Dan Balz's Take
Health Care Reform Outlook Clear? Don't Count on It
By Dan Balz
The gathering of industry leaders standing with President Obama in the White House pledging to cut up to $2 trillion in health care costs over the next decade suggests a gathering of momentum behind one of the president's signature domestic initiatives. The train is leaving the station. All aboard!
Perhaps. While 2009 may not be 1993-94, the truth is that it still may be too early to declare that the constellation of forces in favor of reform is cohesive and strong enough to weather the battle that will surely come. Whatever goodwill Obama can create now he will need later this year to persuade the House and Senate -- and the array of special interests involved in health care -- to enact a comprehensive reform package.
The story line is developing that the political climate is dramatically different today than it was during the Clinton administration, when health care reform ultimately crashed and burned without ever coming to a vote on the floor of the House or Senate. There is some truth to that, but not so much as people might assume.
Consider public opinion. In September 1993, 48 percent of Americans surveyed by CBS News and the New York Times said that fundamental changes were needed to fix the nation's health care system. Last month, when the same question was asked, a virtually identical 49 percent agreed with that statement. In 1993, a slightly higher percentage than today said the system was in such bad shape that it needed to be completely rebuilt. On balance, then, there has been no real change in public opinion.
Or take expectations. In January 1993, 68 percent of Americans surveyed by The Post and ABC News said they believed Clinton would make substantial progress in improving the cost and availability of health care in this country. When the same question was included in a poll last December, an identical percentage said they believed Obama would make substantial progress on the front. Again, no real change there.
For those with short memories, the sight of health industry leaders pledging to cut costs voluntarily reminded veterans of the health care fight of two parallels. Going back to the Clinton days, most industry leaders were pledging support for comprehensive health care reform in the early days of that new administration. They only turned against Clinton's plan when the details were unveiled much later. The details of Obama's plan are not yet known.
More than a decade before the Clinton experience, then-President Jimmy Carter called for legislation to impose cost controls on hospitals as a way to rein in rising medical expenses. The industry came forward and said don't bother with legislation, we will cut costs voluntarily. "Congress never passed cost controls and six months later there was no sign of voluntary cost controls," recalled Robert Blendon, professor of health policy and political analysis at Harvard.
Still, veterans of the Clinton battle believe there is a better chance of enacting health care reform this year. "The sense of momentum and commitment to change is powerfully stronger this time," said Judy Feder, a fellow at the Center for American Progress and a former Clinton administration health care policy adviser.
Her conclusion is based on the belief that the deep recession on top of the already sizable burden of rising health care costs has hit everyone -- businesses, middle-class Americans with insurance, the uninsured, government -- harder now than it did coming out of the recession in the early 1990s. That has gotten everyone's attention and, if managed skillfully, could help Obama do what Clinton could not.
Obama also is looking to avoid missteps that cost Clinton. He began his push for health care reform in the first months of his presidency. Clinton waited until much later in his first year and by the time he was in the middle of the health care debate he had been weakened by earlier battles. Obama starts in a stronger position.
Clinton's process shut out Capitol Hill as a plan was developed. Obama has turned over development of a plan to the Hill. He also is prepared to use the reconciliation process to win passage of a plan, something Clinton never tried.
Obama is not talking about a massive government solution, although conservative critics say that's what he wants. He is talking more about cutting costs for everyone who has insurance as he is about expanding access to those without.
Obama also has avoided demonizing potential opponents at this stage of the fight. By the time the Clintons unveiled their plan in the fall of 1993, the health insurance industry, small business and for-profit hospitals already were dug in against it.
A lobbyist who works for business groups on health care issues pointed to the industry leaders standing with Obama on Monday. "Everyone who showed up at the White House has something they're terrified of," he said. "But they decided to take a chance because from their point of view, the president hasn't openly painted a bulls eye on their back."
Translation: It's easy to be for health care reform as long as the toughest issues aren't yet front and center. To date there has been more controversy created over whether a reform package should include a government-run health insurance package than by potentially more significant questions of whether Obama will try to achieve universal coverage and, if he does, what it will cost.
The most difficult issue will be paying for health care reform. Obama outlined some measures in his budget in February, but already some of those ideas have been shot down by Congress. Even with effective cost containment measures, revenues will be needed.
While Obama was holding his second health care event in two days at the White House on Tuesday, the Senate Finance Committee was holding a hearing on possible ways to raise revenues. One idea raised again was to limit the tax breaks afforded to individuals with high-end health insurance plans offered by their employers. Health care experts concede there are no easy ways to raise the revenue for health care reform.
Blendon believes the economic forces that may be creating urgency to act on health care could, in the end, frustrate efforts for truly comprehensive reform. Businesses may well target a reform plan as one that will kill jobs in a recession. Asking people to pay more in taxes in this economic climate also could be politically difficult. "The climate makes it harder to talk about all these issues," he said.
In the end, Obama may have to settle for far less than he envisioned during the presidential campaign, though some of his advisers believe anything that advances the cause of expanding coverage or controlling costs would count as a victory. They seem to have no illusions about the fight ahead. What happened at the White House this week should not be underestimated as a sign of potential, but the president is far from a victory lap on health care.
Posted at 5:18 PM ET on May 12, 2009
Dan Balz's Take
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