In an effort to be the first president since Lyndon Johnson to succeed in reforming our nation's health care system, President Obama is exhibiting honorable flexibility. Taxing health care benefits for employees? He was against it when running for office, but he is considering it now that the federal budget deficit is growing so rapidly. A new public insurance plan? He promised this spring that it would be a central part of his health care reform efforts, but now he is willing to put it aside in pursuit of more important goals.
And what are those more important goals? First and foremost, the President wants to expand people's access to health insurance, so that their medical care will no longer be threatened by job loss or by what an insurance company determines to be a "pre-existing condition;" and second, he is committed to controlling health care costs, aware that our future fiscal solvency depends on slowing the growth of Medicare and Medicaid.
The time may come for Obama to shed one of these two laudable goals. Indeed, if blue dog democrats begin turning away from health care reform because of budget concerns, Obama will need to give up his immediate plans to expand access to health insurance, and focus his efforts, instead, on showing the American people that he knows how to control health care costs.
I recognize the moral horror that my proposal will create among those people who, like me, are outraged that a wealthy country like ours allows 50 million people to go without health care insurance. Obama is correct, in fact, to be exhorting Americans to recognize our moral duty to offer basic health care coverage to all our citizens.
But with ballooning budget deficits and an economy still on the brink of disaster, it may not be politically palatable to expand health insurance coverage right now. Most conservatives, and even many moderates, are understandably worried that the government will do the easy job of spending money it doesn't have, while ignoring the more difficult job of making our health care system more efficient. After all, Obama has not really laid out a clear plan for how he will control health care costs. Instead, he is simply asking people to trust him: somehow, with a teaspoon of electronic medical records and a few milligrams of "comparative effectiveness research," he will cure the health system's inefficiencies and make our financial problems go away.
I suspect that Obama already realizes that he cannot achieve both of his goals -- expanding access and controlling costs -- in the initial stages of his reform efforts. Instead, his administration appears to be taking a Massachusetts-style approach to health care reform: expand coverage first and then, after costs spiral further out of control, take on the difficult job of ratcheting down health care costs. In this approach, expanded coverage is the horse that pulls health care reform along what will no doubt be a long and winding road.
This access first approach is morally laudable and may even be politically wise. But politics moves quickly -- who, after all, would have predicted three months ago that "death panels" would play such a large role in public discourse about health care reform?
If fiscal concerns threaten to impede Obama's health plan, he will need to change direction. At that point, the best way to expand health care coverage to all Americans will be for Obama to focus, over the next few years, on proving to Americans that he can control health care costs -- indeed, that he has a legitimate plan for controlling government expenditures more broadly. With this proof established, Obama will then be able to propose reforms that will expand health insurance coverage, and the American public will have confidence that these reforms would not break the bank.
With so many Americans worried about rising taxes and runaway budget deficits, Obama should consider putting the cart of cost control in front of the proverbial horse. If Obama can prove to us that he can rein in Medicare costs, the American public will gladly follow him further down the path of health care reform.
Peter A. Ubel M.D. is author of Free Market Madness: Why Human Nature Is at Odds with Economics -- and Why It Matters (Harvard Business Press, 2009), and George Dock Collegiate Professor of Medicine at the University of Michigan.
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