Health Care for All

With prospects quite good for a Democratic Congress and administration in 2009, the United States is on the brink of joining all other industrialized nations in ensuring the provision of some form of basic health care for all Americans.

Reforming American health care is the single most important public-policy issue on the Democratic agenda, and policy experts are weighing in from all sides. I will confine this article to offering some practical reflections on issues that may bear on the final shape of any approved plan.

Get Social Security deficits off the agenda. The supposedly massive future deficits in Social Security will becloud any attempt to get a health-care program passed. The truth is that fixing Social Security is relatively easy. In 2004, for example, economists Peter Orszag, then at Brookings, and Peter Diamond, of the Massachusetts Institute of Technology, developed a menu of tweaks-tinkering with income-based bend points, the cutoff point for covered wages, retirement ages, and the like-that restored the plan to full seventy-five-year funding without crippling changes. The plan was certified as actuarially sound by both the Social Security Actuary and the Congressional Budget Office. The supposed looming disaster in Social Security has befogged campaign debates and will disrupt the introduction of health-care proposals. A Democratic president with a Democratic majority should pass something like the Diamond-Orszag plan as a first order of business, just to exorcise the confusions remaining from the Bush administration’s “privatization” campaign.

Accept the reality of continued health-care spending growth. For most of 2006, I was “embedded” with the cardiac surgery and heart transplant unit of a major New York City hospital. I interviewed patients before and after their surgeries, watched dozens of operations, went on an “organ harvest” run, and was allowed to attend the meetings where the doctors discussed procedures that had gone wrong. Besides being deeply impressed with the technical skills, the dedication, and the ethics of the doctors in the unit, I got a firsthand view of how fast health-care technology is moving. Twenty years ago, open-heart surgery was considered too risky for people over sixty-five. The median age of the patients I saw was about eighty, and the outcome rates were superb.

The iron reality of health care is that death is almost always the lowest-cost outcome. Primarily because of technological advances, we have drastically reduced the death rate from heart attacks. But there are now millions of people who have had heart attacks. And they need expensive followup, high-priced medications, and usually some kind of formal intervention-to repair a stent, to fix a new occlusion-every few years.