Last fall, soon after Barack Obama was elected president, Sheila Burke was waiting to discuss Obama’s campaign promises, via Webcast, with students specializing in health reporting at the City University of New York’s Graduate School of Journalism. Burke, a health-policy expert who now teaches at Harvard’s Kennedy School, laid a spreadsheet on the table and whispered to another guest. “See,” she said, “we had all these provisions before,” and ticked off the similarities between the current effort to pass health-care reform and those in the past. Burke declined to show me the document, saying that it was proprietary and belonged to former Senator George Mitchell, the Senate majority leader during the Clinton-era reform effort.
But whether Mitchell, Burke (who was Senator Bob Dole’s chief of staff during the 1993 debate), or any of the other health-care heavies from the old days want the déjà vu reality of reform, circa 2009, made public, it has become dismayingly clear that that is exactly what is happening, despite abundant rhetoric to the contrary. “The idea that we’ve made a great breakthrough just isn’t so,” says Jonathan Oberlander, a health-policy expert at the University of North Carolina. “Most of the plans today are direct descendants of what was proposed for the ’93-’94 debate. The debate reminds me of one of my favorite movies, Groundhog Day.
With few exceptions, like the fine series last summer by NPR that explained how a number of other countries handle health care, the press has done little to challenge this reality or help to broaden the health-care debate. Rather, it has mostly passed along the pronouncements of politicians and the major stakeholders who have the most to lose from wholesale reform. By not challenging the status quo, the press has so far foreclosed a vibrant discussion of the full range of options, and also has not dug deeply into the few that are being discussed, thereby leaving citizens largely uninformed about an issue that will affect us all.
The consequences of the failure to have a robust debate are likely to be even greater than they were sixteen years ago. In 2009, the government projects, the cost of medical care will consume 17.6 percent of the nation’s Gross Domestic Product, compared to 13.7 percent in 1994; the number of people without insurance is projected to hit 52 million next year, up from 37 million in the early nineties. A new report from the Robert Wood Johnson Foundation indicates that the number of uninsured could grow to more than 65 million in the next ten years, and that business health costs could double. These numbers suggest the need for drastic measures. But the politically acceptable solutions do not involve radical restructuring. Instead, they build on an existing foundation that relies mostly on for-profit commercial insurers to provide the coverage and for employers to pay for it. The word “universal” has come to mean covering more people with private insurance, not a national health system where every citizen is entitled to medical care and pays taxes to support it.
Absent from the debate are not only single-payer systems like the ones in England and Canada, but other systems with multiple payers, like ones in Germany and Japan—or, for that matter, any discussion of why a system that relies on competition among private insurers in The Netherlands hasn’t resulted in lower prices for consumers, as advocates claimed. What’s common to all these systems is that everyone is entitled to health care and pays taxes to support the system, and medical costs are controlled by limits on spending. The specter of a system that takes a significant bite out of stakeholder profits in the U.S. is the real reason the debate is so restricted.
Reform efforts have danced around this impasse for decades. In the early 1990s, for instance, health experts promoted a pay-or-play scheme—an arrangement in which employers would be required to either offer their workers health insurance or pay into a fund to subsidize those who had none. There was also serious talk of an “individual mandate”—a requirement that everyone have insurance—and of making workers pay taxes on health benefits from their employers. (Both proposals are now on the short list.) Experts in the earlier debate also pitched a public plan under which people not covered by their employer would be enrolled in a government plan. The Clintons did not embrace that idea, but President Obama supports it. Early on in their respective campaigns, both Bill Clinton and Obama rejected the idea of single-payer, code for national health insurance. Indeed, single-payer is further off the table than ever despite enclaves of noisy advocates who have been virtually shut out of the political process.