Despite the bad economic news and the even worse international news, it looks like 2009 might just result in real health reform. Why will 2009 be different from 1993? Obama is not making the same mistakes the Clintons did, and that is good news for all of us.
Another reason why 2009 might be different is that even more people lack health insurance than in 1993 and the impact on the overall economy is even more severe, so the issue remains at the top of the domestic agenda. Even as I write this, families all over the country are struggling to pay medical bills, delaying care because they don't have insurance, wrestling with insurance companies over what is covered and what is not - in general, just worrying about their health and how they will pay for services if they get sick. In an economic downturn, health care is pretty recession-proof for providers, but it's a huge source of concern for patients.
The Obama team knows all of this and more, and that's why they have been working on how to introduce health reform for over two years. Here are the things they have been doing to keep the idea of health reform alive despite the recession:
1. Obama wisely has placed the locus of activity for health reform where it belongs - in the House and the Senate.
2. Senate and House staffers have already been working on some of the most urgent issues - renewing and expanding children's health insurance; expanding the use of information technology to lessen the paperwork load on patients and doctors; reforming health insurance laws regarding pre-existing conditions; reforming Medicare and the physician payment system.
4. The Obama website has asked for input from individuals on what they would like to see changed about the health care system, and the suggestions are pouring in.
5. Meetings with health care providers have been posted on the Obama website so we can all see who is asking for what.
How is this different from what the Clinton administration tried to do?
1. The Clintons kept the locus of activity squarely within the White House. And while Democratic House and Senate staffers were part of the internal discussions, Republicans were left out, and there was a fair amount of secrecy about the details of the reform efforts. Even Democratic legislators felt left out and were angry about the way the White House handled Congressional outreach.
2. The Clinton White House made a decision early on to do health reform "large" and comprehensive, rather than biting off more do-able pieces like covering children. And while it makes substantive sense to tie all the pieces together (paying for care, delivering care, etc.), it was politically disastrous to try to reform a sixth of the nation's economy in one piece of legislation, especially when done from the White House and not Congress.
3. Although there was a lot of rhetoric about how secret the process was, the truth is that the working group members numbered almost 500 and thousands of providers streamed into the Old Executive Office Building for months on end, pleading for coverage of their particular part of the health care system. We heard from doctors of all types, nurses, home health workers, pharmacists, dentists, hospital administrators, business and labor leaders -- there were very few providers who could claim they never got to plead their case for why their service should be included and paid for. However, the difference was that those meetings were not disclosed or explained to the American public or the media, so the image of a closed process was the image that everyone remembers even to this day.
4. There was no active internet in those days and no real blogosphere to communicate to or from. Had the Clintons had the resources Obama has today, the process might have been more transparent and thus the support might have been broader and more community-based. As it turned out, organized interest groups in health care had a lot of opportunity for input -most ordinary citizens did not.
5. And maybe most importantly - in the fifteen years since the Clinton effort, the cost of health care has steadily risen; the impact on business has been increasingly devastating; and the number of people without insurance or underinsured is significantly greater. You could make the case that some of the organized opposition to reform now will be less potent precisely because of what has not happened in the past fifteen years. There are several coalitions of rather unlikely stakeholders who have been working to support health reform for over a year -- (only a few of the ongoing efforts). This coming together of diverse stakeholders (business, labor, hospitals, consumers, doctors) promises the potential of stronger support for whatever comes out of Congress.
There is probably less disagreement in 2009 among Democrats than there was in 1993. But Republicans remain wary about what the Democrats can achieve. More substantively, Republicans support a very different approach to health reform -- much more market-driven, consumer-focused and less regulatory -- and that is unlikely to change, even though McCain's rather crazy health reform proposal got no traction in the Presidential campaign.
Even if Democrats manage to come together and agree on a basic approach to health reform in the Congress, will progressives support the compromises that may be made? The Campaign for America's Future - is one of the leaders on the left for progressive health reform and has been central to the design of the Obama health plan. There have been many policy analysts who have promotedthe idea of public plan, including Helen Halpin of UC Berkeley, and Peter Harbage, formerly with the Edwards campaign. David Cutler,Obama's main health care economics adviser, has also supported a public option. Can the progressives hold together their coalition as the details emerge from Congress? Will the single payer advocates support a more gradual roll-out of the elements of health reform if the result is not Medicare for All?
These are the questions that will surface as the 111th Congress gets underway. Health reform will be messy and no solution will please all the interests. Do we even agree on the priorities? There is so much to be done. Can we agree that children need to be covered - now? That individuals who do not have health insurance through their work need access to affordable coverage? Can we agree that we need a better way to pay providers, a way that demands excellence and keeps doctors wanting to stay in practice? An excellent blog on the "myths" of health reform points out the controversy over where to start with health reform, including how much we can and cannot save with the proposals now being discussed. One of the biggest obstacles is what we can afford - now, with the economic situation we face.
As the New Year becomes less new, I remain optimistic that something significant can happen. At least i am going to do my part to keep the discussion going!