Excluded Voices

An interview with Theodore Marmor

The health care discussion of the past year has been remarkable for the narrow range of ideas and opinions that have floated down to the man on the street. Looking back, it appears that journalists have sought out the same organizations and sources to build and shape their stories, offering up what has become the conventional wisdom for reform. To bring more voices into the conversation, our new series, Excluded Voices, will intermittently feature health care experts people who haven’t been on the media’s A-list of sources. (The entire series is archived here.) We want to offer journalists more options for their stories and encourage a deeper discussion. To that end, we’ve asked the experts featured in each post to respond to questions from Campaign Desk readers.

In mid-October, the Philadelphia Inquirer ran an op-ed by Yale professors Theodore Marmor and Jerry Mashaw. The headline, “Health-care plans familiar; Obama and McCain fall into old traps when it comes to financing,” intrigued me—and so did the commentary. “American health policy debates have for some time been dominated by technical fixes, faddish nostrums and gimmicks. The news cycle of commentary about reform ideas is both brief and superficial,” they wrote. I know Marmor, who has also written a classic text on the politics of Medicare, and asked him to elaborate on the points he made in the op-ed—points not being made elsewhere.

Trudy Lieberman: Would you say that your op-ed is bringing a different voice to the debate?

Theodore Marmor: We have a distinctive social insurance voice that has been underrepresented in American public discourse. Social insurance programs in the U.S. are widely popular in a superficial way. You have popularity without understanding. If you were having this conversation in Berlin or Paris, people would easily know what we’re talking about. They wouldn’t use the word “entitlement” as a budget term but a as a social and cultural understanding of the obligation to pay and the obligation to receive when eligible

TL: How has this year’s discussion of health care and possibly next year’s been a rerun of 1993-94, when the Clintons came in with grandiose plans for reform?

TM: Of course, it’s not identical, but the parallels are stunning. The Democrats are all embracing a variant of what we called “pay or play” plans that require employers to provide insurance or pay into a fund to support people buying on their own. The Republicans are all pro-market enthusiasts with more or less commitment to tax credits that permit some expansion of access to care. The variant on this year’s offering is a public plan (promoted by Barack Obama and Hillary Clinton) that over time through competition its advocates hope will become the dominant plan.

TL: What has been missing in this year’s debate?

TM: It’s very different from the debate that occurred from 1989 to 1993, when there was a lot of talk about what we could learn about health care in other industrial democracies. This year’s discussion of that has been anemic.

TL: Why is the debate no better than last time?

TM: A set of analysts have had a mistaken understanding of why the Clinton plan failed. Apparently there is polling data showing that the loss of choice of peoples’ insurance plan explains the loss of support for the Clinton proposals. Pollster interpretation has generated Washington-based wisdom that Americans got scared of losing their employer-provided health insurance, and that’s why they turned away from the Clinton plan. People did fear a big change that they didn’t understand, but that has been reinvented to mean that they are devoted to their employer’s health plan. It’s like equating it to that old saw that a bird in the hand is worth two in the bush except that the bush is fraying at the edges and is disappearing for many. It’s literally idiotic to suggest that the choice of insurance plan rather than the choice of provider is paramount in peoples’ minds. During the campaign, choice of plan became the most important issue as evidenced by Obama’s slogan that if you like your insurance, you can keep it.

TL: Will a public plan work as advocates envision it will?

TM: If it were possible to get enough political agreement to get an attractive public plan to dominate, it would really be possible to get something more straightforward. Supporters have a na├»ve but earnest hope that a “Medicare-like” public plan will be a stepping stone to a dominant public program for most Americans. Those who oppose it will fight like hell to make sure that the stepping stone does not become that attractive.

TL: What are the elements that will make or break a public plan?

TM: Whether the benefits are sufficiently broad to improve on the health care misery that’s out there now; whether they will be simple enough to understand; whether the financing can be managed to account for all the sick people who would join; whether doctors come to see it as a program they can live with more easily than private insurance; whether it will eliminate Medicare’s rigidity in solving problems by formulas rather than by negotiation; whether many more sick people will come to the public plan, making it cost more per capita and thereby less financially attractive than the private alternatives.

TL: Why isn’t Medicare for all being more widely discussed?

TM: It’s too easily a caricature for socialized medicine even though Medicare itself is a popular program. It’s a paradox. To ideological critics, it also represents a tax increase. But ironically, the financial meltdown and the expansion of the government’s role in financial regulation might actually provide an opportunity to open up the discussion in two strategic ways: expanding Medicare incrementally to those between ages fifty-five and sixty-five and adding newly disenfranchised retirees like the auto workers who will lose their health coverage at the end of the year. The second would be a dramatic, one-time chance to expand it to everyone and save the difference in administrative costs between Medicare, which runs about 3 percent, and private coverage, which runs about 13 percent. That is the dirty little secret of Medicare-for-all’s financial advantage.

TL: Is health information technology the new savior for controlling costs, as many have suggested?

TM: It’s an example of wishful thinking on the part of virtuous activists who are mismatched with the problem of cost control. No other industrialized democracy has hit a cost control home run with information technology, and it’s provincial of us to think so. Health information technology may or may not be helpful in other areas like improving care, but it’s not helpful in this one. And it might cost a fortune and become a boondoggle.

TL: What is necessary to control costs?

TM: To control the costs of medical care, you have to constrain the price of medical services, the number of those services, or a combination. The average price of medical services times the volume of those services equals the total of national medical expenditures. That tells you cost control must be controversial. The reason we don’t talk about it is because there will be losers. Cost control requires that there will be financial losers.

TL: What will it take to change the terms of today’s health care conversation?

TM: In my judgment, it would take the president of the United States to lead a fundamental re-examination of the presently limited debate over health care reform.

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.