Consensus emerging on universal healthcare
prospect of bold government action appears to be accepted among
across the ideological and political spectrum, including those
who opposed the
in the 1990s.
Los Angles Times
Noam N. Levey
December 1, 2008
Reporting from Washington
-- After decades of failed efforts to reshape the nation's
healthcare system, a consensus appears to be emerging in
about how to achieve the elusive goal of providing medical
insurance to all Americans.
The answer, say leading groups of businesses, hospitals,
doctors, labor unions and insurance companies -- as well as
senior lawmakers on Capitol Hill and members of the new Obama
administration -- is unprecedented government intervention to
create a system of universal protection.
At the same time, those groups, which span the ideological and
political spectrum, largely have agreed to preserve the
employer-based system through which most Americans get their
The idea of a federal, single-payer system patterned on those in
Europe and Canada, long a dream of the political left, is now
virtually off the table.
Rejected as well is the traditionally conservative concept,
championed by Sen. John McCain (R-Ariz.) during the presidential
campaign, of reforming healthcare mainly by giving incentives
for more Americans to buy insurance on their own.
There also is a widespread understanding that any expansion of
coverage must be accompanied by aggressive efforts to bring down
costs and reward quality care. And key players in the healthcare
debate increasingly back a massive investment of taxpayer money
for healthcare reform despite the burgeoning budget deficits.
Beyond those areas of basic agreement, the details of what would
be one of the most momentous changes in domestic policy since
World War II remain vague.
As a presidential candidate, Barack Obama embraced both expanded
insurance coverage and preservation of the job-centered system,
but since he won the White House he has provided few specifics
about his plans once he takes office.
Disagreements over specifics could again lead to a stalemate.
Even the most sanguine advocates of sweeping reform concede that
difficult negotiations lie ahead.
But what is taking shape is a debate very different from
previous discussions about what
America's healthcare system
should look like.
"A lot has changed," said Karen Ignagni, president of America's Health Insurance Plans, or AHIP, a
leading trade group whose members helped kill the Clinton administration's healthcare campaign
in the early 1990s.
AHIP is participating in talks with other interest groups to
build consensus before Obama takes office in January and
Congress begins debating any healthcare legislation.
Among the issues to be decided as more concrete proposals emerge
in the months ahead is whether the roughly 46 million uninsured
people in the U.S. will be
pushed to buy private coverage or will be enrolled in a
government insurance program, as some consumer groups want.
Hospitals and doctors fear another public program would reduce
what they are paid, as Medicare and Medicaid have done. Insurers
worry they could lose customers to the government.
Also unresolved is what mechanisms might be created to force
individuals or businesses to get insurance, both potentially
And few have tackled how the government will control costs and
set standards of care, proposals that raise the unpopular
prospect of federal regulators dictating which doctors Americans
can see and what drugs they can take.
"There are some very big questions and some very big stumbling
blocks," said Stuart Butler, vice president for domestic policy
at the conservative Heritage Foundation, who has been watching
the healthcare debate for three decades.
"Once you get into the details, the consensus is going to vanish
pretty quickly, I suspect," he said.
At the same time, advocates for a single-payer system, including
the California Nurses Assn., have vowed to continue pushing the
idea next year along with many Democrats on Capitol Hill.
Republican lawmakers, still reeling from their election day
losses, have signaled discomfort with a major expansion of
government spending, a position many in the GOP hope will help
return the party to power.
"Increasing access for the uninsured is not going to come
cheap," Sen. Charles E. Grassley (R-Iowa) said at a recent
hearing on healthcare reform. "And it's clear to me that our
economy cannot stand much further deficit spending."
Nonetheless, the current agreement on principles contrasts
markedly with previous reform efforts. Today, many of the key
players in the debate see the importance of preserving elements
of the current healthcare system that many Americans say they
"There is a growing understanding that you have to give people
choice and you can't take away what they have," said Ron
Pollack, head of Families USA, an influential advocacy group for
healthcare consumers that is working with a diverse collection
of interest groups to build consensus. "One of the big no-nos is
that you must not ever threaten the coverage that people have."
Fifteen years ago, there was much less agreement about
preserving an employment-based system that now insures about 177
Opponents of President Clinton's plan were able to sink it by
raising the specter that government would take away consumers'
choices in a new system that would force them into inferior
But now the prospect of bold government action to address the
healthcare crisis appears to have been accepted far more broadly
by many of those involved in the debate.
Even business leaders traditionally wary of government
intervention now are pushing for the federal government to act
decisively to reshape the healthcare marketplace -- in large
part because of the increasing burden imposed on them by rising
"Doing this piecemeal is not going to work," said Todd
Stottlemyer, president of the National Federation of Independent
Business, which was also instrumental in defeating the
Many involved in the healthcare debate, including Democratic
lawmakers and members of Obama's team, also see healthcare
reform as part of a broader economic picture.
Democratic leaders on Capitol Hill have begun sketching out
plans for healthcare reform that, like Obama's plan, preserve
the employer-based system and create a new system for those
Last month, Senate Finance Committee Chairman Max Baucus
(D-Mont.) outlined such a plan in an 87-page white paper titled
"Call to Action." Similar approaches have been endorsed by House
In contrast, the
administration drew up its healthcare reform plan with little
involvement from congressional Democrats. In the Senate,
then-New York Democrat Daniel Patrick Moynihan, who was chairman
of the finance committee at the time, actively resisted the idea
of sweeping change in healthcare.
There are no signs of a similar rift today, said Jacob Hacker, a
political scientist at UC Berkeley who has written a book about
the failed Clinton effort.
"Possibly more important than policy agreements," Hacker said,
"is the fact that the political forces now are in alignment."
Levey is a writer in our