The Great Debate

Over nearly a century, progressives have pressed for a national, single-payer healthcare system. When it comes to health reform, what have conservatives stood for?

For far too long, conservatives have failed to coalesce around a long-term vision of what a free-market healthcare system should look like. Republican attention to healthcare, in turn, has only arisen sporadically, in response to Democratic initiatives.

Obamacare is the logical byproduct of this conservative policy neglect. President Barack Obama’s re-election was a strategic victory for his signature healthcare law. Once the bulk of the program begins to be implemented in 2014 — especially its trillions of dollars in new health-insurance subsidies — it will become politically impossible to repeal. And as the baby boomers retire and Obamacare is fully operational, government health spending will reach unsustainable levels.

The great irony of Obama’s triumph, however, is that it can pave the way for Republicans to adopt a comprehensive, market-oriented healthcare agenda.  The market-oriented prescription drug program in Medicare has controlled the growth of government health spending. Similarly, conservatives can use Obamacare’s important concession to the private sector — its establishment of subsidized insurance marketplaces — as a vehicle for broader entitlement reforms.

While most Americans view their healthcare system as “free-market,” Switzerland actually has the most market-oriented healthcare system in the West. It translates into universal coverage and low entitlement costs. Swiss government entities spent about 3.5 percent of gross domestic product on healthcare in 2010, compared to 8.5 percent in the United States. That’s a difference of more than $5 trillion over 10 years: real money, especially relative to our $16 trillion debt.

Reuters reports [“No sign Congress meant to limit health exchange subsidy: CBO,” Dec. 6] that a recent Congressional Budget Office letter “could complicate” efforts to stop the Internal Revenue Service from imposing “Obamacare’s” employer mandate in states that refuse to implement a health insurance “exchange.”

In fact, the CBO’s letter devastates the IRS’s already weak case.

The Patient Protection and Affordable Care Act imposes a $2,000-per-worker charge on employers only if one of their employees receives a “premium assistance tax credit,” and the act authorizes those credits only if states create their own exchanges.

If a state opts instead for a federal exchange, as more than 30 states have, the IRS has zero authority to penalize employers there. “As even some health law supporters concede,” Kaiser Health News reports, “the claim that Congress denied to the federal exchanges the power to distribute tax credits and subsidies seems correct as a literal reading of the most relevant provisions.”

Barack Obama may finally be defining himself as president. The question is: What took him so long to seize the narrative and find his character as “leader.”

Obama now has strong public support in the fiscal crisis faceoff. Even as the House Republicans scramble to find a way into the argument, the president has a tight grip on the storyline.

This is a big change from the fierce healthcare reform fight and the 2011 debt limit crisis. The chattering class then continually asserted that Obama had “lost control of the narrative.”

Americans believe in second chances. The oral arguments before the Supreme Court last week were a rare opportunity to dispassionately re-examine the divisive healthcare debate of two years ago. What happens if, after the smoke clears, we get a second chance at healthcare reform?

We’ve long known that healthcare will be a central theme in the 2012 presidential contest. The High Court’s deliberations and June decision only reinforce that reality for President Obama and Governor Romney.

Unlike with the Patient Protection and Affordable Care Act (PPACA), the constitutionality of Governor Romney’s Massachusetts law has never been seriously questioned. States, not the federal government, have police powers, allowing them to require purchases (car insurance, taxes and licensure) and to pass wide-ranging public health laws and public safety laws. The Bay State law enjoys broad popular support.

As part of Reuters’ coverage of the U.S. healthcare reform, Reuters.com asked Peter J. Pitts, president of the Center for Medicine in the Public Interest and Stephen M. Davidson, a Boston University School of Management professor to discuss the issue. Here are their responses.

– David Magnus, Phd, is the director of the Stanford Center for Biomedical Ethics. The views expressed are his own. –

The public discussion of healthcare reform has been full of so many lies and myths that it is less a policy debate than bad theater.

Critics of reform (conservatives hoping to score political points and oppose Obama on anything; free market ideologues; those with threatened financial interests) have stooped to absurdity in their public pronouncements. One publication declared that severely disabled physicist Stephen Hawking would never get life saving medicine in a national health system, ignoring that Hawking is British—virtually all of his life saving treatments were done through their National Health Service.

Here is a devastating critique of the idea of healthcare co-ops in place of a true public option (via Tim Foley at Change.org):

We’re guessing at the details, since they haven’t been divulged. How it would work? Does the government give seed money in the form of grants to set these up? Does it give loans? Who, pray tell, does it give this seed money to? How long would it take to get one of these co-ops up and running? How long would it take them to get a network of doctors? Since the co-op would start with no customers and presumably no bargaining power, how long would it take for insurance companies to be quaking in their boots?

That said, we do know a lot about them:

We know that we used to have health care co-ops in this country. What happened to most of them? As Professor Timothy Stoltzfus Jost explains, “The Farm Security Administration withdrew support in 1947, and they collapsed. They had a hard time getting going anyway.” We know the ones that have been relatively successful have had their own network of providers, like Kaiser or the VA. However, the best of them took decades to develop – up to 60 years. The GAO looked at health insurance co-ops in 2000. These weren’t the same idea – they would allow small businesses to pool their employees in a co-op to shop for insurance. The GAO’s conclusion? They don’t work very well and did nothing to lower costs. The fact that a health co-op is a non-profit won’t in and of itself yield competition. As I pointed out earlier, “Conrad’s home state of North Dakota has 475,000 people enrolled in the not-for-profit North Dakota Blue Cross Blue Shield. That’s not just competition – it’s a monopoly, 60% of the market. Guess what? It hasn’t helped. Premiums jumped 74% in the past seven years.” Most co-ops won’t be as successful as already-existing Blue Cross plans, which means they won’t have market clout to lower costs or change the game for private insurance. Which is, you know, the whole point. Conrad introduced the co-op in June to solve a political problem – find common ground to allow the Senate Finance Committee to release their bill. So far, the Finance Committee remains at impasse, we’ve seen no bill, and every other committee has been done for weeks now. Great job. By the way, Republicans aren’t biting. They say the co-op is a public option in sheep’s clothing. So they’re against it. And, of course, progressives are furious at even the hint that there won’t be a public option, so they’re against it, too.

I guess Conrad succeeded in uniting the left and the right. Unfortunately, they seem to be united against his idea – the same idea whose sole existence is not to make American health care better but to win votes.

President Barack Obama has told Americans to be skeptical of reports of an end to the recession, saying the downturn has "many more months" to run. Given the recent retail sales data, Americans seem to be listening to their economist-in-chief.

Obama may well be right in his dour forecast. Whatever the next quarter or two of GDP numbers say, continuing high unemployment and depleted personal wealth should keep the vibe more recessionary than expansionary. It's tough to be cheerleader-in-chief, after all, when people's pocketbooks are telling them a starkly different story.

But another issue is exacerbating Americans' sour attitudes and raising doubts about the president's competence: healthcare reform. Indeed, a recent Gallup poll shows identical pluralities of 49 percent disapproving of both Obama's handling of the overall economy and his handling of healthcare policy.

The debate over healthcare reform heated up this weekend when a top U.S. health official called into question the government-run health insurance option favored by President Barack Obama.

Health and Human Services Secretary Kathleen Sebelius said on Sunday a public option was “not the essential element” of any overhaul, and that non-profit cooperatives being considered by a Senate panel could also fulfill the White House goal of creating more competition on insurance.

Democratic dissenters of this view come out in full force.

“You can’t have reform without a public option,” Howard Dean, a former Democratic National Committee chairman and a vocal supporter of an overhaul, said on CBS’s “Early Show.”

“I don’t think it can pass without the public option,” Dean said. “There are too many people who understand, including the president himself, the public option is absolutely linked to reform.”

Peter J. Pitts is president of the Center for Medicine in the Public Interest and a former FDA associate commissioner. The views expressed are his own.

In SiCKO, Michael Moore portrayed the British National Health Service and the Canadian health system as particular exemplars of excellence. He backed it up with a lot of statistics, but statistics, as the saying goes, are like a bathing suit. What they show you is interesting, but what they conceal is essential.

And what SiCKO concealed was that systems such as those in the United Kingdom and Canada are cost-based rather than patient-centric models. Facts, no matter how inconvenient to one’s argument, must not be ignored.