Let's start by acknowledging that our health system is broken. Some 47 million of us are uninsured, an embarrassment in a nation this rich. The growth of medical costs is unsustainable—not just for families and companies but for federal budgets. And while the quality of U.S. care can be the best in the world, it is ridiculously uneven.
Unfortunately, though, President Barack Obama and health reform advocates in Congress have been acting as if finding the right solution is as easy as admitting there's a problem. In other words, they're still campaigning on the issue when what's needed is a detailed conversation with the American people about the hard choices involved in improving medical care.
Compounding this reliance on rhetoric is a mad rush to pass a bill. Congress has promised to produce a major health-reform law before August, an artificial deadline driven by lawmakers' monthlong summer recess. Yet the legislation—which currently exists as two major bills in the Senate and one in the House—is nowhere near ready for prime time.
Take the idea of the "individual mandate," which would require all citizens to have health insurance. There's an emerging consensus that this might be a good idea. But in the various bills (and the incomplete piles of paper parading as bills), it's unclear how the mandate would be enforced or what fines would be appropriate.
And what of the proposed "employer mandate," also in all three bills? Dubbed "pay or play," this would levy a tax on businesses that don't offer health insurance. But adding another cost linked to employment may further reduce job rolls. Have we satisfied ourselves that the trade-off is worth it?
Then there's the "public plan," the government-run insurance option embraced by the President and some Democrats as an alternative to private coverage. Those championing this option tell us that "if you like what you have, you can keep it." But according to nonpartisan think tank Lewin Group, as many as 118 million people could effectively be forced into the public "option," because their employers won't be able to compete—and will opt out of providing coverage choices. A government plan, unlike an employer-sponsored plan, can exempt itself from federal taxes and state regulations and compel hospitals to accept submarket reimbursements.
What's more, advocates pointing to Medicare and Medicaid as models seem to be ignoring the budgetary death rattle that endangers the future of these programs. Medicare trustees announced on May 12 that the hospital trust fund—Medicare Part A—will be bankrupt by 2017.
The public needs clear explanations about the trade-offs involved in reform. Instead, we're still getting stump speeches about how we can insure all the uninsured, improve the quality of care for everyone, and reduce total costs. We get stories, many of them moving, about sick people the system has failed. (The Web site for Organizing for America, the Administration's external campaign machine, asks supporters to send in such accounts. "Your personal stories are the most powerful call for change," the home page says.)
Many moderate Democrats are asking the difficult questions: Will the proposed government-centric fixes destroy the parts of health care that work? Oh, and what will health reform cost? The Senate Finance Committee has seen the price tag yo-yo wildly, as its staffers work to slash the Congressional Budget Office's breathtaking estimate of $1.6 trillion over 10 years—to a more vote-friendly $999,999,999,999.
The noble goal of helping the uninsured secure coverage should not be separated from the work of deciding how to finance it. Like killjoy accountants, the public should demand that representatives specify exactly what health reform will cost and what taxpayers will get for their money.
The President tells us it is time for serious discourse. He's right. But passionate certainty that things are broken is not the same as dispassionate clarity about how to fix them. If our leaders fear the specifics of health reform might frighten voters, the bill must not yet be good enough. Our health problems are too big for Congress to prescribe a cure that neither they nor we understand.