obama.jpg[Please welcome Charley from BlueMassGroup with a guest post on Obama's health care proposals. Thanks, Charley! -- CHS]

So a few months ago, Barack Obama got hit pretty hard for seeming like a lightweight on health care. And after all, he was going up against old pro Hillary Clinton, who probably knows more about health care than any other politician in America, and John Edwards, who came out with a fairly ambitious and complete plan of his own. By calling for "roundtable discussions" on health care, it sounded like Obama was proposing some kind of mahogany boardroom Kumbayah:

A Swampland correspondent paraphrases one exchange:

Karen Tumulty: Will you need to raise taxes?

Obama: Did you not hear me? THESE TABLES ARE ROUND.

Now, to his credit, Obama has come out with a health care plan that is definitely substantial and sometimes courageous — the adoption of which would almost certainly lead to more people covered, and getting better value for the vast amount of money that we spend. In spite of its billing, it's not truly universal, but it's still transformational. Obama tapped Harvard econ prof David Cutler to help him wonk out a plan — and to sell it. A veteran of the Clinton 1993 health care wars, Cutler's emphasis has changed to making health care markets work more rationally. So it shouldn't be surprising that Obama's plan is chockful of very appealing market reforms: Heavy on providing more information about the quality of docs, hospitals, and drugs; cutting down on some of the anti-competitive mischief that pharma companies and insurers like to engage in. And it includes a variety of methods to try to ease folks into having health insurance again — while eschewing methods which make people buy it. Bottom line: The Obama plan envisions a much bigger role for the federal government as an honest broker for the health care free market, and bolsters and expands the government health care system to include more people — especially the working poor and children. 

As I've said, notwithstanding the sales pitch, it's not a totally universal health plan – there are going to be some people left out, period. It's a problem where our political discussion cannot reconcile two things: You need to call it "Universal Health Care" these days to get attention (that's good!); but actually doing what it takes to cover absolutely everyone requires methods that are too controversial: mandates, either on individuals, employers, the government, or some combination of the three. Here in Massachusetts, the magical solution to getting everyone covered was the so-called "personal mandate": Thou shalt insure thyself. But this was a political solution — a way to keep the special interests at the table, by shunting most of the responsibility onto individuals. (Yet another irony of our age of special-interest politics.) Whether it works as policy is up in the air right now: Already many folks of modest incomes have been exempted from the mandate, and will remain uncovered. In other words, our supposed "model" plan in MA isn't truly universal, either.

So what is there, there?

Obama's plan does include what's called a "pay or play" provision for employers: Either they insure their own workers ("play"), or they have to pay the government to do it for them. Sounds fair, but guess what? Employers don't like that. In MA, it was amazing to see even those employers that do insure their workers come out against a significant "pay or play" requirement. That's just sad, since they're the ones who are losing out to the deadbeat employers. In any event, if Obama's elected, you can expect there to be major special-interest pushback on this one, and calls to shunt more of the burden onto individuals. 'Cause, like, we don't have as many expensive lobbyists.

Obama proposes two major new devices that will change how health insurance is bought:

  • One would allow those who can't get group coverage elsewhere (i.e. individuals, small businesses) to buy a government-issued health plan, similar to that which federal employees now get. Obama proposes signficant subsidies for those of modest incomes — I would anticipate that the exact degree of subsidy will be a major expense and policy headache. Still, an expansion of government help for the low-income uninsured is correct, humane … and judging by our experience in Massachusetts, surprisingly uncontroversial.
  • The other would create a way for individuals to buy private insurance through the government, regulated and quality-assured. This sounds similar to what we now have in Massachusetts, called the Connector. It's actually very easy now to compare plans and prices, and I've heard it really is a major improvement from the previously Byzantine process of having to buy your own health insurance. ( Here, take a spin.)

For me, anyway, the "red meat" part of the plan deals with cost-control: You know how we hate getting bled dry by fatcat corporations? How they're always out to screw the little guy? Well, they are, and Obama's plan tries to rein them in — with The Truth, baby. By putting together a wonk-hive of Joe Friday-meets-House health care research genuises, we're going to know what technologies and treatments work, and which don't. We're going to know which hospitals, docs and drugs are good, and which suck. (Count on it — they won't like that very much.) We're going to do preventative care, finally; we're going to stop rewarding providers for doing piecemeal services (expensive), and instead reward them for providing health (cheaper). We're going to make insurers open up and tell us how much of our premiums is actually going towards care, and how much towards CEOs' yachts and stogies. Yeah, all this is pretty wonky, but it gets right to the heart of one of the big problems in American health care: We don't know what we're doing — and some people like it that way. Ignorance isn't just bliss — it's gold.

And by the way, no longer will pharma companies pay generic drug makers not to make cheaper versions of their old drugs, or prevent us from getting them from outside the US. Maybe it's just me, but I get all Conan about this part: Crush special interests — see them driven before you — and hear the lamentations of the Republicans. Ahhhh, yes.

Obama also seeks to reinvigorate our public health infrastructure, to take on preventable chronic diseases such as obesity, diabetes and heart disease. I have to say, it's one thing to talk about making school systems and local governments more savvy and able on these issues, but I think we actually need a broader cultural discussion about our priorities: Don't we deserve a little more vacation? Who has time to exercise? Are you going to eat those fries? etc. Obama touts smoking cessation, which is good but ironic. Hey, start at the top, right?

Obama's come a long way on this issue. His plan accomplishes its political goal, in that he's put down a marker as someone with serious and ambitious ideas. You can criticize him for not being audacious enough, for not outlining a true universal care program — but even if every single thing in Obama's, or Edwards', or Hillary's eventual plan were passed by Congress, there are a lot of details still to be worked out. Here in MA, we have a hands-on, progressive Governor, and the folks involved have so far done yeoman's work in implementing a very tricky and often vague law — and we still don't know if it's going to work out.

But as he says, it's up to the rest us to create a genuine movement for universal health care. Considering the fierce mix of special interests involved,  there's no way our politicians will do any of the right things without massive pressure from the outside. So it's up to us to keep guiding the process. We've got to reject Godzilla vs. Mothra politics — of gigantic special interests battling it out among themselves, while the rest of us run screaming. We've gotta own this issue — hell, we're paying for it.

Further reading:
Brad likes it.

I read Ezra a lot.

(Photo via In These Times.)

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