Pulling it Together: On Health Reform, Will All Roads Meet in the Middle?

A few weeks ago a small group of upset single-payer advocates followed Senator Baucus into the parking garage of our D.C. building as he was arriving to do one of our health reform newsmaker breakfasts, cosponsored by Families USA and the National Federation of Independent Business. They were angry because they feel that single payer is not receiving enough attention in the current debate, and it is true that it is not getting a lot of attention. But it could equally have been a group of upset conservatives in the garage that day; their favorite consumer-driven market-based solutions, advanced with great fervor in the Bush administration just a few years ago, are largely off the table.

It has been clear for some time that if there is to be a deal on health reform in this Congress it will be a centrist deal, one that neither purists on the left nor the right will be truly enthusiastic about.  It will build on the current system of employment-based insurance and public programs, contain a heavy dose of private insurance and market mechanisms and lots of delivery and payment reforms aimed at achieving future savings, and allow people to keep their current doctors, hospitals and insurance coverage if they want to. The Democratic majority in the Congress has little interest in the directions championed in the Bush years, but by the same token conservative Democrats and deficit hawks will be leery of a larger government role and will try to minimize future spending obligations. And many Democrats will not want to be vulnerable to being tarred as big-government, big-spending liberals in the next campaign when they go after independent voters to win reelection. Ultimately, political leaders will balance optimal policy as they see it and political needs as the election gets closer.

Much of the jockeying we are seeing can be viewed as the fine tuning of a centrist compromise with elements both the right and the left will not like. Putting together such a centrist bargain on health reform is precisely what my home state of Massachusetts did, although it bears noting that while states have their politics, politics at the state level are more pragmatic and less driven by ideological differences than politics in Washington are. Here are some possible elements of a health reform bargain the right and left may not like:

Some Things The Left Would Not Like:

• It’s not single payer
• No public plan or a watered down public plan
• Weaker regulation of insurance than many on the left want
• A cheaper plan with subsidies that may not go as high up the income ladder as they want
• Capping the tax preference (mainly labor opposition)

Some Things The Right Would Not Like:

• Mandates, especially employer mandates
• A new expensive coverage “entitlement”
• Any form of public plan
• Expanded government regulation of the health insurance industry and health insurance benefits

It is certainly not the time for groups to stop fighting for positions and ideas they believe in. It is too early in the process and the push and pull from all sides is how our system works. But it is also true that the voices on the edges tend to be stronger, and their beliefs more strongly held than those in the middle who are trying to craft a compromise rather than advance deeply held positions. In the end, however, if legislation passes, the American people will not think about it as liberal, or centrist, or conservative, and they do not have an expert position on what constitutes optimum policy. They will view it through their own more pragmatic lens and ask: will my health care be more affordable now than it was before? The question is not whether the public will go for a deal in the middle, it is whether Washington and Congress as currently structured can, while at the same time satisfying enough of the public that they will come out ahead and holding the remainder of the population harmless.