Can It Happen Here?

Monday, 11 August 2008 13:59 By Paul Krugman, The New York Times | name.

Can It Happen Here?
A primary care practice in Amherst, Massachusetts, where universal coverage was mandated. Paul Krugman says despite this plans early troubles, public support has grown and reveals that once a system of universal health coverage exists, people want to keep it. (Photo: Christopher Capozziello / The New York Times)

    The draft Democratic Party platform that was sent out last week puts health care reform front and center. "If one thing came through in the platform hearings," says the document, "it was that Democrats are united around a commitment to provide every American access to affordable, comprehensive health care."

    Can Democrats deliver on that commitment? In principle, it should be easy. In practice, supporters of health care reform, myself included, will be hanging on by their fingernails until legislation is actually passed.

    What's easy about guaranteed health care for all? For one thing, we know that it's economically feasible: every wealthy country except the United States already has some form of guaranteed health care. The hazards Americans treat as facts of life - the risk of losing your insurance, the risk that you won't be able to afford necessary care, the chance that you'll be financially ruined by medical costs - would be considered unthinkable in any other advanced nation.

    The politics of guaranteed care are also easy, at least in one sense: if the Democrats do manage to establish a system of universal coverage, the nation will love it.

    I know that's not what everyone says; some pundits claim that the United States has a uniquely individualistic culture, and that Americans won't accept any system that makes health care a collective responsibility. Those who say this, however, seem to forget that we already have a program - you may have heard of it - called Medicare. It's a program that collects money from every worker's paycheck and uses it to pay the medical bills of everyone 65 and older. And it's immensely popular.

    There's every reason to believe that a program that extends universal coverage to the nonelderly would soon become equally popular. Consider the case of Massachusetts, which passed a state-level plan for universal coverage two years ago.

    The Massachusetts plan has come in for a lot of criticism. It includes individual mandates - that is, people are required to buy coverage, even if they'd prefer to take their chances. And its costs are running much higher than expected, mainly because it turns out that there were more people without insurance than anyone realized.

    Yet recent polls show overwhelming support for the plan - support that has grown stronger since it went into effect, despite the new system's teething troubles. Once a system of universal health coverage exists, it seems, people want to keep it.

    So why be nervous about the prospects for reform? Because it's hard to get universal care established in the first place. There are, I'd argue, three big hurdles.

    First, the Democrats have to win the election - and win it by enough to face down Republicans, who are still, 42 years after Medicare went into operation, denouncing "socialized medicine."

    Second, they have to overcome the public's fear of change.

    Some health care reformers wanted the Democrats to endorse a single-payer, Medicare-type system for all. On the sheer economic merits, they're right: single-payer would be more efficient than a system that preserves a role for private insurance companies.

    But it's better to have an imperfect universal health care plan than none at all - and the only way to get a universal health care plan passed soon is to inoculate it against Harry-and-Louise-type claims that people will be forced into plans "designed by government bureaucrats." So the Democratic platform emphasizes choice, declaring that Americans "should have the option of keeping the coverage they have or choosing from a wide array of health insurance plans, including many private health insurance options and a public plan." We'll see if that's enough.

    The final hurdle facing health care reform is the risk that the next president and Congress will lose focus. There will be many problems crying out for solutions, from a weak economy to foreign policy crises. It will be easy and tempting to put health care on the back burner for a bit - and then forget about it.

    So I'm nervous. The history of the pursuit of universal health care in America is one of missed chances, of political opportunities frittered away. Let's hope that this time is different.

    One more thing: if we do get real health care reform, a lot of people will owe a debt of gratitude to none other than John Edwards. When Mr. Edwards dropped out of the presidential race, I credited him with making universal health care a "possible dream for the next administration." Mr. Edwards's political career is over - but perhaps he and his family can take some solace from the fact that his party is still trying to make that dream come true.

Last modified on Monday, 11 August 2008 16:50