Monday, May 18, 2009

Obama's Health Care Reform: An Indecent Proposal

We watched the marriage on national TV. Both sides said, ‘I do’, as they faced a fawning audience of the press and government dignitaries. The couple, arm and arm, started ambling toward their parked limousine, festooned with bright Just Married signs.

Newlyweds, usually wives, track many of the first events in a marriage. One of the recorded stats is the first argument. When it occurs, savvy husbands should save time and themselves by apologizing profusely and admitting shame and remorse. For most couples, this inevitable post-nuptial event occurs weeks or months after the solemn wedding vows are expressed.

In the White House marriage we watched last Monday between Obama and a coalition of health care groups, the sniping started barely after they left the chapel. Wise bloggers had predicted this outcome, but I admit that I was mildly shocked at the speed that the bride pursued an annulment. What went wrong? Did that prankster Cupid dip his arrows into a vat of single-payer elixir poisoning the affair? This is not a simple example of wedding day ‘cold feet’. It’s more like frostbite.

We all heard the terms of the wedding contract read to us by the proud husband. The 6 medical groups would voluntarily set aside their own interests to serve America. Over the next decade, they would each shave off 1.5% of health care spending, which would save the system over $2 trillion. While successful marriages demand compromises, this agreement sounded hollow to even casual observers of the health care reform process. Groups and individuals will give in to serve the greater good, but they won’t agree to self-destruct. .

The medical groups, barely out of their white gowns, cried foul. “We never agreed to that”, they announced in unison. They issued ‘clarifications’ and tried to set the record straight about what commitments were actually made, which all sides agreed were voluntary and unenforceable. (Shouldn’t Obama, a trained lawyer, have insisted on a pre-nuptial agreement just in case the romance faded?) The medical groups now stated that there was no firm agreement on annual targets, only goals that they would incrementally pursue. Sounds like a he-said she-said spat where each side has its own version of the facts.

This is a very inauspicious beginning of health care reform and a reminder its complexity. The health care players will now become even more suspicious of the president and will be more reluctant to walk down the aisle with him. There will be no shotgun weddings or elopements. Interest groups will insist on very long engagements and will use the time to gain the most favorable terms possible or to derail the effort entirely. Don’t expect hospitals, physicians, insurance companies, pharmaceuticals, etc. to fall on their swords on the altar of health care reform. They know that this is going to be a long chess game and a bad move early in the game could doom the outcome for them months or years from now. Pharmaceutical companies, for example, are doubling down and are pouring money into their lobbying coffers. Obama has to decide whether to proceed with a frontal assault, pursue a flanking maneuver or try to divide and weaken the opposition.

While Obama will revise his tactics, he won’t modify his ultimate objective. I think he knows exactly what he wants our health care system to be, but he hasn’t come clean with us yet. I suppose that every husband is entitled to keep some secrets.


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