I think what they are doing is smart. It would be one thing if they were merely going around seeking to enjoy the adulation of office. But even their most ferocious critics don’t think these are people who have nothing particular in mind beyond perpetuating their own ascent to glory. This administration is committed to getting some very momentous, complicated-and in many respects, extremely disruptive-business done. It must be plain to the people at the top that there is not the smallest chance of their succeeding unless they can engage large segments of the public in the process. Above all, this will be true of their audacious public commitment to have crafted comprehensive health-reform legislation by May 1 and gotten it enacted into law this year. Health-care reform is the big one; it is going to make the present economic effort, tax increases and all, look like child’s play.
I admit that, like many of those who live in Washington and study the folkways of government for a living, I may have an overdeveloped sense of the impossible. One has seen the eventual 12-car pileup of so-called urgent national business too many times before, just one more wreck on the debris-cluttered highway of government. But more than reflexive skepticism is involved here. This issue is going to take missionary work. And so it is not too soon to start trying to put it in perspective and certainly not too soon to be working on the prerequisite education involved. For even though people are all too well aware of the system’s shortcomings, I believe most are not even close yet to understanding the nature of what will ultimately be required and its enormous complication.
Let’s start with what will be required. Surely just about everyone in the country must favor health-care reform. People rightly believe steps must be taken to make things better. But how many are prepared to accept that this may involve making things better for someone else and, possibly, more cumbersome and costly for them? Yes, medical costs must come down, but at what associated other cost to individuals? And may not people be untrusting and scared of any comprehensive alteration of a system-even a system whose conspicuous, terrible defects and crazy prices they abhor-when it upsets in any fashion routines they have come to associate over the years with safeguarding their own family’s health? A thousand times now politicians have admonished that some 37 million of our fellow Americans do not have health insurance and that this is unconscionable and that the rest of us must fix it. Ah, yes, we say, and we are heartfelt in this-but surely not at our own expense?
I take as my cautionary model the energy crisis of 1973. Like the suddenly perceived threat from newly scarce and pricey foreign oil, so now there is the suddenly perceived threat of immobilization and bankruptcy from spiraling medical-care costs, not to mention the threat of loss of care by those who are losing their insurance. And just as the energy crisis was said to require a “lifestyle” change for most Americans in terms of how they drove and how they heated their homes and how, in a general way, they thought about using energy resources, so too this crisis will bring calls for comparable change.
But people hate the hell out of these prospective limitations on their way of life. And, unfortunately, just as there were handy culprits back then-the big oil companies, the OPEC states-there are handy culprits now: the insurance companies, the medical industry, the pharmaceuticals. Far be it from me to defend all of the above. All offer plenty to be sore about. But the inconvenient truth remains that among them all, as with the big oil companies and the foreign oil producers before, there is not by itself the single key here to solving our problem. Even if we did all the reforming we could of those institutions, we would still be required, as we are in the rational use of energy, to pay in something ourselves, to adjust our expectations and tame our more senseless and/or wasteful demands.
That is one reason why it is hardly a moment too soon for the new administration to be starting its efforts to get the public into the process of deciding what kind of reforms there will be. The other is the head-breaking complexity of the subject. Back in the days of Lyndon Johnson when Medicare was enacted, it was widely understood that only a few individuals grasped everything that was in the lengthy and, by and large, completely unreadable legislation-men like Wilbur Mills, then chairman of the House Ways and Means Committee, and assorted experts. And very few comprehended that something widely ignored called the Medicaid provision would turn out to be such a budget buster. This will seem odd today, since we all know that Medicaid, which provides for combined federal and state funds for health-care for the poor, was a gigantic step and an extremely costly one. It was utterly worthy. It can also be called, without too much poetic license, the legislation that ate New York … and some other states. I don’t say that it shouldn’t have been enacted, only that it is very easy in dealing with a tangle like this to end up some place you didn’t know you were going.
My own view is that the deadlines set for presentation and enactment are really cutting it close and that there is a horrendous amount of work to do in figuring out a sensible proposal, addressing its almost unimaginable complexities and getting a consensus for action on the part not just of the public but of all the many constituencies and interests involved. Mind you, at this time last year no one seemed to think Bill Clinton could possibly win election to the presidency, so maybe he and Hillary Clinton, who has been given the job of presiding over the health-care reform, will bring this astonishment off as well. If they do it will owe more than a little, I think, to “talk government”-to all the tromping around and tireless venting of the issues for which they are being so gleefully teased today.
