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November 16, 2008, 9:30 pm, New York Times
In this installment of Health Care Watch, Stuart M. Butler and Ezekiel Emanuel talk about what President-elect Barack Obama should and shouldn't do on health care reform.
Think Small By Stuart M. Butler
Stuart M. Butler is the vice president for domestic policy at the Heritage Foundation, a research foundation. (Full biography.)
My fellow Campaign Stops contributor, Ezekiel Emanuel, is right that Barack Obama's election could be transformative for health care as well as other areas of policy. Let's hope Mr. Obama doesn't blow it, as others have on health care - most notably Bill Clinton. Getting it done right will require Mr. Obama to keep four things strongly in mind or his honeymoon on health care will end soon.
First, he has to make a strong commitment to bipartisanship, which was distinctly lacking in President Clinton's health strategy and helped assure its demise. Not often obvious during the heat of the election season, there has been a good, honest conversation about health reform across the reasonable political spectrum in recent years. We saw it in Massachusetts. We see it in the bipartisan proposal introduced by Senators Robert Bennett of Utah and Ron Wyden of Oregon. We see it, too, in Massachusetts' senator Ted Kennedy's wide outreach in the last several weeks, and in bipartisan conversations about health tax reform and health exchanges. Mr. Obama needs to tell the more triumphalist liberal supporters on Capitol Hill to chill, and that he's looking for common ground.
Second, these very difficult economic and budget times underscore the need to find better ways to use the money we are currently spending on health rather than throwing tens of billions in new money at the health industry in an effort to expand coverage. That's why reallocating the $200 billion tax expenditure on the tax exclusion is so critical. Ezekiel Emanuel and virtually every other health expert agrees with me on that. Mr. Obama must not adopt a "not invented here" attitude just because John McCain proposed reforming the exclusion. It's a real opportunity for him to reach out to his former opponent and craft a workable bipartisan solution. Fortunately the Democratic chairman of the Senate Finance Committee, Senator Max Baucus of Montana, may have opened the door to that in his own just-released health plan by raising the idea of reforming the tax exclusion.
Third, and in the same vein, Mr. Obama should put meat on the bones of his campaign proposal to allow states flexibility to redesign existing health programs and use money more efficiently to reach the goal of maximizing affordable coverage. I wrote about this in my last post. Again, he can go bipartisan. Various bills in the Senate and the House have been introduced to enable states to receive waivers from existing federal programs and laws to try out bold ways to use funds to expand coverage. Mr. Obama should embrace these approaches. Allowing states to try out major changes first means skeptical Americans can see a model of reform before they are asked to accept it. That strategy was essential in building public support for major welfare reform, and it is needed even more for significant change in the especially sensitive area of health care.
And finally, he needs to remember that Americans are very conservative about their health care. Those with coverage are extremely nervous about changing what they already have. John McCain was hurt by claims that his approach to health care was too radical and might result in people losing their employer-based coverage. Mr. Obama's plan actually masks what would be big changes. As I've pointed out, for instance, millions of workers will discover that they will be put into a public plan by their employers. Once workers with coverage know this, they are going to feel tricked and angry if he pushes ahead with changes that are more substantial than they thought they were voting for.
All the more reason, then, for President-elect Obama to tread carefully, to set up models at the state level so Americans can kick the tires of major reforms first, and to reach across the aisle to build trust and broad support for a workable way of reaching the goal we all share.
November 16, 2008, 9:30 pm, NYT
Think Big By Ezekiel Emanuel
Ezekiel Emanuel, an oncologist, is the chairman of the department of bioethics at the Clinical Center of the National Institutes of Health. He is the author of "Health Care, Guaranteed: A Simple, Secure Solution for America." (Full biography.)
The election of Barack Obama is a historical transformative event. As he and his new administration wrestle with health care reform here are five points to be kept in mind.
1) "Make no little plans. They have no magic to stir men's blood and probably will not themselves be realized." So said Daniel Burnham, the architect and urban planner (and fellow Chicagoan).
In health care, big plans are necessary not only to motivate people but as a matter of sound policy. The health care system is broken. It is not enough to just add more people to a broken system. Health care reform must reorganize the system to deliver higher quality care while keeping costs under control. Incremental change that just covers more people will not be sustainable. Reform must include changing the delivery system and how we pay for care. The health care system needs major surgery, not more Band-aids.
More important, as negotiation specialists note, you don't begin with your compromise position. If we have to settle for incremental Band-aids, it should be only as a last resort.
2) Health care policy is fiscal policy.
Forget Social Security or defense, health care costs are the long-term driving force in federal and state budgets. To control the deficit and keep the country solvent, health care must be solved. Therefore, when the president-elect considers senior economic advisers, one test should be whether they really get health care policy.
Fortunately, Peter Orzag at the Congressional Budget Office does. So do some of the people rumored to be leading candidates for appointments - Larry Summers at the Treasury, Jim Cooper at the Office of Management and Budget and Jason Furman at the Domestic Policy Council. This is very encouraging.
3) Comprehensive health care reform is cheaper.
One of the secrets of health care reform that has not yet sunk in, is that bigger changes to the system actually cost less. Consider the Lewin Group's analysis of the different health care from plans, which I wrote about in an earlier post.
4) No plan is perfect, institutionalize tinkering.
Health care reform will be incredibly complex. As improvements are made, problems will arise and unintended consequences will occur. There will need to be numerous mid-course corrections. Good reform will make addressing these issues easy by not requiring major legislation for each adjustment.
5) Everything is connected.
Health care reform cannot be considered in isolation. The new administration must remember that health care is so big - $1 out of every $6 in the economy, dwarfing automobiles and all other economic segments. Everything is affected by health policy, and every decision should be examined for its impact on health care reform.
Consequently, if the heart of Mr. Obama's economic policy is job creation, then it is contradictory to have a health care reform built on an employer mandate or to fund reform with a payroll tax. Employer mandates and payroll taxes stymie job formation.
Similarly, every favor to a constituency should be linked to support for the health care reform agenda. If the automakers want a bail out, then they and their suppliers have to agree to support and lobby for the administration's health care reform effort. This builds grass roots support.
Since 1913, the United States has been trying to achieve comprehensive health care reform. If the Obama administration finally does it, it will truly be history making. The challenge is huge, but the rewards - for the administration and every citizen - will be even "huger."
Reprinted under Fair Use, in accordance with Title 17 U.S.C. Section 107