Health Care: What Ought to be Done?

How should Democrats think about health care reform now? And what should Democrats do about it? The simplicity with which one can pose such questions is misleading. Health care reform is a topic marked by much ideological cant, ferocious interest group lobbying, and the difficulty of finding common ground even among apparently like-minded Democrats.

A good starting point would be for Democrats to reject, rather than adopt and adapt, the language with which and the moral framework within which most Republicans typically address health care reform.

The Democratic reform of American medical care should aim at making it much more likely that people can get the care they need and not face financial ruin as a consequence. We have been struggling with this nest of problems since the Second World War. Forty-five million Americans live without that assurance on any given day, but between sixty and seventy million Americans face a period of being without insurance in any two-year period. And that calculation leaves out entirely the problem of insurance coverage that excludes chronic conditions.

All this takes place in a nation that spends much more on health care, by any measure, than any other nation ever has. The rapid inflation in medical costs of the past few years continues unabated. Tens of millions of uninsured or underinsured live in physical and financial jeopardy; they incur more serious illnesses, more losses of function, and more pain than they would with adequate and timely care; and their lives are being unnecessarily shortened.

Democratic political leaders should make it clear that health care reform is not an empty abstraction, and that it most certainly is not just a debating point for the fall election or a “wedge issue.” As a substantive matter, but also as a political one, Democrats need to make the reform of American health care policy a cause that distinguishes the parties.

Over the past decade, and during the current administration, Republican rhetoric about health care policy has been morally pallid, managerialist in its language, and economistic in its presumptions. Republicans profess to be consumed with “perfecting” the market for health care and with encouraging efficiency and patient choice by deploying incentives and rewards, and, by the way, only rarely are they concerned with penalties. Readers of Bruce Vladeck’s commentary in this issue on the Medicare “reform” bill of 2003 will see the most recent evidence of the Bush administration’s intentions: to attack Medicare’s social insurance roots. But those intentions have a history; they go back decades, though they were often expressed in code.

In the 1970s, the celebrations of health maintenance organizations (HMOs) were for Richard Nixon’s administration a way to harness “incentives” by internalizing the costs of medical care within the very organization that d...