WASHINGTON -- The incompetence of President Obama's health care reform effort is undeniable, and unexpected.
A supremely competent candidate and campaign usually indicate a talent for governing and communications. But on central issues such as the public option and financing methods, the Obama team has been wavering and contradictory. The president's summer recess legislative deadline was hasty and unserious. (As Mississippi Republican Gov. Haley Barbour points out, Obama spent more time picking out the White House dog than he permitted for comprehensive health reform.) Obama allowed the House to lead with a bill that is ruinously expensive, financed by a massive accounting trick and dismissed by a number of Democrats in the Senate. And talk of imposing "go-it-alone," partisan legislation now seems desperate.
But all this amateurism actually leaves a false impression. Despite Obama's best efforts, some type of health reform seems likely. Democrats have a political interest in the passage of less-frightening, more-incremental reforms; a failure to do so would prove them incapable of governing. It is difficult to imagine that congressional Democrats will humiliate a promising new president on his main policy initiative. And it remains possible that more limited reforms could emerge from the Senate, where Democrats on the Finance Committee actually inhabit fiscal reality. A serious Senate plan, with even limited Republican support, could quickly transform the health debate.
So what are the alternatives?
First, there is the one-step-back approach. Obama could drop controversial plans to introduce new players in the health insurance market -- either the public option or insurance cooperatives -- while retaining the core elements of his current plan: health insurance reform, an individual insurance mandate and government subsidies to individuals to purchase insurance. These elements cannot be separated. Insurance reform alone (preventing insurance companies from denying coverage to people with pre-existing conditions or charging higher rates based on medical condition) would permit people to buy insurance when they get sick, and give them no reason to buy it when they are healthy, making the whole system unsustainable. So everyone must be forced to pay into the insurance market through a federal requirement. And this mandate is unrealistic unless people with lower incomes are enabled to buy coverage with a subsidy.