Refocusing the debate

In a make-or-break speech Wednesday on healthcare reform, President Obama is expected to give Congress more details on how he wants to expand coverage, control costs and improve quality. He’s late to the game -- possibly too late. The healthcare debate thus far has been more about politics than policy, with liberals bashing insurance companies and conservatives decrying intrusive government. The president needs to put the focus where it belongs: on the problems in the healthcare system and how to fix them. Doing so, however, will require him to add particulars to the principles he has laid out for “Obama-care.”

The speech is a tacit acknowledgment that the reform effort is floundering in part because Obama decided to let Democratic leaders in Congress lead the effort to draft a bill. The White House took a back seat in the hope of avoiding what happened in 1994, when the Clinton administration’s proposal for “managed competition” sank without a vote in the House or Senate. But Obama appears to have taken the wrong lesson from the Clintons’ failure. The problem wasn’t that the Clinton White House drafted its own 1,000-page bill without attracting enough support from members of Congress. It was the opposition to that proposal from critical segments of the healthcare industry.

This go-round, proponents of healthcare reform have lined up the major industry players -- insurers, physicians, hospitals and drug makers -- behind the key elements of an overhaul. What’s missing, however, is a conviction among voters that the current system is broken. Polls show that most of the insured are content with the status quo and that many of them are unnerved by the talk of fundamental change.

With so many people feeling as if they have no stake in the reform effort, Obama’s opponents have been able to tar the House and Senate versions of the bill with hyperbolic and sometimes nonsensical attacks, such as the fear-mongering references to “death panels” and “socialized medicine.” And as with the proposals to help troubled borrowers, the push for universal insurance has led some consumers to grumble about “responsible” people being forced by Washington to aid the “irresponsible” ones who don’t lead healthy lifestyles. In other words, healthcare reform looks to this group like yet another government bailout.

In laying out his plan, Obama’s first goal should be to offer clear gains for the insured as well as the uninsured. One example would be specific proposals to improve quality and control the runaway costs that threaten to double insurance premiums over the next decade. Those two efforts go hand in hand. The president’s plan should also include measures aimed specifically at chronic diseases, including incentives for prevention and, for those with such diseases, better coordination of care. The bills already moving through Congress offer some good ideas on many of these fronts, but they’re not as aggressive as they should be in combating costs.

Obama should also use his plan to spark a debate over the central principles of healthcare reform -- namely, whether to extend insurance coverage to all Americans and whether it’s desirable to slow the growth in healthcare spending. Universal health insurance is an expensive proposition, with subsidies for the working poor costing $100 billion a year or more. And limiting the money pouring into the healthcare industry means less revenue for someone -- doctors, hospitals, insurance companies, drug makers or all of the above -- and almost certainly a reduction in the services that otherwise would have been delivered. We think the choices are clear. Health insurance should be universal -- it’s not only humane and better for public health, it’s crucial to stopping costs from being shifted from the uninsured to the insured. And unless medical inflation is tamed, healthcare spending will come to dominate the federal budget and the economy as a whole.

Even if the public rallies around those goals, however, the right way to achieve them is still up for debate. Important questions include how to pay for expanded insurance coverage, what role employers should play in health insurance, how to curtail unnecessary tests, how to promote competition among insurers and providers, and how to make consumers more sensitive to costs without discouraging them from getting the treatment they need. By offering his own plan for reform, Obama can finally take a side in those debates and sharpen the public’s focus. Then, perhaps, reform advocates can rally support for systemic change, producing a healthcare system that works for everyone.