The voters have spoken, but it is not clear exactly what they said—at least about health care. When specifically asked, people have made clear in repeated surveys that they like the various elements of the health reform bill. But roughly half of the population is so unsure about what the whole bill portends that they say they would prefer to stick with the status quo, which repeated polls indicate they also recognize as unsatisfactory.
Republicans say that they strongly endorse many elements of the health reform bill, including the regulations on insurers to require them to sell policies to everyone and to bar companies from cancelling policies. But they oppose requiring people to carry insurance and providing the subsidies that are necessary to make those requirements fair. Without requiring everyone to carry insurance, the healthy could go without it until they become ill, at which time they could demand coverage, creating an impossible dilemma: insurers would have to charge outrageous premiums or go bankrupt. So, the insurance market reforms depend on the mandate that people carry insurance; and the mandate hinges on adequate subsidies to make insurance affordable for low- and middle-income households.
The serious risk now is that opponents of the health reform bill, lacking the votes to repeal it, will have enough to cripple implementation, and that supporters will not have the votes or the determination to see that the reform bill is properly implemented. Through a combination of meager appropriations for implementation—or none at all—and appropriation language that hamstrings the administration’s implementation efforts, opponents may have the power to make sure that provisions that could have worked effectively may never be given the chance.
The simple fact is that without major structural reform, growth of health care costs will continue to outpace income growth, causing more and more people to become unable to afford insurance coverage, even as the benefits of modern health care continue to advance. There can be little doubt that the recently passed health reform bill will require changes to correct legislative mistakes. But the way to do that is to implement what was passed as efficiently as possible, note the mistakes, and fix them.
This is just what the state of Massachusetts is doing. It covered two-thirds of the uninsured and then found that they did too little to control the growth of spending. They’re now addressing that problem too. The health reform bill actually contains many provisions to rein in the growth of spending, but more doubtless will have to be done. But the lesson from Massachusetts is clear: do what you can now and then fix the remaining problems when you can. Congress, please take note!