COLUMNIST DAVID BROOKS: Reading the tea leaves on health care
WASHINGTON -- Let's say that you are President Barack Obama. You've inherited a health care system that is the insane spawn of a team of evil geniuses from an alien power. Pay is divorced from performance. Users are separated from costs. Rising c...
WASHINGTON -- Let's say that you are President Barack Obama. You've inherited a health care system that is the insane spawn of a team of evil geniuses from an alien power. Pay is divorced from performance. Users are separated from costs. Rising costs threaten to destroy your nation and everything you hold dear.
Because you have a lofty perspective on things, you know there are basically two ways to fix this mess. There is the liberal way, in which the government takes over the health care system and decides who gets what. And then there is the conservative way, in which cost-conscious consumers make choices in the context of a competitive marketplace.
You also know that these two approaches have one thing in common. They are both currently politically unsellable. Others have tried and perished. There are vast (opposing) armies arrayed against them. The whole issue is a nightmare.
You are daunted by the challenges in front of you until you remember that by some great act of fortune, you happen to be Barack Obama. This calms you down.
You conceive a strategy.
The first step in this strategy is table-setting. You will spend the first several months of your administration talking grandly about the need for reform. You will invite all interested parties to the table, and you will serve a great heaping plate of pabulum.
You will talk about things that no sentient person could possibly disagree with -- about the need for better information technology and for more preventive care.
There will be less health care nitty-gritty here than in your average pre-K circle time, but you are getting everybody talking. You are building relationships.
In stage two, you pass everything over to Congress. You'll need these windbags at the end, so you might as well get them busy at the beginning. This will produce a whirl of White Papers, a flurry of committee activity, a set of legislative rivalries as every chairman in the stable seeks to be the lead horse in the romp to legislative glory.
All you have to do is raise a portentous eyebrow from time to time, signaling grand approval of the various proposals as they blow by.
This brings us to the current stage: The Long Tease. Every player in this game has a favorite idea, and you are open to all of them. The liberals want a public plan, and you're for it. The budget guys are for slashing Medicare reimbursements, and you're for that. The doctors want relief from lawsuits, and you're open to it.
The Republicans want you to cap the tax exemption on employee health benefits. You campaigned against that, but you're still privately for it.
You ran on a platform of hope and, boy, are you delivering. Every special interest in Washington lives in hope that they will get their pet idea incorporated into the final bill.
None will come out and oppose you because they live in hope. Even the different factions in your own administration live in hope. One of your health advisers pretended to smile at one of your economists!
This brings you to the final stage, the scrum. This is the set of all-night meetings at the end of the congressional summer session when all the different pieces actually get put together.
You want the scrum to be quick so that the bill is passed before some of the interests groups realize that they've been decapitated. You want the scrum to be frantic so you can tell your allies that their reservations might destroy the whole effort (this is how you are going to get the liberals to water down the public plan and the moderates to loosen their fiscal rectitude).
The scrum will be an ugly, all-out scramble for dough. You probably can get expanded coverage out of it. You can hammer the hospitals and get much of the $1.2 trillion to pay for the expansion.
But you won't be able to honestly address the toughest issues and still hold your coalition. You won't get the kind of structural change that will bring down costs long-term. In the scrum, Congress will embrace the easy stuff and bury the hard stuff.
Which is why you have MedPAC. That's the Medicare Payment Advisory Commission that you want to turn into a health care Federal Reserve Board -- an aloof technocratic body of experts that will make tough decisions beyond the reach of politics. You can take every thorny issue, throw it to MedPac and consider it solved.
Conservatives will claim you're giving enormous power to an unelected bunch of wonks. They'll say that health care is too complicated to be run by experts from Washington. But you'll say that you are rising above politics. You'll have your (partial) health care victory.
Not bad for a skinny guy with big ears.