The December 2009 edition of the Archives of Ophthalmology reported an explosion in the incidence of myopia during the past thirty years.  In 1971-72, twenty-five percent of Americans aged 12-54 had myopia. By 1999-2004, the number had jumped to 42 per cent. We are becoming nearsighted. The big picture is increasingly out of focus. That’s all the science for today, but maybe it explains our wild and at times wacky health care debate.

Early in the Fall, I accepted LaCuadra’s invitation to put into plain language the major criteria to judge what at least for now will be called ObamaCare (Oct. / Nov. 2009) There were five:

● Could uninsured people buy a decent insurance package at a price, even with a stretch, that they could afford?

● Could the country transition Medicaid from its last-option welfare roots to a streamlined health care program for the poor?

● Could Congress agree how to raise about $50 billion per year in new revenue to add to a similar amount in projected savings?

● Could our national health care cost growth, an outlier against all other industrial economies, be slowed over time?

● Finally, can the deal survive the next two political cycles to imbed itself in the national economy?

At this point, with qualifications, it’s four “yes, we cans” on the policy issues and a “maybe” on the political question as Congress tries to nail down the final deal.

The details follow, but remarkably little substance has changed in the months since Labor Day. As is clear to any observer, the debate has become all politics all the time.  In August the myriad forces of the Right seized control of Congressional town meetings. The “plot” to create death panels emerged as among the milder charges as the shouting crowds denounced Obama’s Fourth Reich, quite a goal for someone allegedly not even born in the US of A.  A constant in earlier debates, the fear of change in our health care arrangements, was exploited into the demonization of anything governmental.  If there were potential moderate Republican supporters, the combination of frenzied constituents and threatened primaries locked Republican incumbents into total opposition.

Schooled in Chicago politics, The White House saw the scope of the potential threat. It absolutely had to regain post Labor Day control of the debate, at least among Democrats. If the Right could demonize government, the President’s team could raise the Insurance demon. When under assault, attack! And soon, the focus of health reform was to control the perceived enemies: the insurance limits on pre-existing conditions; caps on benefits; cancellation of coverage; and wasteful administrative costs. My demon checks your demon. Let’s get to counting votes.

There are real differences between the parties. During the November House debate, Congressman Joe Barton, Republican of Texas and ranking member of the House Energy and Commerce Committee said simply and honestly, “we have a difference in philosophy.”  For Democrats, the bottom line according to Barton was insurance coverage.

Republicans, he argued, want to control costs.  They assert that if you make people pay more out of pocket at the point of service, they will limit their own use of care. The premise is that consumer choice ultimately drives the health care cost equation.  Like other services in the economy, the purchase of health insurance should be a voluntary decision.

The serious Democrats say that this health care “market” doesn’t work. If you’re sick you’re quickly priced out (or closed out) of health insurance. If you face a large out of pocket cost, you may avoid or delay a service that you really need. At some point in the course of illness, you’ll then be likely to enter the health care system with greater need and in a more expensive way. More broadly, buying services piecemeal plays into the market incentives, as they exist, for providers of care (hospitals, doctors, drug and device makers) to increase the volume of the services they provide.  Broad coverage in a structured and regulated insurance market less reliant on fee for service payment, the counter argument goes, is the more effective way to control costs.  Agreeing at least in part with Congressman Barton’s label, these Democrats assert that, yes, insurance coverage is the bottom line in crafting an alternative approach to cost control.

Perhaps the best political observation is that whatever the philosophical differences, the broad health reform issue didn’t dent the Bush 43 agenda, which, following the cyclical pattern of American politics, helped bring a Democrat back to the White House.

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