After decades of failed efforts to reshape the nation's healthcare
system, a consensus appears to be emerging in Washington about how to
achieve the elusive goal of providing medical insurance to all
answer, say leading groups of businesses, hospitals, doctors, labor
unions and insurance companies -- as well as senior lawmakers on
Capitol Hill and members of the new Obama administration -- is
unprecedented government intervention to create a system of universal
At the same time, those groups, which span the
ideological and political spectrum, largely have agreed to preserve the
employer-based system through which most Americans get their health
The idea of a federal, single-payer system patterned
on those in Europe and Canada, long a dream of the political left, is
now virtually off the table.
Rejected as well is the
traditionally conservative concept, championed by Sen. John McCain
(R-Ariz.) during the presidential campaign, of reforming healthcare
mainly by giving incentives for more Americans to buy insurance on
There also is a widespread understanding that any
expansion of coverage must be accompanied by aggressive efforts to
bring down costs and reward quality care. And key players in the
healthcare debate increasingly back a massive investment of taxpayer
money for healthcare reform despite the burgeoning budget deficits.
those areas of basic agreement, the details of what would be one of the
most momentous changes in domestic policy since World War II remain
As a presidential candidate, Barack Obama embraced both
expanded insurance coverage and preservation of the job-centered
system, but since he won the White House he has provided few specifics
about his plans once he takes office.
specifics could again lead to a stalemate. Even the most sanguine
advocates of sweeping reform concede that difficult negotiations lie
But what is taking shape is a debate very different from
previous discussions about what America's healthcare system should look
"A lot has changed," said Karen Ignagni, president of
America's Health Insurance Plans, or AHIP, a leading trade group whose
members helped kill the Clinton administration's healthcare campaign in
the early 1990s.
AHIP is participating in talks with other
interest groups to build consensus before Obama takes office in January
and Congress begins debating any healthcare legislation.
the issues to be decided as more concrete proposals emerge in the
months ahead is whether the roughly 46 million uninsured people in the
U.S. will be pushed to buy private coverage or will be enrolled in a
government insurance program, as some consumer groups want.
and doctors fear another public program would reduce what they are
paid, as Medicare and Medicaid have done. Insurers worry they could
lose customers to the government.
Also unresolved is what
mechanisms might be created to force individuals or businesses to get
insurance, both potentially contentious subjects.
And few have
tackled how the government will control costs and set standards of
care, proposals that raise the unpopular prospect of federal regulators
dictating which doctors Americans can see and what drugs they can take.
are some very big questions and some very big stumbling blocks," said
Stuart Butler, vice president for domestic policy at the conservative
Heritage Foundation, who has been watching the healthcare debate for
"Once you get into the details, the consensus is going to vanish pretty quickly, I suspect," he said.
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the same time, advocates for a single-payer system, including the
California Nurses Assn., have vowed to continue pushing the idea next
year along with many Democrats on Capitol Hill.
lawmakers, still reeling from their election day losses, have signaled
discomfort with a major expansion of government spending, a position
many in the GOP hope will help return the party to power.
access for the uninsured is not going to come cheap," Sen. Charles E.
Grassley (R-Iowa) said at a recent hearing on healthcare reform. "And
it's clear to me that our economy cannot stand much further deficit
Nonetheless, the current agreement on principles
contrasts markedly with previous reform efforts. Today, many of the key
players in the debate see the importance of preserving elements of the
current healthcare system that many Americans say they like.
is a growing understanding that you have to give people choice and you
can't take away what they have," said Ron Pollack, head of Families
USA, an influential advocacy group for healthcare consumers that is
working with a diverse collection of interest groups to build
consensus. "One of the big no-nos is that you must not ever threaten
the coverage that people have."
The Clinton effort
years ago, there was much less agreement about preserving an
employment-based system that now insures about 177 million people.
of President Clinton's plan were able to sink it by raising the specter
that government would take away consumers' choices in a new system that
would force them into inferior health insurance.
But now the
prospect of bold government action to address the healthcare crisis
appears to have been accepted far more broadly by many of those
involved in the debate.
Even business leaders traditionally wary
of government intervention now are pushing for the federal government
to act decisively to reshape the healthcare marketplace -- in large
part because of the increasing burden imposed on them by rising costs.
this piecemeal is not going to work," said Todd Stottlemyer, president
of the National Federation of Independent Business, which was also
instrumental in defeating the Clinton plan.
Many involved in the
healthcare debate, including Democratic lawmakers and members of
Obama's team, also see healthcare reform as part of a broader economic
Democratic leaders on Capitol Hill have begun sketching
out plans for healthcare reform that, like Obama's plan, preserve the
employer-based system and create a new system for those without
Last month, Senate Finance Committee Chairman Max
Baucus (D-Mont.) outlined such a plan in an 87-page white paper titled
"Call to Action." Similar approaches have been endorsed by House
In contrast, the Clinton administration drew up its
healthcare reform plan with little involvement from congressional
Democrats. In the Senate, then-New York Democrat Daniel Patrick
Moynihan, who was chairman of the finance committee at the time,
actively resisted the idea of sweeping change in healthcare.
are no signs of a similar rift today, said Jacob Hacker, a political
scientist at UC Berkeley who has written a book about the failed
"Possibly more important than policy agreements," Hacker said, "is the fact that the political forces now are in alignment."