A Few Senators Away from Having Much Better Health Care By Paul Krugman
The Congressional Budget Office has looked at the future of American health insurance, and it works. A few weeks ago there was a furor when the budget office "scored" two incomplete Senate health reform proposals -- that is, estimated their costs and likely impacts over the next 10 years. One proposal came in more expensive than expected; the other didn't cover enough people. Health reform, it seemed, was in trouble. But last week the budget office scored the full proposed legislation from the Senate committee on Health, Education, Labor and Pensions (HELP). And the news -- which got far less play in the media than the downbeat earlier analysis -- was very, very good. Yes, we can reform health care. Let me start by pointing out something serious health economists have known all along: on general principles, universal health insurance should be eminently affordable. After all, every other advanced country offers universal coverage, while spending much less on health care than we do. For example, the French health care system covers everyone, offers excellent care and costs barely more than half as much per person as our system. And even if we didn't have this international evidence to reassure us, a look at the U.S. numbers makes it clear that insuring the uninsured shouldn't cost all that much, for two reasons. First, the uninsured are disproportionately young adults, whose medical costs tend to be relatively low. The big spending is mainly on the elderly, who are already covered by Medicare. Second, even now the uninsured receive a considerable (though inadequate) amount of "uncompensated" care, whose costs are passed on to the rest of the population. So the net cost of giving the uninsured explicit coverage is substantially less than it might seem. Putting these observations together, what sounds at first like a daunting prospect -- extending coverage to most or all of the 45 million people in America without health insurance -- should, in the end, add only a few percent to our overall national health bill. And that's exactly what the budget office found when scoring the HELP proposal. Now, about those specifics: The HELP plan achieves near-universal coverage through a combination of regulation and subsidies. Insurance companies would be required to offer the same coverage to everyone, regardless of medical history; on the other side, everyone except the poor and near-poor would be obliged to buy insurance, with the aid of subsidies that would limit premiums as a share of income. Employers would also have to chip in, with all firms employing more than 25 people required to offer their workers insurance or pay a penalty. By the way, the absence of such an "employer mandate" was the big problem with the earlier, incomplete version of the plan. And those who prefer not to buy insurance from the private sector would be able to choose a public plan instead. This would, among other things, bring some real competition to the health insurance market, which is currently a collection of local monopolies and cartels. The budget office says that all this would cost $597 billion over the next decade. But that doesn't include the cost of insuring the poor and near-poor, whom HELP suggests covering via an expansion of Medicaid (which is outside the committee's jurisdiction). Add in the cost of this expansion, and we're probably looking at between $1 trillion and $1.3 trillion. There are a number of ways to look at this number, but maybe the best is to point out that it's less than 4 percent of the $33 trillion the U.S. government predicts we'll spend on health care over the next decade. And that in turn means that much of the expense can be offset with straightforward cost-saving measures, like ending Medicare overpayments to private health insurers and reining in spending on medical procedures with no demonstrated health benefits. So fundamental health reform -- reform that would eliminate the insecurity about health coverage that looms so large for many Americans -- is now within reach. The "centrist" senators, most of them Democrats, who have been holding up reform can no longer claim either that universal coverage is unaffordable or that it won't work. The only question now is whether a combination of persuasion from President Obama, pressure from health reform activists and, one hopes, senators' own consciences will get the centrists on board -- or at least get them to vote for cloture, so that diehard opponents of reform can't block it with a filibuster. This is a historic opportunity -- arguably the best opportunity since 1947, when the A.M.A. killed Harry Truman's health-care dreams. We're right on the cusp. All it takes is a few more senators, and HELP will be on the way.
