Health Changes: Incremental Or Comprehensive?

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As President Obama sits down with Congressional leaders to talk about health care, one big dividing line between Democrats and Republicans is how ambitious they are about changing the existing system. The GOP mantra has been that the U.S. should proceed "step by step." The Obama administration argues that the most important steps only work in combination.

STEVE INSKEEP, Host:

Okay, normally, when President Obama convenes a meeting, the TV cameras are allowed in for a moment at the start. Journalists get their video. They're escorted back out, and only later does the business begin. This morning, the cameras stay in the room. President Obama meets Congressional leaders at a square table near the White House on live television.

Democrats want to find a way to pass a massive health care overhaul. Republicans are making a coordinated push for a more gradual approach.

U: We need to set reducing health care costs as our goal and move step by step towards that goal to re-earn the trust of the American people.

U: What they really want us to do is do things step by step.

U: We ought to go step by step to work on the cost problem.

INSKEEP: That's the Republican response, which does present some practical problems. Here's NPR's Scott Horsley.

SCOTT HORSLEY: Comprehensive anything is a tough sell in the Senate. Tennessee Republican Lamar Alexander and his colleagues want a more incremental approach to fixing health care. Alexander dismisses President Obama's proposal as ivory tower arrogance.

INSKEEP: The White House seems to be obsessed with this idea that a bunch of professors sitting around a table can come up with a comprehensive bill and change one-seventh of the American economy all at once. We're not that smart. We don't do comprehensive that well.

HORSLEY: Uwe Reinhardt admits to being a Princeton College professor. He's also one of the country's leading health care economists.

INSKEEP: What's wrong with professors? They, too, can think, by the way - not only senators.

HORSLEY: And Reinhardt has spent a lot of time thinking about health care. One proposal, popular with both Democrats and Republicans, would require insurance companies to provide coverage to anyone that wants it at a community rate, regardless of illness or preexisting conditions. Reinhardt warns that idea would be problematic if adopted in isolation.

INSKEEP: That will lead to a lot of young people not being insured when they're healthy, but throwing themselves on the mercy of the community rate when they get sick.

HORSLEY: It would be like letting people buy homeowner's insurance after their house is on fire. Premiums would soar, or insurance companies would go broke. To avoid that, Democrats would require almost everyone to carry health insurance, and they'd provide subsidies to poor people to help them pay for it. Reinhardt says those three components at the heart of the Democrat's plan are like three legs of a stool: they only function as a unit.

INSKEEP: Once you start with community rating, you have to have the mandate. And once you have the mandate, you have to have subsidies. You cannot take those in step. You have to do all three things together.

HORSLEY: That's why President Obama decided against a scaled-down plan, even after Democrats lost their supermajority in the Senate. The alternative Republican plan would not require insurance companies to cover everyone, but Senator Mitch McConnell says it would make modest changes in an effort to address high costs.

INSKEEP: Things like junk lawsuits against doctors and hospitals, interstate insurance competition, things like small business health plans - those are the kinds of things that target the cost issue, which the American people thought this was all about from the beginning.

HORSLEY: The Congressional Budget Office estimates the GOP plan would expand coverage to about three million uninsured people, compared to an extra 30 million who'd be covered under the Democratic plan. Of course, President Obama himself opted for an incremental approach early on in the health care debate when he rejected calls for a single-payer system as two disruptive to the status quo.

Vermont Congressman Peter Welsh wants the president to reconsider, saying the government would avoid a lot of confusion and complexity by simply expanding Medicare to cover everyone.

HORSLEY: This debate we've had here in Washington that's gone round and round has essentially been, in some ways, avoiding the obvious.

HORSLEY: Welch argues that expanding Medicare would give consumers guaranteed health care and a choice of providers, while sharply reducing administrative costs. But that's one health care overhaul that's too comprehensive, even for President Obama.

Scott Horsley, NPR News, Washington.

INSKEEP: By the end of this day, you can know everything you want to know about this televised meeting. You can go to npr.org throughout the day for live blogging of the event, and join us online and on many NPR member stations at 7:00 Eastern tonight for a special one-hour ramp-up.

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