August was a tough month for supporters of healthcare reform. Instead of pushing a comprehensive bill close to passage by the time Congress adjourned for its summer break, they were still struggling to get to a vote in the House and a key Senate committee. The news media were filled with reports of protesters howling that "Obama-care" would socialize medicine, promote abortion and ration care for seniors. Polls showed support for the reform effort dropping steadily. The month ended with the death of Sen. Edward M. Kennedy, the advocate historically most effective at striking the compromises necessary to get a bill signed.
With the momentum for reform fading, some lawmakers are thinking about abandoning the far-reaching House and Senate bills in favor of more modest changes to the insurance market. We think it's far too early to give up on a comprehensive bill, and we fear that incremental steps won't do much to solve the interrelated problems of high cost and shrinking coverage. The current proposals have flaws -- for instance, they aren't aggressive enough in trying to control costs or reduce demand -- but excessive ambition is not one of them.
A more limited bill would be a concession to Republicans, who have denounced the cost of extending coverage to the working poor -- more than $1 trillion over 10 years -- and the specter of government intrusion in private medical decisions. Their relentless attacks have led some reform advocates to doubt the prospects for a bipartisan bill. But others say lawmakers from both parties would rally around a narrow effort to outlaw some of the tactics insurers use to minimize risks, such as retroactively canceling coverage after a policyholder submits an expensive claim and denying policies because of preexisting ailments. There also is wide support for promoting preventive medicine and helping individuals negotiate more effectively for coverage.
Piecemeal efforts, however, quickly run into the same complexities that make comprehensive reform contentious. Consider the implications of new regulations on rescissions and preexisting conditions. If insurers were required to offer unlimited coverage to anyone who applied, people would have little incentive to buy insurance until they needed expensive treatment. Healthy individuals would drop coverage, leaving the costs to be borne by a smaller pool of those who need care. It's an unsustainable approach, which is why insurers have said they will support such changes only if every American were required to carry insurance. But Washington can't require people to buy something they can't afford, so any insurance mandate would have to be accompanied by subsidies for the working poor. And with that, the modest little consensus bill would run up a price tag in the hundreds of billions of dollars.
It would be easier to draw up a bill that focused only on slowing the growth in healthcare cost, but such a measure would be impossible to pass. Unlike a comprehensive overhaul, which would add millions of new patients and pump billions of dollars into the system, a proposal that tried only to restrain healthcare spending would be all pain, no gain for doctors and hospitals. Nor would it have the humane appeal of the efforts to help the insured. And to be effective, it would have to employ some of the same controls on Medicare that Republicans have blasted as government rationing -- for example, giving a federal panel of medical experts more control over how and how much to reimburse doctors and hospitals for treating elderly patients.
In short, shifting to a more limited bill won't grease the skids for healthcare reformers. Instead, advocates should redouble their efforts to build public support for a comprehensive measure. The loss of momentum could actually help their cause because the breakneck pace leading up to the August recess invited opponents to make an issue out of the process, rather than focusing on the problems in the current system and how to solve them. And it raised the likelihood that provisions of the bill would have unintended consequences because they simply hadn't been given enough thought.