Indulging Our Health Care Fantasies

The problem with Obama's health care plan


It's been 15 years since President Clinton's health care reform plan went down to defeat, and the problems it was supposed to fix have only gotten worse. Costs have soared, the number of uninsured has risen, and public dissatisfaction has mounted.

But now, at last, we are all ready to do what must be done. As President Obama puts it, "I really think that the stars may be aligned here."

Don't bet on it. The Clinton plan lost partly because Americans were not willing to accept that you can't have it all. From everything that has occurred since then, it's apparent they are still unwilling.

The Obama administration understands this crucial point, which is why it has undertaken to assure us that everything we like about the current health insurance system will stay the same, while everything we don't like will be replaced. And, we are led to believe, it won't cost you and me anything.

Estimates of the cost of Obama care start at $1.2 trillion over the next decade. The administration believes it can cover about half that amount through tax increases on the rich and greater efficiencies in Medicare and Medicaid. But it's hard to find anyone else who shares that touching faith. When I asked Robert Bixby, head of The Concord Coalition, a bipartisan fiscal watchdog group, he said, "I don't see any plausible way of getting the savings they need to add the expanded coverage in a deficit-neutral way."

There are only three ways to pay for this expansion of health insurance coverage: increased taxes, reduced benefits, or shiny gold ingots falling out of the sky. Voters emphatically prefer the latter option, so that is the one most likely to be embraced by Congress and the administration.

If health insurance were such a vital asset, you would think Americans would be more than happy to make sacrifices to get it. After all, it assures timely and adequate treatment in times of sickness, peace of mind in times of health, the prospect of a longer and happier life, and protection against financial ruin. Health care reform is supposed to make those blessings available to all.

But when most people talk about reform, what they really mean is guaranteeing the same or better coverage than they now have, but at a lower price. A recent Kaiser Family Foundation/Harvard School of Public Health poll found that 49 percent of Americans aren't willing to pay more in insurance premiums or taxes.

Of those who could accept higher taxes to finance a new system, most are thinking of higher taxes on someone else. As the researchers explained, "The only options with majority support were those likely to impact the fewest people, in particular smokers and the wealthy."

Even among the uninsured, the enthusiasm for insurance is muted. When another Kaiser poll asked uninsured adults how much they would be willing to pay to get coverage, only 64 percent would fork out $100 a month and just 29 percent would pay $200. Given that most are not poor, why is it so important to provide the uninsured with something they don't value highly?

One way to bring down the cost of health insurance is to limit access to certain doctors, treatments, and medicines. But the Kaiser/Harvard poll found most people are averse not only to paying more but also to anything that would "involve government limiting or dictating their choices."

Or anyone else, by the way. Most people have forgotten that in the 1980s, the private sector devised an ingenious way to reduce medical outlays. Known as managed care, it put modest restrictions on the freedom of patients to get care from specialists, limited hospital stays and gave doctors incentives to choose less costly therapies. It saved money, and it didn't appear to reduce the quality of care.

It was a perfect remedy, except for one thing: Patients and doctors hated it. Why? Because it kept them from behaving as though cost is no object.

So managed care is history. But the dilemmas it addressed are not.

One of these days, we'll have to address them, but not now. The administration would rather pretend we can get generous government-sponsored coverage for everyone without higher taxes, higher insurance premiums or rationing of health care. In short, it refuses to treat us like grownups. I wonder why.