The two parties facing off at the White House health reform summit have obvious political reasons for wanting to prevail on both the public relations and legislative fronts: Democrats to prove they can govern and start to fix a festering problem, Republicans to prove Democrats are incompetent, over-reaching, and out of touch.
Yet the real divide is not political, it's philosophical. One side believes the government should help tens of millions of uninsured people get health coverage. The other side calls that a big-government takeover and says it should be killed for the good of the nation. You can watch these dynamics play out Thursday on several cable TV stations that will be broadcasting the six-hour, 10 a.m. ET summit at Blair House, across from the White House.
President Obama has laid out a series of goals for reform plans. He wants to stop abusive insurance company practices against consumers, rein in the rapidly rising cost of health care, cover most of the uninsured, make coverage more affordable, and do it all while reducing the federal deficit. He says his 10-year, $950 billion plan does all that, and he's challenging Republicans to improve on it.
Though it's buried right now by political machinations, there is common cause among Democrats and Republicans on some of these goals. For instance, both parties would like to end insurance company practices such as denying coverage to people with pre-existing medical conditions. The Democrats would make this work financially for insurance companies by requiring almost everyone to buy insurance, including people who are relatively healthy and incur fewer costs. Republicans claim the requirement is an unconstitutional affront to freedom and the American way. But that's pretty naked politics, since many of them used to support the requirement under the flag of personal responsibility.
There is also a consensus about trying to decelerate rising costs, but politics has intervened there in the form of GOP attacks on the Democrats' plan to save a projected $500 billion over 10 years from slower Medicare growth. Republicans have in the past supported similar steps; in fact 2008 presidential nominee John McCain proposed such "cuts" to finance his health reform plan (and found himself under attack from Obama). Just this month, House GOP fiscal expert Paul Ryan floated a budget that would replace Medicare with slow-growing vouchers.
The main substantive point of difference involves covering most of the 46 million uninsured — more than 30 million people in Obama's proposed merger of the bills passed by the House and Senate. Some would be newly eligible for Medicaid. Others would receive subsidies to make private policies affordable. And if you're going to offer subsidies without adding to the budget deficit, you have to raise money somehow — thus the debate over whether Congress should tax the rich (the House bill) or put an excise tax on expensive insurance plans (Senate). Democrats would also try to spur competition — and lower prices — by creating regulated statewide exchanges, or marketplaces, where consumers could comparison shop for policies. They would be modeled on the current system for federal employees, including members of Congress.
Republicans don't want to spend or raise that kind of money, or discuss a federal role of anywhere near that magnitude. "We believe that any health care reform legislation should lower costs and expand access without raising your taxes or adding billions of dollars to the deficit," says a statement at the Senate GOP web page. The senators do not, however, offer a plan to do that.
The only full-scale GOP legislation on the table is a $61 billion, 219-page bill (summary here) introduced last year by House Republicans. It would create a high-risk pool and take other steps to expand coverage. Yet it would cover only an additional 3 million people by 2019, according to the nonpartisan Congressional Budget Office; another 52 million would be uninsured.
The focus of conservative proposals, inside Congress and out, is on competition, individual choices, and incremental steps — as opposed to the government taking big steps to make sure people are covered, as it did decades ago by creating Medicare and Medicaid. It's a philosophical divide that couldn't be more fundamental. Democrats don't want to leave health care to the "cold vicissitudes" of the market, Yuval Levin writes at National Review, while Republicans believe the current flawed system is preferable to one in which "the government enforces efficiencies."
The gulf between the parties is apparent everywhere — in an American Enterprise Institute paper that puts tax credits for working-class consumers at the top of its reform list; a Heritage Foundation study that suggests state-based experiments; a Ripon Society article in which Utah Sen. Bob Bennett says Congress needs to "start over and focus on reducing the costs, improving quality and not adding to the nation's debt."
Those are not necessarily bad ideas or goals — but they don't do anything to change America's status as the only industrialized nation without universal health coverage. That's the historic shift many Democrats are determined to make. So it really doesn't matter whether the White House summit is convivial or combative, or how many GOP ideas Democrats put into their final package (and there are already quite a few on deck). Most Republicans will try to block a comprehensive health reform law every way they can.
They'll do it for political reasons, sure, and but also because this is a defining debate. This is a moment for conservatives to make their stand — not against uninsured Americans, exactly, but against the expanded government role that is needed to insure them.