Health reform is sick again: Is it a chronic illness?

Yet after a year of flailing at the problem, it can fairly be said that the operation has degenerated into a wholly partisan shambles with a bill that might impress Rube Goldberg.

One can think of many reasons why, even after the instructive experience of Bill Clinton’s failed health reform effort during the 1990s, health reform once again is on the sickbed.

First, neither the president nor anyone on his team has bothered to or was able to communicate in understandable terms the main components of the reform bills that were passed in Congress late last year. Evidently there is a difference between President Obama’s skills as an orator and his skills as a teacher.

However, blaming the president for failing to put cost containment first in the reform plan, as is so often done these days, strikes me as unfair. Politicians on both sides of the aisle always talk a good game on cost containment, but when the rubber hits the road they quickly succumb to Alfred E. Neuman’s Cosmic Law of Health Policy, namely: “Every single dollar of spending on health care is someone’s health-care income, including fraud, waste and abuse.”

Whenever their incomes are threatened by serious talk of cost containment in Congress, the politically powerful interest groups who book health spending as health-care revenue — hospitals, doctors, the pharmaceutical industry, the medical device industry and so on — engage the well-paid and highly skilled insurgents camped out on Washington’s K Street to mount a well-orchestrated insurgency on Capitol Hill. Instead of rocket-propelled grenades, these insurgents carry the much more powerful weapon of campaign finance, with which they can purchase the affection of legislators and protect the income side of Neuman’s equation.

So far, no president of either party has ever been able to put down this insurgency for good. President Bush, meanwhile, simply poured more money into the equation: His 2003 Medicare Prescription Drug Improvement and Modernization Act has been deficit-financed since its inception and will add roughly $1.2 trillion to the federal deficit between 2010 and 2019.

But clumsy tactics and the obstacles to cost containment aside, there is yet another and probably more powerful obstacle to meaningful health reform in this country: namely, the chronic lack of a political consensus on the social ethics that should guide the American health-care sector. In this regard, the United States is unique among industrialized nations.

In the ideal world envisaged by left-of-center Americans, the individual’s health-care experience would be independent of that individual’s socio-economic class. The individual’s financial contribution to the health-care system is based on that individual’s ability to pay and is completely divorced from that individual’s health status. This means that the financing of health care in the country would be a collective responsibility in which relatively healthy and/or wealthy people would subsidize through their premiums the health care used by relatively sick and/or poor members of society. Rationing health care on the basis of cost-effectiveness might be allowed in this vision, but not rationing by income class through price and the patient’s ability to pay. There would have to be heavy government involvement to enforce the implied redistribution of income and the regulation of the health-insurance industry.

Right-of-center Americans envisage a world in which the individual’s use of health care is, in the first place, his or her own financial responsibility. At most, some collectively financed subsidies would be granted to low-income families to help them afford at least a bare-bones, minimal package of health-care services. On this view, it is not only acceptable but entirely proper that sicker individuals should be charged higher health-insurance premiums than are charged healthier individuals. Furthermore, the rationing by income class of the quantity and quality of health care, especially of primary and secondary care, is openly countenanced, as it always has been for food, housing and clothing. In this vision, government’s role in health care would be kept to a minimum.

Because these different visions of the ideal health-care system are driven strictly by ideology, we cannot judge one wrong and the other one correct, or even inferior or superior. They must both be respected by all, even if not shared. Unfortunately, the political center in this country has never been able to forge from these two visions a workable and politically dominant compromise.

Uwe E. Reinhardt is the James Madison Professor of Political Economy and a professor in the Wilson School. He can be reached at reinhard@princeton.edu.