Health Care's Odd Couple
Set next to each other, Sens. Ron Wyden and Bob Bennett are a bit of an odd couple. Where Wyden is friendly and effusive, Bennett is deliberate and contemplative, with an almost funereal air. Where Wyden hails from bluish Oregon, Bennett comes from Utah, the reddest state in the union. Where Wyden made his way into politics by forming the Grey Panthers, a legal aid group for the elderly, Bennett's father was a senator and he himself has served as everything from legislative liaison in the Department of Transportation to director of public relations for one of Howard Hughes' companies. Indeed, they appear to have only two things in common. They're both tall. And they want to solve America's health-care crisis.
The latter is what brought me to St. Joseph's University, in Philadelphia, Pennsylvania, for a performance of the Ron and Bob Health Care Road Show. Wyden, smiling broadly, started things off. "Isn't this great?" he enthused. "A Jesuit university hosting a Mormon fellow and a Jewish fellow to fix health care!" It's not their choice of temples, though, that made their joint appearance on stage so surprising. It's their ideologies.
Occasionally, you see bipartisan groups where the various members talk like one another, either because they don't actually disagree or because they're more interested in the deal than in the issue. Not so here. Wyden is a genuine liberal, the type of senator you could imagine voting in favor of Medicare-For-All. And Bennett, who began his talk with a quote from David Frum's new book on renewing conservatism and explained that "my fundamental position is that markets make better decisions than governments do, if they are free to work," is the type of senator you could imagine filibustering Medicare-for-All. And yet, Sens. Wyden and Bennett have co-sponsored health-care legislation that now has 12 senators onboard -- six of them Democrats, six of them Republicans. Wyden, marveling over the strange bedfellows, asked the Congressional Research Service to run a historical search. His suspicions were right. With only 12 percent of the United States Senate onboard, it's the largest bipartisan coalition ever assembled around a concrete piece of universal health-care legislation.
What's remarkable, though, is that Wyden and Bennett, working together, have come up with a bill that is more far-reaching, and more fundamentally transformative to our health system, than anything offered by the presidential candidates.
Our employer-based health system is a costly mistake, the outgrowth of World War II-era wage and price controls and tax breaks that let newly flush employers shield their profits in benefits and escape taxation on health spending. Even today, employer spending on health care is tax deductible, while individual spending is not. It's terrifically distorting, locking individuals into jobs they don't want and stifling entrepreneurship, burdening corporations with duties they shouldn't assume, and vastly increasing their power over employees. General Motors, after all, is a car company. They make cars. Who decided it should be in the health-care business, too? And if their employee decides to set off and make a better car, do we really want his plans foiled because he can't interrupt his daughter's dental care?
Rather than patching up the employer-based system and offering alternatives that individuals would maybe migrate toward, as both Clinton's and Obama's plans do, Wyden-Bennett end the employer-based system. They force employers to account for every dime and dollar they spend on employee health care and, the year after the bill's passage, redirect that cash into employee paychecks. So if your employer is spending $7,000 a year for your health insurance, your paycheck gets a $7,000 boost as soon as their bill passes. You have the money they spent on your health care, but you are no longer dependent on them for that health care.
Under the Wyden-Bennett system, health dollars would be controlled by the individual (a long-time conservative goal) and used within a restructured, heavily regulated, totally universal, insurance marketplace (a longtime liberal goal). Each state would create Health Help Agencies, who would provide easy access to insurance products, along with information, guidance, and advice on how to choose. Insurers would have to meet a minimum standard for comprehensiveness (equivalent to the standard Blue Cross/Blue Shield plan currently offered to members of Congress), and they could not discriminate based on pre-existing conditions, occupation, genetic information, gender or age. Nor could they deny insurance to those who ask for it. In return, every American would have to buy health insurance, and there would be hefty subsidies for those further down the income ladder.
The plan, to be sure, lacks some liberal priorities, notably a public insurance option. But it makes up for that by tightly integrating the system, going much further than Clinton or Obama do to bring the patchwork American health-care mess under one roof, where costs would prove more containable (the Lewin Group, a highly respected health-care consulting firm, estimates that the plan would save $1.4 trillion over 10 years) and future reforms and initiatives would be far easier. And they have done so along with 10 other senators. It's conceivable that, by the time the next president is elected, they will have created a legislative working group that can actually pass health reform -- something we've never had before.
The question is whether that legislative working group will actually hang together when the eventual vote is called. In 1993, apparent compromises often dissolved into surprising betrayals. Some of that was the fault of the Clinton administration, which was astonishingly inept at legislative diplomacy. Some was the fault of congressional Republicans, who had decided to stop Clinton at all costs and were heeding William Kristol's advice that "any Republican urge to negotiate a 'least bad' compromise with the Democrats, and thereby gain momentary public credit for helping the president 'do something' about health care, should be resisted." By the process' close, Sen. Bob Dole had voted against two separate bills that contained his name in the title.
For the next president, the answer to the failures of the Clintons' is clear: Don't ignore Congress. But the question of creating a legislative coalition is harder: Republicans believe they can't pass universal health care without giving a massive advantage to a Democratic president. It's not always the specifics of the bill that lose their vote but the political impact of passing it. The answer, or the closest thing to it, is for it to be a Senate project -- for it not to be a President Clinton or Obama or even McCain initiative, but for it to be a bill that the relevant legislators are actually invested in and are willing to shepherd through the process because they themselves care about its passage.
So much as the list of co-sponsors is impressive, it's not yet clear if they yet comprise such a group. At the event, Bennett recounted the spirit in which he came to co-sponsor the legislation in the first place: "[Wyden] said, 'Bob, everything is negotiable.' He has maintained that posture, which is why we've been able to collect as many senators as we've been able to collect." But signing on to help shape a negotiable document and voting for a final document are very, very different.
Still, Bennett offers reason for hope. "The politics are simply different now," he says. "Republicans who want to say the same thing they said in 1994 are wrong in their sense of the moment. In 1994, voters wanted them to slap down the Clintons. Now they want them to get together with Democrats and do something. I can stand up in Utah, the reddest state in the union, and say I'm working with a Democrat, Ron Wyden, to do health-care reform, and be overwhelmed with applause."
But even if Bennett's sense of the moment is right, reform won't be easy. The event in Philadelphia was put on by AmeriHealth, an insurer that primarily does Medicaid Managed Care work. Dan Hilferty, one of AmeriHealth's executives, was allowed to ask the first question. He began by gushing over the bill, professing agreement with nearly all of its tenets. Except one. Did the Medicaid marketplace really need to be reformed and brought into the main framework? Had Wyden and Bennett seen the wonderful work AmeriHealth was doing? Were they aware of how fundamentally they had changed the Medicaid marketplace in recent years? The comment, in essence, was one that Wyden, Bennett, and their colleagues are going to hear quite often: Your plan sounds great, except for the part that impacts my profit stream.
Even with all the obstacles, though, the process Wyden and Bennett have kicked off is by far the most promising development in health reform. It's more important than anything the presidential candidates have proposed, more important than anything done in the states. Their effort is the hard legislative work, taking place in the relevant legislative body, with constructive participation from an array of the decisive players, and occurring well in advance of the actual fight. If the coalition they are creating can stick together, they will have a tangible, discrete process that the next president can co-opt, and they will hold the possibility of becoming the "Gang of 14" for health reform. And at the center will be health care's odd couple.
Reprinted with permission from Ezra Klein, "Health Care's Odd Couple," The American Prospect Online: February 15, 2008. The American Prospect, 2000 L Street NW, Suite 717, Washington, DC 20036. All rights reserved.