Make the case -- now

After Congress adjourned for its annual August recess, many lawmakers were welcomed home by boisterous protests from opponents of healthcare reform. There's more than a whiff of ersatz outrage -- the backlash apparently has been orchestrated by GOP partisans who think that blocking the overhaul will help them derail the rest of President Obama's agenda. Nevertheless, the protesters' ability to overrun town meetings reflects how small a stake most attendees feel they have in the reform effort and how skeptical people are about the need for fundamental changes to the way healthcare is provided and financed.

A poll by the Kaiser Family Foundation in July found that only 39% of those surveyed believed they would be better off if Congress passed a healthcare reform bill; 32% said it wouldn't make much difference, and 21% said they'd be worse off. Those numbers, more than the noisy demonstrations, spell trouble for advocates of a healthcare overhaul. Unless their constituents demand them, lawmakers won't push for contentious changes in such a vital part of the U.S. economy. Any proposal will founder in the face of the inevitable complaints from interest groups. But the monthlong break in the congressional schedule gives proponents a chance to build a stronger foundation for reform. They should use it to convince Americans that the existing healthcare system badly needs repair, while also rebutting the argument that Washington is trying to take over the healthcare system.

Costs of the current situation

The case for an overhaul should be easy to make, at least in principle. Healthcare costs have been rising rapidly for years, eroding coverage, squeezing family pocketbooks and consuming an ever-greater amount of federal and state budgets. Meanwhile, millions of people with a history of illness have been unable to obtain coverage, and tens of thousands have been bankrupted each year by medical bills -- even many who had insurance. Left unchecked, healthcare spending will not only drive the Medicare program into insolvency within a decade but will eventually dominate the U.S. economy. And although Americans spend more per capita on healthcare than people in other industrialized nations, they get less from their investment.

At the same time, support within the industry for major changes has never been greater. Insurance companies, doctors, hospitals, pharmaceutical companies and device makers have all agreed to help slow the rise in costs significantly over the next decade. Insurers have also pledged that if all Americans are required to obtain policies, they will no longer deny coverage to anyone or raise premiums on the sick. These concessions alone would be a major victory for consumers, millions of whom are a layoff away from being uninsured. Broad agreement also exists among policymakers about fundamental flaws in the current system that promote wasteful spending, encourage overconsumption by the insured and downplay prevention.

The consensus weakens, though, when the focus shifts from diagnosing the problems in the system to prescribing solutions. There are important debates to come on how to pay for covering the uninsured, the most costly piece of the package by far; how to guard against under- insurance; how to change reimbursements to encourage efficiency and wellness instead of rewarding volume; how to increase the availability of primary and preventive care; and how to provide patients and doctors with better information about the cost and effectiveness of treatments. Many of these steps would reduce revenue for some segment of the industry or impose new regulations, which is why they won't become law without a fight.

'Single-payer' panic

The staged public tussles have rarely touched on these details. Instead, opponents have tried to tar healthcare reform with the same brush used on Obama's other initiatives: It's an attempt, they say, to impose centralized control from Washington. Exhibit A is the public insurance plan proposed in bills approved by two House committees and one Senate panel. This federally managed coverage would be available to those not protected by a group plan, ostensibly to compete with private insurers and hold down premiums. But the government would dictate the terms of that competition by requiring private insurers to meet the same minimum standards for coverage as the public plan.

Echoing the complaints from insurers, who say the government can't be trusted to compete fairly, conservatives say the so-called public option would drive private insurers out of the market. They also argue that the proposals lay the groundwork for rationing care to the elderly. We've said before that those claims aren't credible. But some backers of healthcare reform have fed the fear of a government takeover by calling it a first step toward their preferred model: a "single-payer" system in which the government, not private companies, provides all health coverage. Obama's previous support for a single-payer approach has been a factor too, as has Washington's aggressive interventions in the automobile, banking and insurance industries.

Having a public option could spur competition and provide a proving ground for techniques to promote wellness. But advocates of healthcare reform should bear in mind that the main goal is to pass a bill that expands coverage, restrains costs and improves quality -- objectives that can be achieved without creating another health insurance program run by the federal government. They also should pay more heed to the public's distrust of government. For instance, the House bill includes a lengthy provision authorizing Medicare to pay for counseling on "end-of-life services" -- a proposal that some critics allege is designed to save costs by cutting short care to the elderly. It's a cynically absurd accusation. But until the voting public recognizes the real stakes in reforming the healthcare system and how much they stand to gain, we're left to debate absurdities instead of substance.

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