THE TREATMENT SEPTEMBER 9, 2009
The White House is warning everybody not to parse tonight’s speech for bargaining positions. President Obama’s address to Congress, officials say, is about connecting with the American people--reminding them about why health reform is necessary and why, done properly, it will work. It is not about issuing ultimatums.
Still, people will be looking for clues about Obama’s priorities. That’s particularly true for those of us who follow the debate closely, whether we’re watching from inside the House of Representatives or, like the rest of America, from inside our living rooms. We all know what Obama wants to do and how he he proposes to do it. But he can’t get everything he wants. What’s most dear to him? What will he defend to the last? What will he give up, grudgingly but willingly?
Some of us will focus on the public plan; others, on less visible issues like malpractice reform or insurance regulations. Me, I’ll be paying attention to the concept of universal coverage.
It’s not a particularly sexy word, or so the political consultants say, so I don't really care if Obama invokes the phrase. But I care about the idea. It’s the idea that anybody can get health insurance, regardless of income or medical status; and it’s the idea that, as a practical matter, just about everybody actually has health insurance. And, by health insurance, I mean good health insurance that protects people from financial catastrophe--and gives them access to the medical care they need. If you earn $40,000 a year and have to fork over $15,000 to pay your medical bills, that’s not good insurance.
Universal coverage makes sense for myriad reasons, at least some of them appealing, in principle, even to conservatives. A system where everybody has insurance--and everybody pays for that insurance, at least within their ability to do so--is more economically efficient than what we have today. But, at least for me, universal coverage is a bedrock principle because of a more fundamental, more personal argument. Simply put, it means everybody can get health care when they need it, at a price they can afford. It’s a moral issue, partly, in that it’s about protecting those people who don’t have such access now. But it’s also a matter of self-interest--because almost every one of us is just one layoff or one illness away from facing the prospect of financial or medical catastrophe.
In an ideal world, reform would achieve universal coverage in relatively short order--two or three years, the time it would take to put in place the institutional framework for delivering coverage, whether it be public insurance, private insurance, or some combination of the two. But doing that costs a lot of money. I’ve said before reform, done right, would cost more than $1.5 trillion over ten years. (Ideally, it would start to pay for itself not long after that.) But the political environment does not support that. Obama has put just under $1 trillion on the table. And it’s not clear Congress will go even that far. This stinginess is disgraceful, in my view. But it’s also reality.
So what’s the fallback? If you have $1 trillion to spend, how can you spend it? One possibility is to acknowledge that reform this year is merely incremental--to cover kids and maybe some working-age adults, and leave it at that. It’d still be a historic achievement, one that would make life better for millions of Americans--and one on which more expansive reforms could later be built. No liberal in good conscience should shun such an option.
But it’s still possible to spend a $1 trillion a little differently--to set up the institutional framework for reform and then pump money into the system, gradually, so that by some fixed date in the future nearly everybody has insurance. My understanding, like Ezra’s, is that many members of the administration favor this approach. And the bills that have made it through committee so far more or less hit that mark. All of them would take several years to phase in but, by the end, they would have brought insurance to 97 percent of legal residents. (Undocumented workers are another matter, alas.)
The danger is that, in order to squeeze out votes from conservatives skittish about taxes or other revenue sources, Congress pares back the funding even more--that instead of spending around $1 trillion, as these bills would, Congress appropriates even less, forcing even more compromises. But if the trajectory has to change, the destination shouldn’t. Universal coverage within ten years isn’t as good--isn’t nearly as good--as universal coverage within five. But it’s still an important threshold to cross.
Why? Among other things, it establishes a principle that everybody should be guaranteed access to insurance. And if that principle is enshrined in law, it will take an act of Congress to change things--an act we’re not likely to see. The great thing about universal coverage--the element that really spooks Republicans and conservatives, as it famously did in the 1993-94 fight--is that, once established, you can never take it away, precisely because the people cherish it.
In the past, Obama has said this principle is important to him. Notwithstanding the consultants' wisdom, his budget promised that health reform would "aim for universality"--specifically, that it would "put the United States on a clear path to cover all Americans." The wording was deliberate and the result of internal debate. It was seen as, and meant to, set a standard--one that might not be met for a long time but one that Obama wanted to meet eventually. It would be good if, tonight, he could reaffirm that commitment--or at least indicate, somehow, that he’s not giving up on it.