WASHINGTON -- It is a political fact that all the divisive debates and massive expenditures of the early days of the Obama presidency -- from stimulus spending to bank bailouts to the nationalization of auto companies -- have been distractions from an aside within a sideshow. After hundreds of billions in new spending, Barack Obama hasn't yet gotten around to his top legislative priority: health care reform.
An economic emergency makes this understandable; it also makes health reform more difficult. With an appetizer this expensive, what will the main course cost?
Given Washington's imbalance of political power, Obamacare -- requiring employers to provide insurance or pay a fine, creating a government-operated insurance option and subsidizing the purchase of insurance for the poor -- is widely thought to be inevitable. Actually, it faces accumulating obstacles. The absence of Tom Daschle and the illness of Ted Kennedy have left a void of compelling leadership on the issue. Concerns are growing about the new public insurance option, which could undercut and crowd out private plans, gradually creating a universal Medicare. And the administration has yet to detail a realistic way to fund additional health entitlements that will cost about $150 billion a year. Obamacare should only be regarded as inevitable when someone, anyone, knows how it will be paid for.
Republicans in Congress, however, also face an intrusive, potentially humiliating health care test. Whatever their success in challenging or blocking the Obama plan, being the "party of no" on this issue would communicate indifference to public concerns and intellectual bankruptcy.
Fortunately for Republicans, health care is an issue where conservative policy wonks have been creatively at work for a decade. Most Republican reforms involve shifting away from employer-based health insurance coverage -- replacing the massive tax breaks for companies with subsidies to individuals and families to purchase coverage on their own. Employer-based coverage, in this view, has eaten up salary increases, hidden the rising costs of health care and made workers afraid to change jobs in an economy where flexibility is essential.