The first reason to support the Senate health care bill is that it would provide insurance to 30 million more Americans.
The second reason to support the bill is that its authors took the deficit issue seriously. Compared with, say, the prescription drug benefit from a few years ago, this bill is a model of fiscal rectitude. It spends a lot of money to cover the uninsured, but to help pay for it, it also includes serious Medicare cuts and whopping tax increases — the tax on high-cost insurance plans alone will raise $1.3 trillion in the second decade.
The bill is not really deficit-neutral. It's politically inconceivable that Congress will really make all the spending cuts that are there on paper. But the bill won't explode the deficit, and that's an accomplishment.
The third reason to support the bill is that the authors have thrown in a million little ideas in an effort to reduce health care inflation. The fact is, nobody knows how to reduce cost growth within the current system. The authors of this bill are willing to try anything. They are not funda-
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mentally disrupting the status quo, but they are experimenting with dozens of gradual programs that might bend the cost curve.
If you've ever heard about it, it's in there — improved insurance exchanges, payment innovations, an independent commission to cap Medicare payment rates, an innovation center, comparative effectiveness research. There's at least a pilot program for every promising idea.
The fourth reason to support the bill is that if this fails, it will take a long time to get back to health reform. Clinton failed. Obama will have failed. No one will touch this. Meanwhile, health costs will continue their inexorable march upward, strangling the nation.
The first reason to oppose this bill is that it does not fundamentally reform health care. The current system is rotten to the bone with opaque pricing and insane incentives. Consumers are insulated from the costs of their decisions and providers are punished for efficiency.
If this bill passes, you'll have 500 experts in Washington trying to hold down costs and 300 million Americans with the same old incentives to get more and more care. The Congressional Budget Office and most of the experts I talk to (including many who support the bill) do not believe it will seriously bend the cost curve.
The second reason to oppose this bill is that, according to the chief actuary for Medicare, it will cause national health care spending to increase faster. Health care spending is already zooming past 17 percent of GDP to 22 percent and beyond. If these pressures mount even faster, health care will squeeze out everything else, especially on the state level. We'll shovel more money into insurance companies and you can kiss goodbye programs like expanded preschool that would have a bigger social impact.
Third, if passed, the bill sets up a politically unsustainable situation. Over its first several years, the demand for health care will rise sharply. The supply will not. Providers will have the same perverse incentives. As a result, prices will skyrocket while efficiencies will not. There will be a bipartisan rush to gut reform.
This country has reduced health inflation in short bursts, but it has not sustained cost control over the long term because the deep flaws in the system produce horrific political pressures that gut restraint.
Fourth, you can't centrally regulate 17 percent of the U.S. economy without a raft of unintended consequences.
Fifth, it will slow innovation. Government regulators don't do well with disruptive new technologies.
Sixth, if this passes, we will never get back to cost control.
The basic political deal was, we get to have dessert (expanding coverage) but we have to eat our spinach (cost control), too. If we eat dessert now, we'll never come back to the spinach.
So what's my verdict? I have to confess, I flip-flop week to week and day to day. It's a guess. Does this put us on a path toward the real reform, or does it head us down a valley in which real reform will be less likely? If I were a senator forced to vote today, I'd vote no. If you pass a health care bill without systemic incentives reform, you set up a political vortex in which the few good parts of the bill will get stripped out and the expensive and wasteful parts will be entrenched.
Defenders say we can't do real reform because the politics won't allow it. The truth is the reverse. Unless you get the fundamental incentives right, the politics will be terrible forever and ever.
NEW YORK TIMES NEWS SERVICE