As Clarke Cochran observed in these pages (“The Health-Care Issue,” September 24), debates about reforming health care are back with a vengeance. Both major presidential candidates are offering their laundry lists for change, but a healthy skepticism seems in order. If the partisan reactions to recently proposed increases of 17.4 percent in Medicare premiums are indicative, both Democrats and Republicans remain in a state of denial about the scope of the challenges ahead. Republicans are correct that the premium increase is the “automatic” result of a formula devised as part of a 1997 deficit-reduction bill. They are wrong to single out Kerry for supporting that bill, since eighty-four other senators, including most Republicans, voted for it. Democrats are correct to note that the projected increase represents a 56-percent rise in Medicare premiums since 2001. They are wrong to focus narrowly on efforts to block the current increase without facing squarely the need to rein in health-care costs more broadly.
The statistics that Cochran rehearsed about rising costs and rising numbers of those without insurance are familiar and depressing. Yet unless some sort of overlapping consensus can be developed at the level of shared social vision, debates about policy details are likely to remain mired in Foggy Bottom rhetoric. Why do we seem to lack the political will to provide universal access to basic health care-a failure unique among developed nations? On the one hand, for reasons both moral and pragmatic, we created Medicare and Medicaid in response to the obvious needs of the elderly and the poor. Various national commissions and professional groups during the last two decades have affirmed our social obligation to provide decent basic health care for all. On the other hand, as an object lesson, President Bill Clinton’s effort to bring about systemic health-care reform went nowhere. “Hillarycare” was dead on arrival, done in largely by untruths about “socialized medicine” and, to a lesser extent, by the hubris of experts devising blueprints for wholesale change without adequate input from the public. A chastened Clinton thereafter spoke of “incremental” reform, which, in light of recent statistics, sounds like benign neglect.
Is anything likely to change? After all, as Cochran noted, the same cast of characters remains largely in place. Critics from the right decry any role for government as “socialized” medicine. Meanwhile, private insurance companies raise their bottom line by “cherry picking” to exclude sicker patients. Pharmaceutical houses still lobby Congress to maintain record profits. But maybe, just maybe, things will be different this time, because current calls for reform enlist a stronger set of allies from corporate America. Several recent studies identify the dramatic increase in health insurance costs as a major culprit in the relatively jobless recovery of the last three years, with the largest job losses in industries that provide the best benefits. Moreover, pressure created by federal deficits as far as the eye can see, projected shortfalls in Medicare and Social Security, and health-care costs running at three to four times the rate of general inflation may converge to force a sense of realism and urgency.
Still, I share Cochran’s skepticism that either party, or candidate, is likely to move beyond rhetoric during this political season. The centerpiece of Bush’s plan is the creation of health-savings accounts touted for their portability from job to job. But his $3,000 tax credit for low-income families to purchase insurance is miserly. Family premiums have risen nearly 40 percent during the last three years, and now average $9,700 annually. Bush also wants to allow small businesses to form associations to provide insurance to employees. But that proposal, while supported by small business groups, is sure to be opposed by key players in the private health-insurance market. Given Bush’s obvious predilections, he is unlikely to buck the insurance industry-either to contain costs or to increase access significantly.
Kerry’s plan is clearly better on the access issue. He wants to roll back the Bush tax cut for persons making more than $200,000 per year, using that revenue to extend coverage to many of those currently uninsured. His proposed reinsurance plan would transfer costs for the most serious illnesses to the federal government. And he would allow small businesses to participate in the insurance program now offered to members of Congress. These are all good ideas, but even if they were enacted, Kerry’s proposal does not address the perverse incentives for providers to exclude sicker individuals. Nor does it candidly face the estimated shortfall, even after a tax rollback on the wealthy, of perhaps several hundred billion dollars. Thus, while Kerry passes the “vision” test on improving access, his plan fails to offer effective ways to contain costs and ensure the quality of care. A broader strategy will still be required, including the need for publicly acknowledged and justified limits on health-care spending and services.
We are facing quite a dilemma. Incremental approaches cannot address the systemic problems facing health-care delivery. Comprehensive approaches remain political poison. Thus Cochran’s endorsement of Faithful Citizenship, the recent bishops’ statement, set me to musing: What of an unabashedly moral argument as a way to break the gridlock? One element largely muted in the current conversation is the Catholic emphasis on universal access to basic health care as a requirement of social justice. Why don’t the bishops raise a strong voice on this issue? Let Catholics and others know that basic medical care is as much a requirement of the common good as basic education or basic housing or basic sustenance. Granted, how that right will be guaranteed is the $60 billion question. But it’s time, well past time, for the Catholic voice on this moral issue to ring as resoundingly as it has, with such selectivity, on other issues during this campaign.
