While I'm generally trying to stay away from the evening news about health care reform because it's so god-awful stupid and off the mark, I was listening to MSNBC a few nights ago, and caught Newsweek's Jonathan Alter's thoughtful remarks on the prospects for passage of health care reform---he thinks it looks pretty good---when suddenly the MSNBC commentator shifted the subject to public opinion polls showing growing concern about health care reform.
The MSNBC commentator (David Shuster) said, excitedly, "Everyone's talking about it!"
Exactly what is the "it" that everyone is talking about? Is Washington excited that the public is now worried about reform and Obama's "plan"? What Obama plan? There are "plans" in Congress. The public hardly knows anything about what's happening in Congress and the experts don't know much more. But there is no Obama plan.
What the public opinion polls are clearly registering is the general nervousness about everything, including the deficit, the economy, the bail-outs, and what have you, and they're worrying that we may bobble this whole reform process.
Why shouldn't the public be worried? We're all concerned as hell that Obama and the Democratic Congress may bobble this thing. But most certainly the public still wants reform. Even after the failure of the Clinton "plan", the public opinion polls showed that the public wanted reform, and not just by a small margin.
This is because, as the president has said, not doing anything is no longer an option. Without reform the private insurance plans we have today will cost twice as much 10 years from now. How could that possibly be a good thing? Will we all be making twice as much in 10 years?
The public almost certainly knows that doing nothing is no option. They just don't want Congress to screw it up. I know it's hard to believe that there is so little confidence in the U.S. Congress.
My guess is that we will get passage of a reform bill, probably in October, that will represent real progress but it will be far less than it should be. My guess is that some form of the public plan will survive without much real teeth in it but it will be fixable.
The total bill will be very expensive but the expense will be offset in substantial part by raising taxes on the very rich (which is a good idea on the face of it after the Bush tax cuts) to help pay for this and other measures. I'm betting the public will grasp this and will gradually grow comfortable.
The next battles will come as the next steps are taken to really begin to slow down cost growth and to strengthen the public plan. One important battle is the need to pass cost control from Congress to a group of outside experts called MedPAC (Medicare Payment Advisory Commission).
The trouble is, and this is the major problem with the way reform is being advanced by Congress and Obama, when it is all over the public that already has insurance may still have a hard time figuring out what Congress and Obama have accomplished for them. It may not feel much like our middle class anxieties about health insurance will be assuaged. And that's not good.
And the Republicans and the Blue Dog Democrats will rail and rail and rail about the costs (even after passage). These are the very same people who voted for President Bush's disastrous tax cuts for the rich and the disastrous Medicare prescription drug bill.
Both of these measures were fiscal equivalents of health care reform and both made the future all the more difficult for all of us by not even pretending to become fiscally responsible. The reason we're all talking about costs is that Obama and the Congress are trying to be fiscally responsible. That's in part because this is being advanced under the rules of the Budget Reconciliation Act which requires fiscal accountability.
Here's the point. The public opinion polls for reform will sag, and continue to do so for the foreseeable future. That's natural. The public wants reform and yet it also is nervous about reform. That shows the wisdom of the public.
What the Congress needs to do and the press needs to remember is that whatever we wind up with must have some palpable reassurance to the middle class that they are safer in the future against soaring health care costs than they are today.
In fact, this need for public understanding should have driven the reform agenda from the very beginning.
The reason I'm always going on about starting reform with an expansion of Medicare, in some important way, is that the whole reform process starts with something the public knows, understands, and generally supports. The public plan should have been billed as "building on Medicare," giving it a new but familiar name, like Med 2 or Med21 or perhaps constantly refer to it as "Medicare-like."
Senator Kirsten Gillibrand, D.-New York, calls it "Medicare-for-All." I really like that.
And thoughtful commentators like Jonathan Alter use similar language.
The public program, while it will contain many who are poor, should be so designed so that the middle class who lose their insurance can join it. (I'm not sure that the House bill will include this provision.) The public should be given important assurances that we're headed for a future that will make their lives easier and more secure.
And reforming the private insurance industry should require them to provide the Medicare benefit package, or something similar, to again give the public a clear sense of where we're heading. The private insurance industry already processes the paperwork for Medicare and they are well familiar with the program.
The industry clearly smells an "all-payer" system based on Medicare's power to negotiate provider rates for all insurance, public or private. This is not a single payer system but in truth that may be the best we can get in the next decade or so.
Medicare is popular and expanding it, modestly at first and in cautious but novel ways, will force the Republicans and the Blue Dog Democrats to attack a program that's popular even in the South. Like the hypocrites they are, these "I'm against it" foes of progress will wail that Obama is going to ruin Medicare, the very program they ache to privatize and eventually ruin.
And we should have fought for some visible and understandable cost control measure, like giving Medicare the right to negotiate with the drug companies over the cost of pharmaceuticals.
If we had won that fight, the public will know that this battle is for real and not a nightmare of complexity.
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