What's the most important element missing from our national conversation about health care reform? I'll boil it down to one word: governance.
Consider the story so far. We've known for decades that our health system is unsustainable; there is no question that it cannot continue on its present course. So Congress finally rounds up enough votes to pass the Patient Protection and Affordable Care Act and what happens? The debate starts over as if there's a magic wand out there somewhere that will let us have everything we want in health care without any cost.
There is no magic wand. What's more this whole discussion is a test of our ability to govern ourselves. How can we govern when we're so divided over complex and philosophical questions? How can we govern ourselves when we don'êt even agree on the basic facts?
Start with the general state of our health care system. The Center for Economic and Policy Research puts it this way:The U.S. health care system is possibly the most inefficient in the world: We spend twice as much per person on health care as other advanced countries, but we have worse health outcomes, including a lower life expectancy. The government, through programs like Medicare and Medicaid, pays for approximately half of the country's health care, almost all of which is actually provided by the private sector. Thus, the bulk of our projected rising budget deficits are due to skyrocketing health care costs.
The CEPR has a fascinating budget deficit calculator that shows if we get our health costs under control, "our budget deficits will not rise uncontrollably in the future. But if we fail to contain health care costs, then it will be almost impossible to prevent exploding future budget deficits."
This is where democracy itself is tested. How do we, those who ultimately govern, control costs? It's easy to say no. We dismiss redesigning the system, we fight benefit cuts, we oppose tax increases, and we continue the political fight over the very premise. This is not self-government, but a national self-delusion because the demographic imperative — the aging of our population — is absolute.
Yet in congressional districts across the country there are calls to repeal the health care reform bill. Last week Rep. Eric Cantor, R-Virginia, told CNBC: "We've got to repeal the bill and replace it, though, because no one's accepting the status quo. OK? So repeal this bill."But let'ês be clear about the mechanics of repeal. No matter what happens in the November election there will not be the votes in Congress to repeal the law in 2010.
But let'ês be clear about the mechanics of repeal. No matter what happens in the November election there will not be the votes in Congress to repeal the law in 2010. President Obama will have more than enough to sustain a veto. In 2012, this question may surface as a theme in the presidential race —and let's suppose the country votes in a Republican with a Republican Senate and House. Even then there may not be enough votes (thanks to the supermajority requirements in the Senate) for repeal.
Repeal, if it were to happen, will take years of debate. But what then? Will there suddenly be a consensus of what should be done? Will we resolve the deep political divide about the role of government in our health care system?
Meanwhile budget deficits will continue to grow. And we will be giving ourselves fewer alternatives about how to cut health care costs or how to tax and pay for those services. As we debate — and re-debate — health care reform the fastest growing government "program" is interest on the debt. The Concord Coalition estimates that interest due from the federal deficit will reach $533 billion a year by 2015, or roughly, a third of federal income taxes.
Demographics (our country'ês aging) and deficits both deal with hard numbers. We can cling to any ideology we want, but in the end the numbers are the numbers. We are a people growing older — and that's a good thing. But it means our system must be adapted to account for that shift. It'ês the same with interest on the debt. We can shrink the size of any government program, but the growing debt service is a bill that must be paid.
That brings me back to the challenge for a self-governing nation. We need to get away from the "either, or" discussion. Our framework is stuck. Either health care reform, or repeal. Either cut social welfare benefits, or tax. Either, or.
What we need now, instead, is a series of policy options. We need the language of "if 'ê¦ then." If we do this, then here are the implications. If we spend energy on the repeal of health care reform, we lose time really trimming our debt load. If we return to a smaller federal government, then what are the implications for each of us?
The health care reform bill is not perfect. There's much that could be improved. But it's now law and a tool that could bring health care costs down — along with the deficit. There ought to be consensus on that goal.