HEALTH - OCTOBER 8, 2003

The illogic of incremental universal health insurances

As the Demo-cratic presidential contenders have decided that health care will be a big issue in the 2004 election, it’s time to take stock of what they have to offer – as the U.S. health care non-system continues its tailspin all around us.

Two things immediately become evident. First, most candidates declare themselves “in principle” in support of universal access to health care for all Americans. Second, most of them have offered proposals for health reform that fall considerably short of universal access for all. Only two candidates have come out in favor of the simplest and most comprehensive manner of covering everyone, a single-payer health care system. Those are Dennis Kucinich and Carol Moseley Braun, neither viewed as a front-runner.

Symptomatic of the main pack is physician and former Vermont Gov.Howard Dean. To hear the folks spout off about it, you’d think that Dean as a) some sort of fire-breathing extreme left wing radical, and b) a major champion of health care reform. Fact is, the Physicians for a National Health Program, which endorses universal access and favors a single-payer approach, have panned Dean’s health proposals as falling seriously short of universal coverage.

So if we assume that the “mainstream” candidates are listening to their pollsters and handlers, the conventional political wisdom seems to be that the only way to win votes is to appear moderate and middle-of-the-road on health care. Let’s look at whether that makes sense.

There’s a very big policy reason to go whole hog on health care reform rather than choose incremental proposals: You don’t really get into substantial cost savings until you have truly universal coverage. If we decide, say, to cover all kids, or to add a prescription benefit for seniors, you don’t save much money on administration; you simply add a further program which creates additional red tape. You can save $50 billion or $100 billion annually on bureaucracy immediately if you have a single plan that covers everyone. But let’s lay that concern to one side, since it doesn’t fit well with the 15-second sound bite on the evening news.

Now, no one, no matter how off the deep end in favor of radical reform, thinks that any serious reform will happen overnight. Even if we had a political consensus this minute on what to do – far from the case – inevitably there will be a protracted start-up. Given the huge budget deficits that our present administration has saddled us with, it would even make sense to slow down the start-up of any truly comprehensive plan that much more, even to the tune of 10 or12 years. A slower start-up might have additional advantages in gradually winning over sectors of the health care system and its personnel who may initially balk at the changes proposed.

Given that the start-up will be rocky and troublesome, as well as delaying the day we finally have what we are after, why would one want to propose that when that day eventually comes, we’ll have only a partial plan that provides coverage only for some of the 44 million Americans now without insurance? If you say you are for universal coverage, why not come up with a sensible, moderate plan to get us to universal coverage in the next decade? Why claim to be for universal coverage, and give us a proposal that will still take years to fully implement, and even then would take us only part of the way?

There’s only one reason to go the incremental route. As soon as Candidate Jones announces her health reform plan, the press wants to know – what will it cost the taxpayers? And a partial plan comes in at a lower price tag.

Is that how our would-be Democratic “leaders” want to convince the country to support universal access to health care – by pretending that we can have it for less than what it will really cost us? Do they really want to “lead” us to health reform the same way that President Bush “led” us into Iraq?

So at present I am puzzled how the incremental approach to health reform came to be seen as the politically safe and wise way to travel. At least a couple of candidates have figured out that when our present non-system is unraveling at the seams, moderation in defense of stupidity is no virtue.

Howard Brody teaches family practice and medical ethics at Michigan State University. You can reach him at brody@msu.edu.

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