There's been tons written about why this time is different than last time. The conventional wisdom has it that last time health care crashed because of the arrogance of the Clintons. A plan devised in secret, crazy in its scope, was presented to Congress with a take-it-or-leave-it disdain and the thing naturally failed leaving tens of millions of uninsured and incremental steps until now, when the Obama administration is supposedly doing the right things.
I never bought the Clinton critique. Sure, the First Couple made mistakes. Would they have
been wiser to let Congress come up with a plan? Probably. But the idea
that that the Clintons were unwilling to take half-a-loaf back then is
total revisionism. And the idea that their plan was some crazy piece of
crap because it topped a thousand pages--Matt Bai was still pushing
this in the New York Times magazine a couple of weeks ago--is one of the tropes of the health
care debate. The sainted NAFTA was more than a thousand pages, as
Jim Fallows noted in these pages some years ago. The Clintons made
plenty of mistakes along the way but they didn't kill health care. The
opponents of universal care killed it and, if I had to guess, I think
they will again even on this skillful president's watch.
Yes, circumstances are better for passage this time, as every analyst notes.
People are more sick of the current system than ever. There's a big
Democratic majority in both houses. Some of the canards of last
time--you'll lose your doctor-- have less impact now that HMOs are no
longer a novelty but the norm. Who actually really gets to choose their own doctor anymore without paying some kind of price for it? And it helps that after $10 trillion of anti-Depression spending a hundred billion a year for universal coverage doesn't seems so bad. But the bottom line is that a lot of
people have to give something up to make this work and that is what's
likely to kill the bill. And now that the outlines of a real plan are on the table we see the wolves gathering, first in opposition to the very seensible idea of a public plan--because Karl Rove and Newt Gingrich HATED their health insurance when they were in government--and then surely later to the whole cost of the package.
I hope I'm wrong. I hope some kind of unviersal plan passes this year, but I'm not optimistic. I think too many of the players are too set against it. If you think we haven't had health care just because of the mistakes of the Clintons, then I think you're being naive about how Washington really works.
I think the bigger danger here is that a health reform bill does get passed, but one that is so watered-down and incrementalist that it effectively does nothing (or, worse, ends up helping the big insurance/pharma corporations at the expense of the taxpayer).
Ultimately, it all comes down to Obama: will be fight for real, substantive reform, or will be make concession after concession to the opponents of reform in the name of "bipartisanship"?
At the end of the day, the rubber has to meet the road for Obama. We get a lot of rhetoric but not much follow through. Same for the financial regulation overhaul that is shaping up to be a downright cave in to the special interests. Will President Obama and his team ever fight the entrenched interests for a change, and instead of 'compromising' so much?
I'd rather have an effective health care bill with a bare majority of Democrats voting for it than having a 'bi-partisan' bill that will be a disaster in the long run. The American people will judge the Obama administration based on results and not 'bi-partisanship'.
I think there's a better-than-even chance of failure for real reform, and the big reason is that Congress just can't pay for the damn thing. Look, any reform bill that's worth it's name--a robust public plan, mandatory insurance for all, etc., is going to cost AT LEAST $1.3 trillion over the next ten years. The only way to pay for this is to 1) tax ALL of the employer-provided benefits, not just above a certain amount; 2) significantly reduce physician and hospital Medicare reimbursements, to the tune of more than $350 billion, as well as reduce Medicaid expenditures for the poor; and 3) significantly reduce the rate of growth of private insurance costs, with REAL consequences for failure to to so.
The odds of any of those happening are slim. Unions and many others oppose taxing the employer-provided benefits, at almost any level. Some compromise may emerge, but at best it will still be a generous exemption and will raise nowhere need the needed amount. If you think the AARP, the doctors, the nurses, the hospitals, and other Medicare stakeholders will accept ANY cuts or re-working of the current reimbursement, you are sadly mistaken. Expect little to no real savings from that sector. Ditto for Medicaid--liberals will NEVER allow reform "to be paid for on the backs of the poor." Finally, the 1% reduction in growth that the private insurers agreed to a while back is eyewash. It was PR bullshit. Only serious legislation with serious penalties will ensure real savings, and that will never happen.
All in all, we'll see nowhere near the amount needed to pay for real reform. And there's no chance in hell of borrowing the money, thanks to the bank and auto bailouts. So one of two things will happen. Either we'll see pie-in-the-sky legislation like the recently-released Kennedy bill (Medicare for all--at twice the price!), or more kick-the-can-down-the-road stuff. My money is on the latter. It will be a classic Max Baucus production of kabuki theater--a mandate to buy insurance, but with so many exceptions and loopholes as to be relatively ineffective. No real public plan alternative--instead, the recently-insured will have the choice of shitty private plans paid for with government subsidies. The subsidies will come from a limited tax on the employer exclusion, coupled with cosmetic Medicare "reforms" and moderate deficit spending. The private insurers will gladly take the subsidies and still merrily hike the rates of the rest of their customers. Meanwhile, Medicare will continue on its merry way, and the real problem will continue to fester.
I don't think real change will actually occur until people stop buying U.S. government debt.