Is There Hope for Health Care?

What a difference a year makes. Just 12 short months ago, health care was nowhere on the political agenda, and pundits were confidently stating that, after the failure of the Clinton health plan a dozen years prior, Americans continued to be wary of serious action. Affordable, quality health care for all Americans was a pipe dream.

Fast forward to Saturday morning, when leading presidential hopefuls gathered in Nevada for the "New Leadership on Health Care" forum, jointly sponsored by Center for American Progress and the Service Employees International Union. The event didn't create the kind of political fireworks that journalists crave. No Republican candidates showed up, unfortunately, and the Democrats who came -- in the order they spoke, John Edwards, Bill Richardson, Barack Obama, Hillary Clinton, Chris Dodd, Dennis Kucinich and Mike Gravel -- were all civil and, to varying degrees, substantive. But the event did showcase something far more important than inter-campaign squabbles: Health care is the number one domestic policy issue going into the 2008 presidential race.

Why now? Surely, American health financing is a mess. The United States spends far more than any other nation on health care, yet leaves nearly 50 million of its residents uninsured. Even insured Americans are pervasively insecure. Medical costs and health premiums are skyrocketing while employers are cutting back on coverage, and medical debt is a mounting even among the middle class. Perhaps half of all personal bankruptcies in the United States are due, at least in part, to medical costs and crises.

But while these problems are substantially worse than they were when Bill and Hillary Clinton, as president and first lady, pledged to provide health security to all Americans, they are not qualitatively different. What's really changed is perceptions of the politically possible. The 2006 midterm featured a highly successful drive by winning Democrats to highlight the insecurities created by the new economy, especially on health care. Yet it's three deeper changes in the debate that best explain why bold reform plans, rather than piecemeal fixes, were talked about on the campaign trail in 2006 and are now atop the agenda.

Acknowledging Failures, Changing Positions

The first is the clear failure of the incremental policy strategy of the past fifteen years. Yes, expansions of Medicaid and the creation of state children's program have done enormous good. But they have not stanched the rise in the number of uninsured and underinsured, because employers have raced away from providing insurance even faster than government has signed up new enrollees. And these fixes have done little or nothing to deal with the underlying cost explosion that is the root cause of health insecurity. All the leading Democratic presidential candidates made clear on Saturday that "stay the course" is no longer a viable strategy on the health policy battlefield.

The second change concerns the positions of business and labor. We hear a lot about the business conversion -- earlier this year, Wal-Mart's CEO famously appeared alongside service workers head Andy Stern (a cosponsor of Saturday's event) to declare that real reform is desperately needed. Though many corporate leaders were favorable toward action in the early 1990s -- at least until the Clinton plan came out and Republicans and key industry interests went on the warpath -- even more today seem to recognize that absent action, they will increasingly be caught between the rock of rising costs and the hard place of hurting their workers by dropping coverage or providing bare-bones plans.

The shift in organized labor's stance isn't as obvious or discussed, but it shouldn't be overlooked. Leading unions were deeply split in the early 1990s over the right course on health care, and a substantial number still clung to the notion that the generous employer-provided benefits they negotiated after World War II could be sustained against the tide of economic transformation and business resistance. Today, there's a bold new pragmatism evident in the labor movement, born of greater realism about the health of voluntary employment-based benefits. Labor leaders know their movement's future rests on getting health care right, and that clearly means moving beyond the current system.