effect, they
would become giant purchasing cooperatives-- which, as it happens,
is more or less what the dreaded Clinton plan would have done.
Bennett denied the similarity, but his explanation wasn't
particularly convincing--and it was fair to wonder whether he, or
other potential GOP supporters, might change their minds once
Congress takes up the issue seriously. Moreover, will
bipartisanship still sound appealing if it means passing a bill for
which Democrats will, undoubtedly, get most of the credit?

Bennett thinks there is plenty of political credit to go around--and
warns that a strategy of pure obstruction could simply build
momentum for a single- payer system. (This is one of many reasons
why it's so important to keep single- payer part of the
conversation; it scares opponents.) And at least one veteran of the
Clinton effort--New America economist Len Nichols, who helped craft
the Healthy Americans Act--is equally optimistic: "Is there enough
common ground to build a real reform? Absolutely."

Even my own skepticism waned a little after speaking to Bill Johnson
of Vernal, Utah, who attended Bennett's speech back in May. About
ten years ago, Johnson told me, he had to sell his small mobile
home construction company and take a job with a bank, in good part
because his wife had developed several chronic conditions,
rendering her uninsurable in the individual market. "I think she
takes about twenty-five different drugs," Johnson said, "and if we
had to pay for them out of pocket, we'd go bankrupt in a pretty
short amount of time." Johnson called himself "a pretty staunch
right-wing type of person ... pretty typical for us out in Utah."
As such, universal health insurance was not an idea he had
entertained seriously--until he saw Bennett's presentation. "I'm
not going to say we should implement this thing tomorrow, but let's
take a closer look at it," he said. Given the history of
conservative thinking on health care, that's progress.

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