William Sonnenstuhl, professor at Cornell University, maintains that the time has come for President Obama to take charge of the nuts and bolts.
Leaders need to know when to talk nuts and bolts and when to talk ideology. President Obama’s speech on health care was a middle-of-the-road argument targeted on uniting the conservative and progressive wings of the Democratic Party with a bit of give-the-Republicans-Hell for their obstructionist behavior and scare tactics thrown in to keep everyone’s emotions revved up…. By talking about preserving the market for private health insurance and making health reform deficit neutral, he was appealing to the Blue Dog Democrats to sign on to “our” plan. By talking about guaranteeing coverage for all and holding the health industry’s feet to the fire, he was appealing to progressive beliefs in social and economic justice.
The real target of his speech, however, was the American public, both the insured and uninsured. Here he needed to talk nuts and bolts to win them over and motivate them to pressure their Representatives and Senators to get health reform done this year. Unfortunately, the nuts and bolts were in short supply because no one really knows what is in “our” plan. Unlike President Bill Clinton, Obama provided Congress with guiding principles for health reform and left both houses to work out the details. Today there are at least 5 versions working their way through Congress and no one can say what the details are or will be. That is why the American public remains ambivalent about health reform. Obama has to figure out what the nuts and bolts are and how to educate Americans about how they fit together to improve the health care system.
Here are a few pressing questions that require nuts and bolts answers. Obama says that he will pay for reform by wringing savings out of Medicare but gives no details. Seniors love their Medicare and fear losing it. He needs to explain exactly what savings he is talking about and why it will not hurt seniors’ health care. A case in point is Medicare Advantage, in which Medicare pays private insurance providers a 14-18 percent premium over its regular program to provide the same health care to seniors. Studies show that Medicare Advantage is draining the Medicare Trust Fund without providing better care to seniors. This is just one nut and bolt seniors who vote in droves need to hear about when Obama talks about savings. Where are the others and how will they affect Medicare?
Another pressing question is how will those who are uninsured pay for mandated health coverage? This is the most vexing question of all and the nuts and bolts for answering it are not evident at all. The general answer is that they will get insurance through a new exchange, which may or may not have a public option, and that the government will subsidize those who can not afford to pay. But, there are no nuts and bolts available for those working Americans who cannot afford insurance. For instance, how does a two-earner family with 3 children making $60,000 per year pay for a family plan? What will be in the plan? How much will it cost? If it is as much as $8,000, how much will the family be required to pay and what might the government subsidy amount to? These crucial nuts and bolts do not yet exist because Obama has let a partisan Congress work out the details.
The devil is in the details. If Obama wants health reform, he needs to talk nuts and bolts to the American public. We can all agree that the US health care system is in crisis. We pay more for less care than any other country in the world. Yet, we are the only country in the world that rations health care through the market. Others simply accept it as a basic public good, like police and fire protection, and have created a variety of mechanisms to ensure their citizens have decent health care. If Obama wants to be remembered as the president who provided health care to all, he needs to start working on the nuts and bolts and selling them to the American public.
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