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Senator Tom Daschle

In 1991, the political landscape was changed by a teacher from Pennsylvania who ran--and won--by saying, if every prisoner has a lawyer, every American should have a doctor. I remember being one of the sitting senators who made presentations to Senator-elect Harris Wofford in the hopes that he would work with us on our plan. The excitement was palpable--and optimism was high. I don’t think a freshman senator has gotten that kind of attention from his colleagues since. And it helped set the stage for the presidential election and debate over health reform in 1993 and 1994.

Health care is back again--and it just might be that it is back stronger than before. It is present in full force in the presidential campaign, with all the Democratic candidates, and some Republicans, offering comprehensive reform plans. All the major newspapers have run front-page stories on the politics of health care. The central domestic policy fight in Washington is between Congress and the White House over the State Children’s Health Insurance Program (SCHIP). And poll after poll tells us that health care is typically second in importance only to Iraq for the American public, regardless of their party affiliation.

The Cusp of Change?

But as a veteran of the 1994 battle and a student of previous efforts’ lessons, I view these facts as only suggestive, not conclusive, that we are on the cusp of health reform. A sober political analysis must answer two questions: Are the circumstances any different now than during previous attempts, and are we ready to accept the pragmatic over the perfect solution?

Beginning with the “good news,” some circumstances are now more propitious for reform. On one level this is a bad news-good news story. That is to say, the problems with the system are so bad, the failings of the current administration so monumental, and the thirsting for leadership is so large that there is increased attention to the issue.

That’s bad--but potentially good news.

Unlike the early 1990s, when recession and job insecurity drove concern, today the problem is less about job loss and low-income people. It is increasingly a concern among the educated, middle-income, older, and insured population. It is exacerbated by the chronic disease epidemic that is crippling the nation. And so many people have seen someone they know struggle with the system that everyone fears they are not immune from an underperforming system.

High costs and complexity are driving business leaders’ frustration, which is leading to new levels of mobilization in that community. According to a McKinsey analysis, healthcare costs will exceed profits at Fortune 500 companies by next year, and over the past seven years, we’ve seen wages go up 24 percent, while healthcare premiums have gone up 98 percent. Costs were a problem in the 1990s too, but today legacy costs are new--and crippling.

These costs are undercutting competitiveness, a fact not lost on business leaders. This is why we are seeing maverick CEOs like Howard Shultz of Starbucks and James Sinegal of CostCo buck Wall Street and push not only for generous benefits for their employees but also for comprehensive reform of the system. And that’s why we are seeing coalitions like Wal-Mart/SEIU in “Better Health Care Together” and Safeway and the Business Roundtable demanding comprehensive reform.

At the same time, the media have democratized. The Internet has led to media reporting and political organizing that magnifies possibilities for reform. The 24-hour news cycle, challenged by blogs and other forms of communication, can catalyze anger and pressure for action. At a recent gathering of college students, I was told that healthcare reform is the civil rights fight of that generation--and the new media offer the possibility of virtual rallies analogous to the marches of the 1960s that involve millions more Americans in the debate.

Last, we are in a very unique political situation. About 70 percent of the country is convinced we are on the wrong track. For the first time in 80 years, there is no incumbency, legacy, or trail of policy inertia in the presidential campaign. And the foreign policy failures of the current administration may create a demand for a domestic policy success.

Challenges to Reform

Yet these new positive indicators must confront deep, perennial challenges to health reform.

First is the complexity of health care. Seeking health care is not like buying a car; classic economic theory need not apply. There is an imbalance of knowledge. Clearly, our health professionals are highly trained, and we typically trust them to do the right thing. Yet we have seen that supply can determine demand, most recently with the explosion of sophisticated imaging and tests that may not always be needed. And health care is literally a matter of life or death, making it difficult on the demand side to distinguish what is necessary from what is interesting or optional or, even, a long shot.

This difficulty is made worse by layer after layer of complexity. In the federal system alone, consider the differences in benefits and payments a South Dakotan in a program such as Medicare can expect from a South Dakotan in the Indian Health Service from a South Dakotan in the Veterans Health Administration--and then consider how you answer concerns about each as you walk through a parade on the Fourth of July.

Second, there are special interests. Unlike Social Security or other programs, there is a layer of “intermediaries”: health insurers and providers of care. One person’s savings is another’s salary--or profit. And in terms of political clout, the health industry is second to none. Between 1998 and 2006, pharma and other health product companies spent over a billion dollars on lobbying--twice as much as the oil and gas industry. Not surprisingly, insurers, including health insurers, were number two in spending on lobbyists. These special interests have also created and funded patient front groups, using “human shields” to protect payments and profits. No other industry has done this as well.

Third, we struggle with some myths. Because fear can trump hope, defenders of the status quo oversell what we have now and warn about unforeseen dangers lurking around the corner of reform. Let me give you three of the myths that drive the politics of health care.

One myth is that we have the best health care in the world. You’re familiar with the statistics. Think what would happen to the chairman of the U.S. Olympic Committee if the United States comes in 37th place in the next summer Olympics. Well, that’s where we rank in life expectancy. It is a national shame that on Pine Ridge Indian Reservation in South Dakota life expectancy is 47 years--about 10 years more than in Botswana, where one in three adults has HIV.

The next myth is that the cure is worse than the disease. We are seeing this play out on SCHIP. SCHIP is one of the most popular, bipartisan health programs we have. Yet we are hearing from the president--who gets the best care in the world at Bethesda Naval Medical Center, by government funded-physicians, in a government-built building, and on government-owned machines--that we should not support government-run health care.

And perhaps the most misleading myth is that we can’t afford reform. The most common question asked of all the presidential candidates is, how are you going to pay for reform? Cynics suggest that even the most modest plans are the nose under the tent of a more generous and more expensive solution. Yet at $2 trillion per year and 16 percent of gross domestic product, I fear we can’t afford the status quo.

These myths are easy to exploit. Sometimes it is by special interests whose motivation is crass: that status quo means dollars and cents to them. Other times, it is for political gain. Bill Kristol and Newt Gingrich saw the defeat of health reform in 1994 as a political victory. The same seems to be happening with SCHIP: A sinking White House wants to drag down Congress with it. How else can you explain the awkward attempt to pin ideological concerns on a program that represents a true, bipartisan compromise?

Part 2 of this piece--How to Fix a Broken System--will be posted tomorrow.

Sen. Tom Daschle completed 26 years of public service in January 2005, having represented South Dakota for eight years in the U.S. House of Representatives (1978-86) and 18 years in the U.S. Senate (1986-2005). He served as Minority Leader of the Senate from 1994 to 2001 and from 2003 to 2005, and Majority Leader from 2001 to 2003. Today, Daschle is an adviser to the law firm of Alston & Bird, Washington, D.C., and is a Distinguished Fellow at the Center for American Progress, Washington, D.C.