The final disposition of the unpopular Senate health
care bill in the House of Representatives does not
end the national debate on the future of American
merely enters a new and even more divisive phase.
Conservatives should redefine the terms of the health
care debate and retake the offensive on health policy.
If the 2,700-page Senate bill becomes the law of the land, it would routinely force Congress to block, modify, or fix the inevitable flood of administrative refinements to its legislative handiwork. But if the bill does not pass, Congress can rest assured that the debate on
health care problems—cost, quality, and coverage—would
quickly remerge in full force. Americans clearly
want consequential health care reform, even as they
register strong opposition to the congressional legislation.
is thus critical that conservatives in Congress advance
an aggressive and positive agenda for reform. The
key elements of that conservative agenda should:
- Address the anxieties of middle-class Americans
over access and cost,
- Transfer control over health
care decisions and dollars to individuals and
- Restore the traditional (and now dangerously
attenuated) doctor–patient relationship.
Liberal Rhetoric v. Reality
the Obama health plan and the Clinton health proposal
of 1994 include a highly prescriptive federal definition
and control of the content of “ acceptable” health
insurance benefit packages; individual and employer
mandates to purchase federally approved health insurance
plans; multi-year Medicare cuts to finance the expansion
of health care coverage; the centralization of federal
control over the health insurance markets (manifest
in federally designed health insurance exchanges
in the Obama version and geographically based “regional
alliances” in the Clinton version); and federal control
over health care financing—characterized by taxpayer
subsidies and premium rate regulation in the Obama
version and “premium caps” and a “global budget” governing
all health care spending in the Clinton version.
Recurrent Rhetorical Gaps. But
both Clinton and Obama were undermined by yawning
gaps between their rhetoric and reality. In Clinton’s
stirring September 1993 speech to a joint session
of Congress, the President emphasized the need to
curtail the role of bureaucracy and to rely upon
the free market forces of choice and competition.
But when Clinton unveiled his 1,342-page Health Security
Act one month later, the reality was a massive, mind-numbing
bureaucratic system of federal command and control
over virtually every aspect of the health care system.
Obama, in his September 2009 speech before a joint
session of Congress and in other forums, likewise
promised that Americans who were satisfied with their
health plans would be able to keep them, the health
care cost curve would bend downward, proposed Medicare
cuts would not affect benefits, there would be no
middle-class tax increases, families would see an
annual reduction of $2,500 in their health care costs,
and taxpayers would not be forced to fund abortion.
Moreover, even as the President has proposed federal
control over both health benefits and health financing,
he disavowed that his proposals amounted to a federal “takeover” of
On all of these topics, the President’s repeated
assertions were thoroughly refuted by both official
and independent analyses of the legislative language.
Financial Gaps. In
1994, President Clinton insisted that his massive
health plan would not add to the federal deficit,
that it would “pay for itself.” But in February 1994,
the Congressional Budget Office (CBO) reported that
the Clinton Plan would in fact add tens of billions
of dollars to the deficit.
In 2009, President Obama
promised that his proposal for $900 billion in additional
spending would neither add to the deficit nor bend
the “cost curve” upward. In fact, the Senate legislation meets “deficit neutrality” targets
only by taking liberties with common sense.
the CBO modeled the Senate bill on the sponsors’ bold
assumption that the Medicare payment rules would
remain unchanged, thus effecting an initial 21 percent
reduction in physician payments. Sponsors also assumed
that Congress would follow through with hundreds
of billions of other Medicare payment cuts, and they
carefully crafted the 10-year financing to make sure
that the revenues would commence immediately and
benefit payouts would commence later.
on the Senate floor, Senator Max Baucus (D–MT) conceded that the real 10-year cost of the Senate health bill—depending on when and how one calculates the combined revenues and payouts—could be $2.5 trillion. The Heritage Foundation’s Center for Data Analysis estimates that under the Senate bill America’s
publicly held debt would be $755 billion higher by
Recurrent Popular Opposition. In
1993 and 1994, initial polling showed strong popular
support for comprehensive health care reform, and
the Clinton Administration rode that initial wave
of popularity. But with public scrutiny of the provisions
of the Health Security Act, popular support plummeted.
In the spring of 1994, congressional town halls were
a public relations disaster for the Clinton health
plan, just as the August 2009 congressional town
halls proved disastrous for the Obama Administration.
In both cases, increasingly sophisticated information
technology guaranteed rapid transmission of legislative
details. And in both cases, opponents successfully
framed the terms and decisively won the debate
in the high court of public opinion.
Political Defeat and Policy Victory
the fall of 1994, the Clinton health agenda died
on the Senate floor without a vote. The intense
public hostility to the Clinton health plan itself—not the
failure of Congress to defy public opinion and
enact it anyway—directly contributed to the 1994
Republican takeover of the House of Representatives.
But neither President Clinton nor his congressional
allies lost control over the health policy agenda.
The Health Insurance Portability and Accountability
Act of 1996 included large chunks of the text of
the Clinton Health Security Act, including the complex
HIPAA “administrative simplification” provisions that were obviously not; the State Children’s Health Insurance Act (known as SCHIP), which has since blossomed into the equivalent of a new and costly entitlement for middle-class families; and the Balanced Budget Act of 1997, which included an unprecedented statutory restriction on private contracting in the Medicare program; a historic government intrusion into the traditional doctor–patient
The Next Battle
Obama has already surpassed President Clinton’s success in expanding the role of the federal government in Americans’ health care. In 2009, Congress enacted a major SCHIP expansion. Shortly thereafter, with the enactment of the giant stimulus bill, the President secured a major Medicaid expansion, an unprecedented role for the federal government in the regulation of health information technology, and the creation of a government council to oversee “comparative effectiveness” of
medical treatments and procedures.
in Congress, playing defense on the emerging regulatory
regime is not enough. They should instead advance
a consequential health care agenda that would positively
impact the lives of millions of Americans. This
can be done by:
- Fixing the glaring inequities of the
federal tax treatment of health insurance, giving
millions of Americans new opportunities to secure
affordable, portable private health insurance;
- Pursuing aggressive state-based experimentation,
with grants and waivers, which unleashes robust
competition on health insurance markets while
guaranteeing affordable, high-quality care for
the poorest and sickest citizens who depend on
the safety net.
Meanwhile, centrists and conservatives in Congress alike should also recognize that real cost control begins with the nation’s largest entitlements, Medicare and Medicaid, programs for which they have direct responsibility. The health care debate is never over.