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Health Care: How a Summit Can Work

04/19/2010 05:12 am ET | Updated May 25, 2011

My first view of the summit was that it was a bad idea; one in which the risks were disproportionately being taken by President Obama. But the general gridlock in the Congress, and particularly the polls that came out at the end of last week have changed my thinking.

Just to be clear, a deep skepticism continues to be a strong minor chord in how I think about summit meetings in general, and this one in particular. Summits work best when the conclusions are reached before the summit begins, and the role of the attendees is to put an approval stamp on them. Summits are terrible vehicles for the discussion of major open issues; and it is hard for me even to imagine how a televised summit can possibly work.

But... this reasoning is only correct if you think that the situation and position of the Administration is just fine and will stay that way. More melodramatically, if you think the country is in fine shape. If, however, you believe the situation is precarious, that some kind of change of strategy is essential, and on the minor question of the substance, even a start at real health care reform is unlikely without a game-changer -- then the situation looks different. That's where I think we are. I found two recent columns quite convincing. Ruth Marcus, writing in the Washington Post on Feb 10, argues that while the path to a summit may not have been particularly orderly, it may be that if the President is willing to "ladle some meat into the bowl" -- that is, by making a real move away from the current non-starting health care legislation on the Hill, he might actually move some Republican Senate votes. I think so also, and I think the recent polls suggest why.

In Friday's New York Times, David Brooks argued that "the original Obama project, the third Democratic wave (of domestic transformation), is dead." He then goes on to say that the Obama project that can still be successful ought to be to show that the nation is governable once again, and that people can reach across the aisle and come to real agreements. I don't think that the substantive Obama agenda is "dead," but I do think it can only happen with major modifications. I also think it can only happen if the President does indeed show that our nation is governable again. The only way the President can begin to restore trust on the part of the American people in government is to show that the system can produce something.

Finally, the newest polls say that while Obama remains somewhat below the 50% mark in terms of popularity, the Congress hits new lows by the day. Democrats are marginally more popular than Republicans but both sides in Congress are in trouble. Fewer than 10% of Americans believe that members of Congress deserve reelection. At the same time, President Obama is about 5 times more popular than the Congress. He is seen by Americans as less likely to favor special interests, and as someone who understands their needs and problems and has made more of an effort to be bipartisan. Congress really does have to show that it can do something, and its only available partner is President Obama, who is much more popular. This is particularly true for Republicans. Their barely disguised effort to take the president down by making sure nothing works may hurt Obama, but it will hurt the Republicans more.

This Summit could be productive. There remains a shot at real health care reform, and President Obama could come out of a productive summit in quite good shape. It all depends on what he has in mind, and how he plans to proceed. So lets look at that.

The White House has announced that it will put its own health care proposal on line a few days before the summit. I hope that proposal (1) steps away from the current bills in the House; (2) is clearly bipartisan in the sense of adopting some important proposals that some Republicans have put forward; (3) does not try a total all at one time transformation but rather proposes some actions for now and offers a roadmap for the future; and (4) shows a more balanced concern for costs of as well as increased access to health care. I think you can do all of this including adopting some key Republican proposals.

If I were writing the policy proposal, I would go in the following broad general directions.

(1) In terms of exchanges acting as a basic mechanism for long run cost control, we do not now have any general mechanism that permits and requires the cost conscious exercise of true choice by consumers. Most employees have their choices made by a human resource bureaucrat in their company. The remaining "market" is a small rump market which is balkanized between the states so there is no conceivable way it can function. Both the House and Senate bills put exchanges forward unenthusiastically; the bipartisan Wyden-Bennett bill had exchanges as its centerpiece; and it is a market mechanism the Republicans should love. Lets strengthen the exchanges, take away the antitrust exemption of insurance companies, but at the same time allow them to compete nationally.

(2) We need a major commitment to access to health care for all kids under 18, including pre-natal care; coupled with a road map for the future. I've written on this topic within the last week and will not repeat myself, but this has to be a direction that would be attractive for both parties. But at the same time lets make a move toward broader access, and fairness -- even if we can't afford to do everything now. Let's agree with the Republicans on medical savings accounts and provide a tax sheltered way for the self-employed to pay for health care. Some Republicans suggest providing federal money to states "to establish high-risk pools, for people with chronic illnesses who cannot find private insurance at an affordable price; I think the Summit should take this idea seriously.

(3) Tort Reform - This is a central cause for Republicans, President Obama has spoken favorably about it; it should be a central part of the Administration's proposals.

(4) We need to adopt the "cadillac" tax. The complete tax sheltering of all employer provided health insurance is bad policy: it is unfair, and it makes cost conscious individual choice impossible. I would rather turn the current exemption into a credit available to everyone but the tax is what is possible today.

My point is simple. As soon as you step away from the debate we have been mired in for a year that focuses entirely on the current House and Senate bills -- as soon as you allow other ideas to enter in -- a large number of feasible directions emerge that Republicans will have to think long and hard about before they turn on and oppose. I like the picture of President Obama presiding over a summit in which he has put forward a truly bipartisan proposal. I think he comes out of such a summit either with a health care direction that can work; or with the Republicans pushed into a corner they will have trouble getting out of.

There is just one problem with all of this I do not understand. Simultaneously, on a completely different track, in a universe far away, the House and Senate leadership is preparing to go forward with the existing Senate health care bill and with reconciliation legislation that will be jammed through the Senate. There is probably a level of political tactics here so deep, so subtle, so devious that ordinary humans will never understand it. But this would seem to me to blow up any chance that the summit could be successful.

This post originally appeared on New Deal 2.0