"The Pain Before the Plan"

Hopefully, it’s safe to say that "The road to fiscal responsibility goes through health care" week has ended in Washington.  But it should also be safe to say the White House efforts are just beginning.  So what have we learned about President Obama’s approach to health care?  First and foremost, we know it’s not a script we’ve seen before on selling the plan to the public.

Madison Powers writes in Congressional Quarterly, “Rather than craft the intricate details of a plan that will risk a death by a thousand cuts, even before facing the rhetorical hammer of those who will fret over how to pay for it, Obama is leading with efforts to build some consensus on funding at least $634 billion of the $1 trillion medium-term price tag.”  As she puts it, Obama has put the pain before the plan.

When others have launched bold health care initiatives, it’s always been presented in terms of the plan, as us coming together to solve a great problem with ingenuity and good policy.  Richard Nixon, Bill Clinton and the Massachusetts legislature couched their speeches about achieving universal health care in terms of what the plan would be and what it wouldn’t be, not in terms of the cost for the stakeholders of our health care system.  That’s probably why the pain of Clinton’s plan – what individuals and business owners would have to sacrifice in order to achieve health care for all – were so unknown and became so easy to demagogue.  Clearly in Massachusetts, which has come close to coverage for all but greatly underestimated the costs of doing so, the focus was on solving the problem, not on what the state would have to pay to get there.

But for the Obama Administration, you don’t get to universal health care without shared sacrifice and shared responsibility.  The tax provisions and changes to Medicare which provide revenue for the health care reserve fund aren’t just about Obama’s commitment  to health care reform.  They’re setting up expectations that everyone will have to contribute to get it done – everyone will have some pain.

In this context, it’s actually important that there’s no bill yet.  If you know you have some pain coming – someone who’ll have to pay extra taxes, or won’t get a deduction after she’s hit a cap of $110,000 in charitable giving, or a business owner who’s going to either pay or play, or a physician who’ll either be much busier or facing compensation cuts on a certain procedure – you’re naturally compare it to the perceived benefit.  But there is no specific plan to compare it to, no tiny detail you don’t agree with to get bent out of shape over.  Instead you have a steady drumbeat, from Peter Orszag to the President to the Congressional Budget Office to the President’s budget, that not fixing health care will lead to greater costs and insolvency in our federal budget.  It’s a little pain now or unbearable pain in the future.  That’s an easy choice to sell.  And frankly, no matter how worrisome a detail is, that's what the debate should be about -- we cannot endure our health care system as it is.  We won't survive it.

Beginning next week, I expect to see the White House go forward with the game plan that Obama promised every day on the campaign trail.  You’ll see a health care summit next week.  C-SPAN viewers will see a big open process where economists, doctors, nurses, patient advocates, business advocates, labor, faith groups and politicians are at the table with insurance companies and pharmaceutical companies.  (Ted Kennedy may still be having his working groups behind closed doors, but Kennedy never ran on a platform of transparency.  The president did.  And as much esteem and influence as the Senator for Massachusetts is, he's not the President of the United States.)  You’ll see the White House continue to be all hands on deck for health care reform, especially given the news that Gov. Sebelius will be named HHS Secretary but not health care czar.  Slowly the plan will come together in Congress.  Continuously, the economic necessity of fixing health care will be fueling the public debate.

In these tough times, people have demonstrated they’re willing to make sacrifices to regain economic security.  The pain had to come before the plan.  Now that the sticker shock is over, we can get to work.