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.