The U.S. health care system, which is in dire condition, will require prompt attention when Barack Obama takes over the Oval Office, experts say.
In this occasional series, NPR will follow the transition from the Bush administration to the Obama administration through a series of stories, conversations, commentaries and essays that will outline the many issues and challenges facing the new occupant of the White House. From a broken military to a troubled economy to a National Park Service in need of a major overhaul — we'll provide the briefing paper, the options and the obstacles.
Just about every Democratic president since Franklin Roosevelt has tried — and failed — to overhaul the nation's health care system. While Lyndon Johnson managed to pass Medicare for the elderly and Medicaid for the poor, the others came away with little more than scars for their efforts.
As President-elect Barack Obama prepares to take office, the state of health care in America is more dire than it has been for any of his predecessors. Forty-six million Americans lack any health insurance coverage, according to the U.S. Census Bureau; an additional 25 million are underinsured, according to a study published in the policy journal Health Affairs. Yet the U.S. spends more than $2 trillion annually on health care, far more than any other industrialized nation.
Even if the new president was tempted by the sagging economy to put off his promise to address the health care mess, he would do so at his peril, says Bob Blendon, who studies public opinion at the Harvard School of Public Health. Not only did voters who cited health care as their top issue flock to Obama in huge proportions, Blendon says, but "60 percent of his voters expect that if he became president, something big would be done about this problem."
"That is the really big number here," Blendon says, adding, "It's something his voters expect him to do something big about."
Conflicting Attitudes About Care
Of course, a big problem is that voters still disagree about what "something big" in health reform would look like. Americans remain divided about whether they want more or less government involvement in the health care system, about whether they are willing to pay higher taxes in order to have more people covered, and about whether businesses or individuals should be required to provide or purchase insurance.
Another long-standing obstacle is the difficulty of fighting the status quo in a health system that has made a lot of people a lot of money. Rep. Jim Cooper (D-TN) knows all about that. He is a veteran of the last, unsuccessful effort to reshape the nation's health care system, in the 1990s.
Cooper says that if the new president fails to make health care anything other than a top priority, he "simply won't have the political capital to bust through the $2 trillion of vested interests that are there."
With a wry grin, Cooper says that he has "never had anyone come by my office saying, 'Congressman, I'm wasting taxpayer money. Stop me for doing this.' Everybody claims that they are spending it wisely, which is sometimes a lot of baloney."
Groundwork Has Begun
One bit of good news for Obama is that a lot of bipartisan groundwork on health care already is being laid in Congress this year. Across Capitol Hill, members and staff have been in deep discussions about how to avoid past pitfalls and find common-ground solutions.
Some of those involved in this effort weren't around the last time. Freshman Sen. Sheldon Whitehouse (D-RI) says he would like to see Congress initially focus not on the huge reforms but on fixing the nuts and bolts of the way health care is delivered — things such as computerizing medical records and changing the way doctors and hospitals are paid.
Such changes are more broadly bipartisan, and they are the kinds of things that will need a long lead time to provide a payoff, says Whitehouse. That will coincide with the time 78 million baby boomers will really start to put financial stress on the Medicare program.
"The kind of reforms that can make the system more efficient, provide better care, save money and humanize the system will take 10 to 15 years to really ... see results and claim the savings," Whitehouse says. "My view is, that wolf is going to be at our door about 10 to 15 years from now, so everything tells me that the start date, if we're going to get things done the humane way, is right now."
Funding Persists As Top Problem
The biggest obstacle of all has been how to pay for health reform. Independent health policy analyst Jeff Goldsmith says that with the economy in the tank, even if there were consensus on how to fix health care, it still would be awfully hard for the next Congress and the new Obama administration to do much to improve the system.
"It's really a tremendous challenge for anyone who wants to increase coverage for the uninsured to do it in the fiscal and economic climate we're in right now," says Goldsmith.
He says the time to expand government-subsidized health insurance coverage "is at the top of an economic cycle, when the economy is throwing off cash and when government budgets are generating revenues. That's absolutely not where we are now."
Still, the public will be expecting some action on health care. The challenge is going to be to figure out what form that will take.