The Status Report: Obama and Health Care Reform

One year ago, Brookings experts wrote a series of 12 memos to the incoming president on the most pressing policy issues facing the country. Now they assess the administration’s progress on those issues in The Status Report, a daily series of commentary with video to be featured in POLITICO’s Arena. Because Congress has not yet enacted legislation to reform health care, Henry Aaron assigns a grade of ‘incomplete’ on this issue, noting that history will judge the president depending on whether the effort succeeds or fails in the long run.

Reform Health Care: Incomplete

That health reform would be a major issue during the Obama administration was a given. Policy and politics both called for action. The budget threat from rapidly growing health care spending, the unevenness of the quality of care, and the lack of insurance by close to 50 million Americans meant that the issue was too important to disregard. How to reform health care delivery and finance had been a central issue during the contests for the Democratic nomination and the presidency itself.

But how to approach health reform was up to president Obama. He immediately made two crucial decisions: to go for large scale reform and to set forth general principles but not draft detailed legislation. The first decision increased the stakes—the potential rewards of success and the possible cost of defeat. The second decision left to Congress the detailed work of finding common ground within fractious Democratic majorities in each House and, if possible, with at least some Republicans.

The first decision—to swing for the fences—is the sort of choice only presidents can make. Nothing other than the course of history can assign a grade to that crucial action.

The second choice—to leave detailed drafting to members of Congress—has come in for criticism from some. Wouldn’t the Administration have been able to move faster and more purposively if it had presented Congress with draft language and worked hard for its acceptance? The answer is probably not. President Clinton had tried and failed with the more prescriptive approach, although, of course, the whole political environment in the early 1990s differed from that of 2009.

The central reason why leaving to Congress the task of drafting legislation, rather than presenting a complete bill to Congress, was the right strategy is that the task of reforming the U.S. health care system is not principally a matter of technical design. It is more akin to avoiding a lethal misstep while negotiating a political minefield. The ‘locals’—in this case, the leaders in Congress—are best able to do the job. So many issues, many of them seemingly extraneous, come up in fashioning large-scale health system reforms, that no one central political agent, even one with the resources of the modern White House, can adequately manage them. A very partial and incomplete list of these issues would include: abortion policy, the treatment of undocumented aliens, how to correct past legislative blunders such as efforts to slow growth of physician salaries, the role of private insurers, the role of a publicly managed insurance option, drug patent rights, whether and how to change Medicare, the proper reach of Medicaid, how to prop up rural hospitals of dubious long-term viability, how much age-related and other variation in insurance premiums to permit, and what information to give to the terminally ill regarding options for care at the end of life.

That the administration set ambitious goals is indisputable. That it eventually put the full political resources of the administration behind the effort is equally clear. Democratic party unity has been elusive; cross-party cooperation on health reform has been non-existent. With so many hurdles cleared, passage of a reform bill is now within grasp. The debate will not end with a signing ceremony, however. Many provisions will not be implemented until 2013 or 2014, leaving perhaps two elections to continue the debate.

History’s fickle judgment on the skill with which this effort has been carried out will depend almost entirely on whether it succeeds or fails. With success, analysts will judge astute the very decisions that, with failure, they will indict as shallow blunders. A more modest approach might have had smoother political sailing. The reward for boldness will be a permanent and honored place in American political and social history.

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