Forward Progress

"Make no little plans; they have no magic to stir men's blood." -- Daniel H. Burnham

With one exception, the health plans released by the Democratic presidential contenders are a set of little plans. They leave the current system largely intact and use subsidies and tax credits to reduce the number of uninsured -- as if the whole system were not broken. With slight variations, this is the approach chosen by both former Vermont Governor Howard Dean and Massachusetts Senator John Kerry. And North Carolina Senator John Edwards and Connecticut's Joe Lieberman will likely do the same. Congressman Dick Gephardt, by contrast, had the nerve to throw a long pass. The problem is that he hurled it in the wrong direction. Gephardt began well. He proposed to repeal Bush's entire 2001 tax cut. He added another bold feature: opening Medicare to people over 55.

But the rest of his plan mainly gives tax breaks to corporations that provide health coverage for their workers. This sounds good, until you remember that most large corporations already provide some kind of health coverage. For them, the money will be mainly windfall. (Kuttner's Corollary to Burnham's Law is that if you're going to make bold plans, they had better be the right plans.)

Any of the Democratic plans are an improvement on what Bush proposes, which is mainly to shift even more risks to individuals. Reportedly, the Republicans will soon press legislation that is the mother of all bad health bills -- privatizing Medicare, turning Medicaid into a limited block grant, limiting malpractice suits, and doing a pro-drug-industry version of prescription coverage.

But the Democrats will need to do more than play defense. They need something bolder to get real political traction from health insurance, let alone to solve the problem.

What is the nature of the health care crisis? For starters, coverage is eroding, even for the insured. There's a squeeze on corporate profits in a climate of rising health costs. So health costs are being shifted from plan to individual, with the result that many people go without needed treatments that the plan won't cover and that they can't afford out of pocket.

The number of people without insurance is also increasing. Smaller businesses won't provide insurance. More people are self-employed. And as bigger businesses increase the employee share costs, many lower-paid workers decline the insurance because they can't afford it.

Costs keep escalating for three distinct reasons. Science keeps inventing new tests, new treatments, new drugs, all of which add to the overall costs. The population keeps aging. And the system is stunningly inefficient, with its patchwork of fragmentary health plans and its profiteers taking bites out of each medical transaction.

If we leave intact the present system, with its wasteful fragmentation, billing, underwriting and insurance company profits, there is only one big place to reap savings -- by withholding more care as nonessential and by avoiding the sick.

Yes, there are other containable costs, however they are not the main story. The much-touted crisis in malpractice insurance needs fixing, but it is only a small fraction of the cost problem. And we need to reduce escalating drug costs, by shifting to generics wherever possible and preventing the drug companies from continuing to extend the patents of medicines that should be in the public domain. But that, too, is not the main engine of medical inflation.

The real problem is a system where health insurance is optional for employers and run through private insurers. This leads tens of billions to be wastefully spent, on everything from billing, to second-guessing doctors, to shifting costs, to avoiding subscribers likely to get sick.

Other advanced nations face the same march of science and even more difficult demographic realities -- their populations are even older on average, thanks to two generations of better health care. But they are better equipped to contain costs and get the most for their health outlays because they have universal health systems. Yes, there are difficult choices, but they are typically made by panels of doctors, citizens and ethicists, not by private insurance companies.

The best solution here is national health insurance. We already have it for one segment of the population, through Medicare. The program is easy to understand, and even fits on a bumper sticker: "Medicare for all."

The one declared Democratic candidate with a fleshed out, Medicare-for-all plan
is Dennis Kucinich. Congressman Kucinich is considered a long-shot, but for
reasons other
than his views on health care. Indeed, a recent Wall Street Journal poll found
that Americans, by a margin of nearly 55 to 36, would rather have the
government pay for
health care than bestow more tax cuts. The issue is a winner with voters, if
Democrats just have the nerve to pursue it.

Face it: Even incremental proposals by Democrats will be attacked as too costly and entailing too much government. They might as well do it right.

Robert Kuttner is co-editor of the Prospect.

This column originally appeared in yesterday's Boston Globe.

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