Health Overhaul Has Long Road Ahead

The House of Representatives worked into the wee hours Saturday night and came away with landmark legislation that would reshape the health care system. But there's a long way to go, as professor Jonathan Oberlander tells host Guy Raz. Oberlander, a professor of health care politics at the University of North Carolina in Chapel Hill, draws a few parallels between last night's action and the birth of Medicare in 1965.

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GUY RAZ, host:

We're back with ALL THINGS CONSIDERED from NPR News. I'm Guy Raz.

The House of Representatives passed landmark legislation overnight - the Affordable Health Care for America Act - its version of health care reform. President Obama hailed the bill today, even though his plan to overhaul health care still has significant hurdles to overcome.

President BARACK OBAMA: Now it falls on the United States Senate to take the baton and bring this effort to the finish line on behalf of the American people. And I'm absolutely confident that they will. I'm equally convinced that on the day that we gather here at the White House and I sign comprehensive health insurance reform legislation into law, they'll be able to join their House colleagues and say that this was their finest moment in public service.

RAZ: The question now is how much of what the House passed last night will eventually become the law.

Well, Jonathan Oberlander might have the answer. He teaches health care politics at the University of North Carolina in Chapel Hill.

Jonathan Oberlander, welcome to the program.

Professor JONATHAN OBERLANDER (Health Care Politics, University of North Carolina; Author, "The Political Life of Medicare"): Thank you very much for having me on.

RAZ: The White House is touting last night's vote as a landmark moment, a move, they say, as significant as the 1965 law that created Medicare. But this bill now may not actually resemble what eventually becomes the law, right?

Prof. OBERLANDER: I think if you look at the bill that the House passed last night, major provisions of the bill are likely to become law and will be in the Senate bill, including the regulation of private insurance, the provision of subsidies to low-income and middle-income Americans, a mandate that Americans must have health insurance. So, all those central pillars, I think, are likely to survive.

RAZ: Hmm. Well, what specifically did the House pass that might not get through the Senate and land on the president's desk?

Prof. OBERLANDER: Well, the most obvious part of the legislation will be the national public plan that they enacted in the House bill. That is a Medicare-like public insurance option available to uninsured Americans under the age of 65 and small businesses.

In addition to the public plan, if you look at the financing in the House bill, that may not survive through the Senate. The House relies through a great extent on increasing income taxes, the so-called millionaire's tax, for affluent Americans. So far, the Senate has wanted no part of that.

RAZ: Jonathan Oberlander, anyone watching the debate in the House yesterday would have noticed Michigan Congressman John Dingell, presiding from the speaker's chair, he actually did the same thing in 1965 when Medicare was being debated. Was that debate as contentious?

Prof. OBERLANDER: It was, and it's worth remembering that Medicare, although it is a very popular program right now, if you look back at the debate, it was a very contentious debate, a very partisan debate. The idea for Medicare was first announced in 1952. The first legislation for Medicare was introduced in Congress in 1957, and there was an eight-year fight and a very bitter fight.

RAZ: You've written about the history of Medicare and how it was never really designed as a plan to serve just senior citizens, that it was seen as kind of the first step in introducing universal health care in America.

Prof. OBERLANDER: That's right. Medicare was a reaction to the defeat of the Truman administration's plan for national health insurance in the late 1940s. The idea was that Medicare would be the cornerstone for a universal national health insurance system. You would start with the elderly, then you would add in children and eventually, you would cover all Americans. It never happened that way.

RAZ: If Medicare was seen in that way as a sort of the first step, why didn't it go further in the subsequent years?

Prof. OBERLANDER: Two major reasons. The first is that the political landscape changed. The advocates in Medicare grew up in the New Deal and they grew up in a world where Democrats really dominated. And what they could not foresee in 1965 is that within a decade, American politics was going to shift to the right with the election of Richard Nixon and then the economic problems of the 1970s and a real erosion in the face of government. All of that made it very difficult to expand Medicare.

The second thing that happened after Medicare, and partly as a result of Medicare, was an explosion of health care inflation. We had very high health care costs in the late 1960s and early 1970s. And so really, the dominant question in Congress became not how to expand the Medicare program, but how to control spending in the U.S. health care system.

RAZ: Do you suspect that some members of Congress view this current legislation, you know, in the same way as kind of the opening step in eventually getting a system of universal health care in place?

Prof. OBERLANDER: Well, you can argue this is a much bigger step than Medicare and significantly less incremental in that, it's not based on demography, it's not based on age group, but it's trying to create a system of at least universal access to health insurance. And this is not going to be the last step in a health reform. This is going to be the beginning rather than the end. And you can bet that many members of Congress are going to come back and want to fill in the holes in the American health care system over time.

RAZ: That's Jonathan Oberlander. He's the author of the book, "The Political Life of Medicare." He teaches health care policy at the University of North Carolina.

Professor Oberlander, thank you so much.

Prof. OBERLANDER: Thank you again.

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