Jonathan Cohn: The Big-Picture Reasons The U.S. Needs Reform, Daschle Or No Daschle





At first blush, the findings of a study group called the Committee on the Costs of Medical Care might not seem particularly surprising. It's no longer news that millions of American families face financial ruin or physical catastrophe because they have no way to pay medical bills. Nor is it a great revelation that, as a committee staff member put it, "[v]ery few of these families are indigent in the accepted meaning of the word. They have a home, they buy their own food and clothing and pay their doctor's bills in ordinary illness." But it's not the novelty of the committee's findings that makes them so compelling. It's the timing. The report appeared in 1932.

It was the culmination of a five-year study, sponsored by a group of philanthropies, designed to provide the first comprehensive survey of health care spending in the United States. Back then, medicine was just entering what we now consider the modern era. Thanks to anesthesia, the sanitary method, and other innovations, health care had suddenly gotten a lot more effective--and a lot more expensive. For the first time, worrying about illness inevitably meant worrying about paying doctors and hospitals--a situation, the committee knew, that wouldn't go away after the Great Depression.

The committee's report was pretty big news. And, to the liberals then serving in Franklin Roosevelt's new administration, the response was obvious: The United States should follow the lead of Germany and create a national insurance system for medical care. Everybody would pay a premium in the form of taxes; the government would then pay everybody's medical expenses, drawing the money from the collected premiums. The New Dealers perceived national health insurance as a logical extension of what they were trying to do with Social Security: insulate people from the whims of the free market and the full fury of chance. They wanted to save capitalism from its own failures, which in this case meant making sure nobody would become indigent just because he or she had the misfortune to get sick.

FDR ultimately decided against pushing national health insurance, deeming it an unacceptable political risk. Two generations later, the job remains unfinished, only now our health-care crisis is a lot more complicated. One thing, however, has changed for the better. Unlike in 1932, there is today broad agreement that the system needs fixing. Perhaps nothing better symbolizes this consensus than the existence of a coalition called "Divided We Fail," whose members include longtime health reform advocates like the Service Employees International Union and longtime opponents like the Business Roundtable.

As a result, the prospects for sweeping changes to our health care system seem brighter than at any time in recent history. But the consensus is as fragile as it is broad. While the environment might now be conducive to bold changes, such political moments can prove maddeningly ephemeral. Once the squabbling over details begins, the obstructionists will get louder. National health insurance, they will vow, is a form of socialism--a charge they deployed during the New Deal and in every health care debate since.

But, just as the critics reach back to history to formulate their offensive, proponents of reform can find ammunition there, too. They must reprise the arguments for reform that were offered during the 1930s--and explain why they have only grown more urgent in the past few decades. Moreover, just as New Dealers were willing to take what they could get--to settle for imperfect but politically tenable programs rather than hold out for more ambitious measures and risk ending up with nothing--reform advocates may have to accept proposals that come up short of their ideal solution. Finally, they must press the case that, in the best New Deal tradition, health care reform isn't an effort to chip away at capitalism--but rather a bid to save it....

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