It should come as no surprise that Barack Obama does not support a national health insurance system like most other countries have. He made that clear during the campaign. What is surprising is that he has been so vague about exactly what kind of healthcare reform he has in mind. It’s becoming clearer that reform will include some or all of these options: requiring everyone to carry health insurance (an individual mandate à la Massachusetts); subsidizing a portion of the 85 percent of the uninsured who can’t afford to buy a policy; taxing some of the health benefits workers now get from employers to pay for insurance for the uninsured; letting people keep the coverage they have even though it’s likely to cover less as time goes on; shoving more people onto Medicaid; and trying to get insurers to insure sick people. There may or may not be a public insurance option–maybe like Medicare, or maybe not–that would compete with private insurers and theoretically reduce the cost of insurance.
Most of these elements are controversial. Former single-payer advocates, for instance, are banking on a public plan to open the door to a single-payer system. Insurers know that and are working overtime to make sure that doesn’t happen. Aside from saying he supports a public plan, the president hasn’t gotten his hands dirty in the political muck. Is he pursuing a conscious strategy to be above the fray or waiting to see what Congress does before jumping in? Is the president being strategically vague or abdicating to Congress because he, too, is feeling the heat from the special interests that contributed millions to his campaign?
Campaign rhetoric led the electorate to believe that a new president was ready to overhaul the healthcare system and bring health coverage to everyone. A poll released by the Kaiser Family Foundation indicates that there is strong support for health reform but that the public can be swayed on the details. “There is still a tremendous opportunity for leadership,” says Kaiser CEO Drew Altman. But the special interests can still move the debate in one direction or another.
During his April 29 prime-time press conference marking his first 100 days in office, Obama peppered his remarks with his healthcare accomplishments to date–expanding S-CHIP, giving more money to community clinics, helping laid-off workers pay for COBRA coverage. Here and there, he dropped a few hints about what appears to be the focus of his healthcare agenda: bringing down the cost of medical care. “New investments in healthcare will cut costs for families and businesses,” he said at one point. At another, he said, “You can expect us to work on healthcare reform that will bring down costs while maintaining quality.”
Absent from the president’s press conference were any comments about that pesky and elusive goal of universality. Unlike the Clintons, who focused on health coverage for everyone, the Obama administration appears to have embraced lowering the cost of medical care as its centerpiece. Indeed, Obama has said that once costs go down, more people will be able to buy health insurance. One of Obama’s eight “principles for reform” said only that he would “aim for universality.” He did not say he was determined to accomplish it anytime soon.
The Congressional budget agreement includes a provision for a reserve fund to pay for the subsidies needed to help the uninsured buy health insurance. It suggests no specific amount such as the $634 billion offered in the president’s budget message. Instead, the various committees dealing with health reform will decide how much can be spent in this budget cycle. The administration is in sync with this approach. The resolution is also budget-neutral, which means Congress must find an offset of money from other programs or a new source of funds. Obama had proposed trimming the deductions allowed for charitable contributions for wealthy Americans, an idea many members of Congress rejected. He also wants to cut excess payments to Medicare Advantage plans, which is meeting stiff opposition from insurers.