Once More, With Feeling!

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In the last month, Michael Jackson departed us for the great Neverland in the sky, and Jon dumped Kate for a younger woman. And yet, with perhaps the grim exception of Larry King, health care reform is now dominating the media. These days, you can't turn on the news, flip through a newspaper, or open a Web browser without hearing about it. And the material is hardly frothy. Should insurance exchanges include firewalls? Should we change the Sustainable Growth Rate? Is it time to create an Independent Medicare Advisory Council? Score one for American political discourse.

And, while these discussions may not always make for scintillating television--more than one commentator came away from Barack Obama's prime-time press conference complaining about the professor-in-chief's tedious explanations--in many ways, the focus on arcane legislative details is a good thing. It's a sign that the president and Congress are serious about the issue--and dealing with it in a serious way. They're way past broad principles and slogans, deep in the weeds of writing actual legislation. And you can't get legislation right if you don't spend time working through the inevitable complications of reorganizing one-sixth of the U.S. economy.

Still, something strange, and not entirely welcome, has happened in the last few weeks: The focus on policy minutiae has crowded out part of the big picture. Health care has become almost entirely a technical discussion, rather than a personal one. It's all about deficit neutrality and bending the curve, instead of making sure every American can get affordable medical care.

Of course, it's true that reform requires more government--and large swaths of the public don't trust the government; many equate government spending with government debt, which they then equate with a bad economy. To win over these voters, Obama and his allies have rightly emphasized their determination to make sure reform pays for itself--and that, over the long term, it will reduce the cost of medical care. By its very nature, that's a complicated, technical discussion.

But the more we talk about making the numbers add up, the less we talk about what those numbers mean. One reason we're talking about reform today is that our system forces Americans to pay too much for what are, frequently, substandard results. But another, perhaps more important reason is that our system leaves a large number of Americans, including many members of the middle class, profoundly vulnerable to the effects of illness. People losing their life savings or their homes because of their medical bills, people skipping necessary care because they can't afford it--these things should not happen in a responsible, modern society. We can't stop people from getting sick, but we can stop sickness from ruining people's lives--or taking their lives away altogether.

Elevating this part of this discussion--the moral dimension--is important for at least one practical reason: It sets boundaries for what constitutes acceptable compromises from legislation. To take one recent example, there's now an intense debate on Capitol Hill over whether to phase out subsidies for insurance purchases at three times the poverty line or four. If it's three, the reform won't require spending as much government money. And that sounds like an appealing choice--until you rephrase the question in human terms. Reducing the subsidy levels to three times poverty would mean that families making more than $55,000 per year would have to pay the full cost of insurance--likely more than $10,000 per year--on their own. That's a pretty big hit, particularly after years of stagnating middle-class wages. And many families simply wouldn't be able to afford it, leaving them vulnerable to precisely the sorts of shocks against which reform is supposed to protect them.

As for the politics, a greater emphasis on morality may help there, as well. Yes, many Americans remain suspicious that Democrats who talk about morality want only to crusade on behalf of the poor--and use middle-class tax dollars to do so. But members of the middle class, even those with insurance, really do worry about dealing with medical bills they can't pay. A promise to erase that insecurity is bound to resonate with them. And, while they'll also want to be reassured about the cost of a program--a reassurance that will inevitably require some technical gobbledygook--a clean, simple message might also put their minds at ease.

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