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November 18, 2008

Think Small

By

In this installment of Health Care Watch, Stuart M. Butler and Ezekiel Emanuel talk about what President-elect Barack Obama should and shouldn't do on health care reform.

My fellow Campaign Stops contributor, Ezekiel Emanuel, is right that Barack Obama's election could be transformative for health care as well as other areas of policy. Let's hope Mr. Obama doesn't blow it, as others have on health care -- most notably Bill Clinton. Getting it done right will require Mr. Obama to keep four things strongly in mind or his honeymoon on health care will end soon.

First, he has to make a strong commitment to bipartisanship, which was distinctly lacking in President Clinton's health strategy and helped assure its demise. Not often obvious during the heat of the election season, there has been a good, honest conversation about health reform across the reasonable political spectrum in recent years. We saw it in Massachusetts. We see it in the bipartisan proposal introduced by Senators Robert Bennett of Utah and Ron Wyden of Oregon. We see it, too, in Massachusetts' senator Ted Kennedy's wide outreach in the last several weeks, and in bipartisan conversations about health tax reform and health exchanges. Mr. Obama needs to tell the more triumphalist liberal supporters on Capitol Hill to chill, and that he's looking for common ground.

Second, these very difficult economic and budget times underscore the need to find better ways to use the money we are currently spending on health rather than throwing tens of billions in new money at the health industry in an effort to expand coverage. That's why reallocating the $200 billion tax expenditure on the tax exclusion is so critical. Ezekiel Emanuel and virtually every other health expert agrees with me on that. Mr. Obama must not adopt a "not invented here" attitude just because John McCain proposed reforming the exclusion. It's a real opportunity for him to reach out to his former opponent and craft a workable bipartisan solution. Fortunately the Democratic chairman of the Senate Finance Committee, Senator Max Baucus of Montana, may have opened the door to that in his own just-released health plan by raising the idea of reforming the tax exclusion.

Third, and in the same vein, Mr. Obama should put meat on the bones of his campaign proposal to allow states flexibility to redesign existing health programs and use money more efficiently to reach the goal of maximizing affordable coverage. I wrote about this in my last post. Again, he can go bipartisan. Various bills in the Senate and the House have been introduced to enable states to receive waivers from existing federal programs and laws to try out bold ways to use funds to expand coverage. Mr. Obama should embrace these approaches. Allowing states to try out major changes first means skeptical Americans can see a model of reform before they are asked to accept it. That strategy was essential in building public support for major welfare reform, and it is needed even more for significant change in the especially sensitive area of health care.

And finally, he needs to remember that Americans are very conservative about their health care. Those with coverage are extremely nervous about changing what they already have. John McCain was hurt by claims that his approach to health care was too radical and might result in people losing their employer-based coverage. Mr. Obama's plan actually masks what would be big changes. As I've pointed out, for instance, millions of workers will discover that they will be put into a public plan by their employers. Once workers with coverage know this, they are going to feel tricked and angry if he pushes ahead with changes that are more substantial than they thought they were voting for.

All the more reason, then, for President-elect Obama to tread carefully, to set up models at the state level so Americans can kick the tires of major reforms first, and to reach across the aisle to build trust and broad support for a workable way of reaching the goal we all share.

Stuart M. Butler, Ph.D., is Vice President for Domestic and Economic Policy Studies at The Heritage Foundation.

First Appeared in NYTimes "Campaign Stop" blog

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