Obamacare: Better Than It Looks
The health care primary, Part 1.
I'm giving serious thought to becoming a single-issue voter in the 2008 presidential election. The candidates themselves aren't making a deep impression, possibly because there are so damned many of them. Remember when we all chuckled back in 1987 about the "seven dwarves" chasing after the Democratic nomination? This year I count eight—nine in the unlikely event that Al Gore, one of those earlier "dwarves," jumps in—plus 11 Republicans. And that's just "major" candidates. Who can keep straight the various character strengths and weaknesses of 20 presidential candidates? Better to focus on issues.
The issue of greatest immediacy is the Iraq war, but none of the candidates has a brilliant idea about what to do. Even if he (or she) did have an effective plan, it would still be a crapshoot as to whether he (or she) would implement it if elected. Presidents seldom do what they've told voters they were going to do when it comes to fighting wars or making peace. Anti-terrorism is important, too, but the main differences among the candidates are in styles and degrees of chest-thumping, not policy. (I assume, perhaps naively, that whoever I'm even vaguely tempted to vote for can be counted on to undo Bush's suspension of habeas corpus.) Immigration is the hot issue of the moment, but I presume that by Election Day either it will be resolved or the warring parties will have resolved not to resolve it.
That leaves health care.
Health care has lately ranked second, third, or fourth in polls asking what the federal government's greatest priority should be, and I predict it will soon settle in for a long run as No. 2. (For the foreseeable future, the Iraq war will remain No. 1.) As I've noted before, the American health-care system is in an advanced state of collapse owing to the failure of an 80-year experiment in market economics. Politically, the problem has grown more urgent because rising health-care premiums and diminishing coverage are starting to cause serious problems for the middle class. Health insurance costs more and more and covers less and less. Per capita health-care costs are about twice what they were when Hillary Clinton tried unsuccessfully to reform the system in 1994, and the ranks of the uninsured have increased by 13 percent. Universal health insurance, which has eluded the political system at least as far back as 1912, when former president Teddy Roosevelt endorsed it in his failed Bull Moose bid, is starting to look inevitable. Even insurance companies think so, according to a May 30 article by Jackie Calmes in the Wall Street Journal. According to the Journal, the insurers have given up blocking universal health care, "Harry and Louise"-style, and are now redirecting their energies toward co-opting it.
It's a shame no one has alerted this year's presidential candidates to the public's growing radicalization on health care. Almost none of their proposed solutions goes far enough. What follows is the first in a series of columns measuring the candidates' various health plans by a consistent set of yardsticks.
Candidate: Sen. Barack Obama, D.-Ill.
Elegance:Sen. Obama is a very elegant candidate, as the comely Obama Girl attests in her lip-synched video, "I Got a Crush on Obama." But I refer not to the man but to his health-care plan (click here to read it), which is not remotely elegant. The Hawaii-raised candidate has given us a pupu platter of regulations, employer mandates, subsidies, public-private partnerships, and new programs.
Market gimmicks:Obama would establish a National Health Insurance Exchange that would create "rules and standards for participating insurance plans." Anyone could buy private health insurance through this exchange, and presumably be guaranteed a certain price (on a sliding income-based scale) and a certain breadth of coverage. Participating insurers would not be permitted to exclude less-desirable (i.e., sick) customers. This scheme is based on the new Massachusetts health-care plan signed into law by former Gov. Mitt Romney, who is seeking the Republican nomination. As a presidential candidate, Romney himself previously distanced himself from the plan, but at a June 5 debate he managed to tout it ("The market works. Personal responsibility works.") without saying "Massachusetts," a word his advisers have urged him to avoid. The National Health Insurance Exchange isn't very gimmicky, but I'm not convinced it would be very effective. (It's too soon to know how well it's doing in Massachusetts.)
Susceptibility to the insurance lobby:Nothing in Obama's plan says that insurers would be required to participate in the National Health Insurance Exchange. That will please insurers. To whatever extent the Exchange were to become a significant market, insurers would of course want to participate, and would pressure Congress to allow them greater freedom to set rates and coverage as they saw fit. The hazard with regulatory schemes in general is that the more complex they are the more susceptible they become to pressure from lobbyists to weaken them.
Cost: $50 billion to $65 billion annually, funded by allowing Bush's tax cuts for families earning more than $250,000 to expire at the end of 2010. Obama says his plan will save a "typical American family up to $2,500 every year on premiums." Note use of squishy terms like "typical American family" and "up to." Obama would invest $50 billion over five years to accelerate adoption of electronic health records, a vital and necessary reform that would reduce medical errors and thereby save lives. It would also save money by avoiding needless duplication such as blood tests that have to be performed more than once because paper records have gone missing. How much? Obama cites a Rand Corporation study that predicts savings of "up to" $77 billion. A similarly laudable proposal to allow Medicare to negotiate prescription drug prices would produce savings that "could be as high as $30 billion." Overall, it's impossible to get a real fix on the cost of Obama's plan, because there are too many "up tos" and too few hard numbers.
Timothy Noah is a former Slate staffer. His book about income inequality is The Great Divergence.