The Crisis of Health Care Reform

By Michael Gerson (Archive) · Wednesday, September 9, 2009

WASHINGTON -- President Jimmy Carter once sent a note to an adviser extolling the importance of crisis to leadership. "When a president has authority to act unilaterally (as in a crisis), his leadership can be exerted. Otherwise, compromise, delay and confusion are more likely. It's our system. I like it."

Politicians, like the rest of us, are often victims of their wishes. Carter was eventually smacked by the waves of crisis he sought to ride.

But encouraging a sense of crisis is a traditional tool of executive leadership. And using a joint session of Congress to address a single domestic issue is the most dramatic expression of this approach.

Carter did it effectively in April 1977. He spoke of the energy crisis as "the moral equivalent of war." Energy resources were "simply running out." (Carter's CIA predicted worldwide oil shortages by the mid-1980s.) America needed to "cope with a crisis that otherwise would overwhelm us."

The speech had immediate influence. The number of Americans who viewed the energy crisis as a serious problem jumped nine points to 54 percent. One congressional staffer enthused: "It's damn near unpatriotic to oppose the president right now."

But the effect was temporary. Carter's energy reform bill passed the House, but the Democratic Senate resisted on key issues, resulting in an impasse. Eventually, the energy crisis faded in comparison to unsought emergencies such as the Soviet invasion of Afghanistan and the taking of American hostages in Iran.

And so Barack Obama's address to Congress on health care, at a minimum, must answer the question: What is the crisis? When an individual can't get needed health care, it is certainly a crisis for them. This, Obama might argue, creates moral responsibilities for the rest of us to help. But this would argue for a more incremental approach, adding coverage for the working poor instead of remaking the American health system for everyone.

The overwhelming majority of Americans, by the definition of denied care, do not face a health care crisis. Most polls show that about 80 percent are "very" or "somewhat" satisfied with their health plan. Those in the greatest need are often the most satisfied -- 90 percent of insured Americans who suffered a serious illness are satisfied with their health care. According to a study published by the Cato Institute, a very small percentage -- even of the uninsured -- are "dissatisfied or highly dissatisfied" with the health care they get in other ways. On health care, the American public seethes with satisfaction -- though most are concerned about rising costs.

So perhaps this is the crisis: rising costs that will eventually overwhelm state and federal budgets and consume more and more of individual paychecks. But this is precisely the area where current Democratic approaches are least credible. Obama abandoned his pledge to reduce the government's health costs long ago; now he only aims at budget neutrality. But every pending health reform bill in Congress increases both short-term and long-term deficits, failing even on Obama's modified terms. Americans get the joke. While Obama has made cost control a centerpiece of his public message, only about 20 percent of Americans, in one poll, believe Obama will keep his promise not to increase the deficit with health reform.

The main challenge for Obama is this: Announcing a more credible, specific approach to cost control on health care will not solve his political problem. Aggressive cost control options -- squeezing Medicare fees even further, abandoning fee-for-service in Medicare entirely, restricting "unnecessary" procedures through an all-powerful medical board, putting more cost burdens on individuals -- tend to be frightening or difficult. Major tax increases would lessen the need for drastic cost reductions. But the obvious source of revenue -- eliminating the health insurance deduction for employers -- would open a new front of controversy.

America has an ongoing crisis -- an economic crisis of rising unemployment and negative economic growth. Obama clearly believed the economic emergency would give him the opportunity to do anything on the progressive agenda that he wished. Actually, it gave him the burden to do one thing well -- responding to the economic emergency. Insofar as health reform is seen as complicating this task -- particularly by the addition of massive, inflationary debt -- the narrative of crisis will continue to work against Obama instead of for him.

It is all very Carter-like. Obama presents a political priority as a national crisis. But the economy, Afghanistan and Iran may be crises enough for anyone.

(c) 2009, Washington Post Writers Group

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