Framing Health Care Reform
Washington is giving national health care reform its most serious attention since 1994, when the Clintons’ Health Security Act went down in flames. Gordon Smith highlights a salient political consideration in the political debate over the years—high levels of personal satisfaction with one’s own doctors and other providers. There’s no question that Gordon is right that a major obstacle to reform has been that “[p]eople in the middle class tend to be more or less satisfied with their own health care.” From my research on public opinion about health care reform, I can vouch that the public has reported satisfaction with surprising consistency over the years about their personal health care. Surveys over the last thirty years through today find that roughly four out of five Americans are satisfied with the quality of their medical care. Given that the middle class has been reasonably happy with many aspects of their health care, it has a lot to lose, and as Gordon summarizes from his personal perspective, “reformers have not made a case that health care reform will do anything other than make my life worse.”
A problem for Obama and Democrats in favor of health care reform is that Gordon’s view is not only winning out right now, but it assumes away one of the strongest arguments for reform of some form—that health care costs are increasing at unsustainable rates. In other words, part of the pro-reform response ought to be that doing nothing is also likely to make Gordon’s life worse. The main reason that increased government involvement in health care has gained new support from business groups is that their health care costs are rising rapidly, with little reason to expect any improvement in the absence of reform. Insurance premiums for family coverage have already more than doubled on average over the last decade, and the Congressional Budget Office projects that total spending on health care will account for almost 40 percent of the national GDP by 2050. In other words, if Gordon thinks his health care is manageably expensive today, any successful argument for reform may depend on convincing him that it will be unmanageably so before too long.
It is worth noting that Gordon’s view won the public’s collective mind in 1994. The Clinton initiative was doomed when the middle class, though unhappy with certain aspects of the health care system, decided that reform would give them rationing of care and less freedom of choice over providers. What happened in the absence of reform? Using managed care to slow down cost increases, private insurers instead of government restricted choice to the point that a political backlash ensued and inspired HMO legislation to curb unpopular, at times unethical insurance practices. Once insurers squeezed the cost savings they could find through managed care, costs resumed steep annual increases. Today, fifteen years later, the public finds itself worried again about spiraling costs and the uninsured, with the middle class again worried about government restrictions on choice. The pro-reform argument might be that if reform fails again, we’ll end up in an even worse place in another fifteen years. My point is not a partisan one that any particular plan will or will not limit per capita costs over the next fifteen years, but a short-term framing of the issue might doom even a plan that would.
Of course, even if doing nothing is bad, there’s no guarantee that current proposals for reform actually offer an improvement over doing nothing. As its critics allege, reform could be even worse. A criticism of these proposals is that they would exacerbate, not limit the annual increases in health care spending. Arguments matter about how much health care reform might increase total spending on health care, how well it would limit per capita costs, the value of universal coverage, and so on. These are the fine points of a debate that is getting increasingly heated. But if Obama and Democrats in favor of reform hope to fare better than their counterparts from 1994, then they’ll need to persuade the middle class that the status quo will be really bad in another fifteen years and that health care reform therefore offers something “in it for them” over the longer term.