All the President’s Words, Part II

Slogans for change, or a movement for change?

What case did the president make for reform Wednesday night? Not a very persuasive one, in my view. For me, the big takeaway from President Obama’s press conference was that finally—finally—he revealed what this year-long exercise has been about. Whether viewers caught it among all the rhetoric was another matter. For the most part, learning anything specific took a lot of listening between the lines of his sometimes long, rambling, and off-point answers. They left viewers in the dark about most major issues.

In his opening remarks, the president let slip that health reform at its core was about health insurance reform. After a few words about his Recovery Act, the president said “we must rebuild it (the economy) stronger than before. And health insurance reform is central to that effort.” He did not say reform was fundamentally about covering the growing ranks of the uninsured, or making certain that insured people have enough coverage when serious illness strikes, or guaranteeing health care as a right without having to buy an insurance policy to pay for it.

For those who like their coverage, the president promised “more security and more stability.” But employers provide the security and stability through the benefits they choose to offer. The government doesn’t have control over that. He promised that reform “will keep government out of health care decisions.” But insurance companies make those decisions now, and they will continue to do so under Obamacare.

For those without coverage and for small businesses, Obama said they could choose a “quality, affordable health plan” through a health insurance exchange, which he said was a marketplace that promoted choice and competition. Those Celinda Lake words again. No insurance company would be able to deny coverage for preexisting conditions, he noted, but he didn’t mention that companies still might be able to charge older (and presumably sicker) people more money.

The individual mandate is central to health insurance reform efforts that would make carriers cover sick people. Insurers insist on a mandate which will require all Americans to have some kind of insurance, either through a government program, their employers, or policies bought on their own. But hardly anyone has mentioned the mandate, or how it would force cash-strapped citizens to either buy insurance or pay a tax penalty. Wednesday night the president did not tell ordinary Americans why the individual mandate was a good idea. There was only a cursory reference to it in response to a question from NBC’s Chuck Todd, who asked how the president planned to expand coverage. The president said that the bill estimates that 97 or 98 percent of people would be covered, adding:

There might still be people left out there who, even though there’s an individual mandate, even though they are required to purchase health insurance might still not get it or, despite a lot of subsidies, are still in such dire straits that it’s still hard for them to afford it and we may end up giving them some sort of hardship exemption.

One thing the president did make clear was that his plan would not add to the deficit, and must also slow the growth of health care costs in the long run. His recipe for doing that: change payment incentives, so doctors and nurses can give the best care rather than the most expensive care, and transfer some authority for setting doctor fees to an independent agency, in order to help eliminate some of the politics that inevitably surround payment decisions. It’s hard to say whether people really understood what all that meant. His pledge to refrain from increasing the deficit raised the thorny problem of paying for subsidies needed to help the uninsured buy insurance. (About 85 percent of uninsured people will need them.) Here, there was little clarity.

The AP’s Ben Feller asked whether the president had told House and Senate leaders how he wanted to pay for subsidies. “Are you willing to share that stand of yours with the American people?” Feller probed. The president digressed, offering a verbal tour of health care inflation. Then he mentioned his favored solution—limiting itemized deductions for rich people. “People like myself could take the same percentage deduction that middle class families do,” he said, adding that he was open to other ideas. He said the House had suggested a surtax on those with incomes greater than $1 million, a solution that meets his principle of not burdening people who are already having a tough time. Exactly what he supports, he did not reveal.

When ABC’s Jake Tapper asked about what Americans must give up to make reform happen, the president replied: “They’re going to have to give up paying for things that don’t make them healthier. And I—speaking as an American, I think that’s the kind of change you want.” Then Obama’s answer dissolved into a long discourse on doctors and hospitals not doing enough to coordinate care, and how that adds to premium costs. He talked about the deficit, and how his administration would continue its efforts to reduce it by eliminating waste in the system, like the F-22 weapons program.

Other than a question about obtaining a list of health care execs who’ve visited the White House, there were no questions and no words about the special interests swarming over Congress. In the past, the president used his national bully pulpit to rail against them. More astonishing was the lack of questions or remarks about the Massachusetts health plan, the model for the legislation coming out of Congress. The plan has run into serious financial trouble, which has caused state officials to drop some people from subsidized coverage. Even though the president mentioned that preventative care like check-ups and mammograms save lives and money, no reporter challenged the assertion about saving money. As Campaign Desk has shown, that would have been an easy one to push back on.

And there wasn’t much talk about the controversial public plan—no details on whether everyone could use it, or whether it would pay doctors rates similar to Medicare, which would help deliver its presumed cost advantage. Only near the end of the conference, in response to a question from Cleveland Plain Dealer reporter Steve Koff, did the public plan come up. The president repeated what he has said before: a public option would “help keep the insurance companies honest.”

For the most part, the press didn’t push hard enough. Perhaps that’s because of the constraints set by a presidential press conference. There isn’t much opportunity for follow-up questions; and, after all, if your intitial question is too tough, you won’t be invited to ask one the next time. But the press still has another chance. Reporters can bone up on what they didn’t ask this time, and try for the nuances and particulars at the next one. Or they can use the conference as a starting point, and tell their own stories about what the president did not say.

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Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR's healthcare desk, which is part of our United States Project on the coverage of politics and policy. She also blogs for Health News Review. Follow her on Twitter @Trudy_Lieberman.