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5 Steps to Major Health Care Reform

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Barack Obama's poll numbers are falling as Congress heads into recess without passing a sweeping health care reform bill. Some voters may believe the criticisms from the Republicans that the Democrats are plotting a government takeover of health care, while other voters may be lamenting that such ambitious plans have now been taken off the table. The irony is that Obama's much maligned strategy of letting Congress hammer out the details of health care reform is just now starting to look quite sensible.

After several ideas have been floated only to sink from the weight of too large a price tag, there continue to be negotiations in both the Senate and the House where liberals and moderates are slogging through the messy details and making progress toward a set of incremental reforms that actually have a chance of passage and could make a real difference in improving the life and health of millions of Americans. Rather than criticizing incremental reform as half measures and sellouts, this is just the kind of progress progressives should be ready to embrace.

Let's Pass Health Reform I and Debate Health Reform II
One of the things that is increasing the temperature of the health care debate, making passage of reform more difficult and less likely, is the false view that whatever happens in 2009 will be the last word for a (political) generation. Republicans believe that if they can defeat health reform now, they can weaken Obama and defeat him in 2012. Liberals believe that anything left out of this year's deal is an opportunity lost forever.

There is room to negotiate a health care bill that achieves many, but not all of the current goals for reform, and continue to build support for broader measures. Rather than one giant leap, we can get where we need to be through a series of steps.

Step 1 -- Fund Evidence-Based Medical Records Keeping -- DONE: Although most people may not know it, the most important element in the whole package has already been passed into law. The illusive goal of extending coverage to more Americans and lowering the cost of health care is unattainable unless we can find ways to deliver more effective care at lower costs. If we fail to do this, whatever else we think we are passing this year will blow up the budget and become unaffordable over the long term. But the key element of long term cost containment -- evidence-based medical records keeping -- already received full funding in the American Recovery and Investment Act. In a few years, medical experts will be armed with a wealth of new data about what procedures and practices really work and are most cost effective in keeping people healthy.

Step 2 -- Health Insurance Reform: There is broad support for a package of reforms and regulations for the health insurance industry that would provide real protections for consumers and at the same time level the playing field for health insurance providers. It is quite possible that any deal that emerges from Congress would require health insurance portability eliminating the problem known as "job-lock" and also eliminate coverage exclusions for pre-existing conditions. These changes would go a long way toward addressing the health care anxieties for large numbers of people.

Step 3 -- Give Consumers More Choices: There are several ways to do this. Some are controversial and others are not. The least controversial idea, included in most reform proposals, is Health Insurance Exchanges. Health Insurance Exchanges are markets where employers and individuals can shop from a wide variety of competing plans to find plans that offer the benefits they want at a price they can afford. This system is already working in some states and for federal employees. If Health Reform I establishes strong regional exchanges or one national exchange, and people still believe more choice is necessary, then Health Reform II can look at the more controversial options like a public health plan or health cooperatives.

Step 4 -- Make Health Insurance More Affordable: Real health care savings may be possible in the longer term, but in the short term the only way to make health insurance more affordable to people is to lower the cost by spending government money. But the goal of making health insurance more affordable cannot come at a price that taxpayers find un-affordable. Public opinion polls continually show strong support for "health care reform" but little support for any of the new taxes needed to fund extended coverage. The politically viable price tag may not be zero, but it is substantially lower than current estimates of $1 trillion, or more, over the next 10 years. To get a deal that moderate Republicans and moderate Democrats will want to support, the number will have to go down. This means the goal of universal health coverage will not be achieved in Health Care Reform I. That is why we need Health Care Reform II.

Step 5 -- Add Government Mandates Only If They Do Not Mandate Bankruptcy: With all the attention on the revenue needed to pay for reform, too little attention is being given to the other legislative heavy lift, the possibility of government mandates. Whether the government requires all employers to provide insurance or pay into a government fund ("an employer mandate") or requires that all individuals have health insurance ("an individual mandate") or both, there will be a lot of details to work out and a lot of potential opposition.

Neither idea is unprecedented. Every employer is mandated to contribute to Social Security and Medicare. Every driver has an individual mandate to have automobile insurance. Still, however the lines are drawn and whatever exceptions are granted, in the current economy we can expect thousands of stories of struggling businesses that will not be able to keep their doors open if a new cost is added, or healthy individuals that will have to choose between the mortgage payment and the new cost of health insurance. If compromise legislation includes any mandates on businesses or individuals they are likely to include a lot of exceptions and opt-outs and still they will open up a whole new line of criticism for the plan. Getting this right will be another challenge for Health Care Reform II.

Progressives Should Embrace Progress. America voted for change last November, change away from winner-take-all politics toward a government that works to solve pressing problems. It would be nice if everyone agreed on what form health care reform should take, but that's not very realistic, and while it is easy to attack the motives of those whose do not share the same vision of reform, doing so does not represent a great deal of change from previous years' debates.

More than a be-all-and-end-all health care bill, what progressives really need right now is progress. Any bill that improves health care for a substantial number of Americans would be a clear signal that politicians can do something right and government can make things better. The more Americans that believe this, the greater the opportunities in the future to do what needs to be done.