The health care reform summit on Thursday presents one of the most interesting and intriguing political challenges and dynamics I have seen. President Barack Obama is not handling it in a low-key way — he is telling everybody and anybody to tune in to the televised session, raising both its visibility and its stakes. Is there any chance that it can actually break our partisan division in at least a small way?
[IMGCAP(1)]Let’s start with some plain reality: The plan that Obama has put up on the White House Web site, while basically built on the Senate-passed bill as amended by the House and refined by the president, is no radical leftist plan, much less a government takeover of our health care. It has no public option, and it is built on managing competition of private insurance companies through exchanges. It moves to end the practice of pre-existing conditions in the only practical way: expanding the risk pool by requiring people to have insurance. Companies that do not now provide insurance would have to do so, or help employees, and there would be assistance from the government for small employers.
Without an individual mandate, people would game the system, waiting to get insurance until they got ill, forcing insurance companies to raise everyone else’s rates substantially. To require insurance means having some sort of penalty for those who fail to get insured (and, as we know from our long experience, now go to emergency rooms when ill, adding to the costs paid by the rest of us). It also means subsidies for working- and middle-class individuals and families who otherwise can’t afford a penalty or insurance costs.
At base, this plan could best be characterized as Mitt Romney’s Massachusetts plan married to the Chafee/Durenberger/Grassley 1994 alternative to the Clinton health care plan. Call it the moderate conservative Republican option. David Durenberger, the former Minnesota Republican Senator who remains one of the most thoughtful and knowledgeable observers of health care and health policy in the country out of his Minnesota base (I strongly recommend reading his regular newsletter), is almost aghast when he sees his former GOP colleagues mischaracterize the current approach as radical and socialist.
What is also true is that surveys show that each of these individual ideas has healthy support from voters. The public unhappiness with health care reform is built not on the substance here but on the distrust of Washington pols, the messy and rancorous process and the unease about a leap of faith to get change.
Rhetoric aside, there is room here for common ground. The guidelines for it are found in an interesting piece by Minnesota Gov. Tim Pawlenty (R) 10 days ago in the Washington Post and a series of observations by conservative Republicans earlier this week in the New York Times. Pawlenty offered five ideas for reform, including incentives for patients to be smart consumers, payments for performance, malpractice reform, the ability to shop across state lines for insurance, and modernizing the insurance system.
What about the Times’ contingent? Former Senate Majority Leader Bill Frist (R-Tenn.) asks for “bundling” of Medicare payments to reduce the pernicious effect of fee-for-service; former Ronald Reagan and George H.W. Bush staffer Jim Pinkerton calls for more money for medical research; former Food and Drug Administration Commissioner Mark McClellan wants more capacity in Medicare to provide data and measure patient outcomes. As the Post’s Ezra Klein smartly notes, the Frist suggestion is already in the Obama bill and the Pinkerton idea was in the stimulus bill in a big way. And the McClellan idea is a strong one.
So here is my suggestion for how the summit and its aftermath might go. First, the president could explain the core components of this plan in ways that will reassure Americans that this is no wacky or extreme venture. Second, there could be ample opportunity for Republicans to offer their ideas, including discrete ones like Pawlenty’s and comprehensive plans like Wisconsin Rep. Paul Ryan’s. Have a lively exchange of views.
And then follow the summit with a statement by the president to this effect: “I said at the House Republican retreat that I welcomed constructive Republican ideas for health reform that would make a better, fairer and more effective health care system. There were several outlined today. I am going to incorporate many of them into my plan, including better malpractice reform and ways to reduce defensive medicine, more choice for empowered individuals through Health Savings Accounts and the ability for people to buy insurance across state lines — but with federal minimum standards so we do not get the race to the bottom that we experienced with credit cards. I will add more resources and leeway for Medicare to gather and provide data and measure outcomes.
“As soon as I can get such ideas translated into legislation, I will give a new, revised and scored bipartisan plan to Congress and ask Harry Reid to schedule a vote in the Senate. I will ask Republicans to support the new plan — or at minimum to allow an up-or-down vote and not engage in a united effort to filibuster the bill.”
I have no idea if the White House has this approach in mind — but if it did, it would make sense to raise the specter of using reconciliation and including in it a public option — to make it clear to mainstream Republicans that they can really improve a mainstream bill, or end up with something much less to their liking. At the same time, it would make sense, as the Obama plan does, to leave out a national insurance exchange, and then add in a variation of it after the summit as a way of enabling consumers to buy insurance across state lines.
Of course, to have a chance of making this strategy work, the additions by the president would have to be real, not done for show via demonstration projects or halfway measures. But a real effort at compromise has at least a small chance of success. If it doesn’t work — if an outstretched hand is slapped aside and 41 Republicans joined in a filibuster — at least the rationale for using reconciliation would be clearer.
Norman Ornstein is a resident scholar at the American Enterprise Institute.