If the main objection to health reform is ideological -- concern about the federal government undermining private health insurance -- the one-step-back approach might blunt opposition. But if the main public concern is spending -- which it is -- this option doesn't solve the problem. By inflexible mathematics, universal insurance coverage is expensive. Even squeezing the subsidies makes only a marginal difference in the overall cost.
Second, Obama could abandon universal coverage and concentrate on health care access for the poor and working class. A serious expansion of Medicaid -- already included in House and Senate health proposals -- is separable from other reforms and scalable to whatever level Congress deems affordable. And because this option expands an existing federal health care role instead of creating a new one, it is less scary.
The primary objection comes from governors. Medicaid is a shared cost between the federal government and the states. Adding several million people to Medicaid involves a future cost to state governments. Even if the federal government foots the entire bill for a few years, states would eventually be forced to pay their share. Congress would need to offer state governments a sweet deal.
Third, Obama could maintain his commitment to universality but dramatically reduce the ambition of coverage. It is catastrophic health costs -- often coming after yearly or lifetime caps in an insurance plan are reached -- that force individuals into bankruptcy. Obama could propose a plan that funds health costs for patients once their bills exceed a certain level.
A combination of options two and three would be politically potent. Obama would be saying: We can't get everything we want in this fiscal environment, but we will cover more of the poor while making sure no one in America is bankrupted by catastrophic health costs. We will offer something for those in the greatest need -- and something for everyone at their moment of greatest need.
Neither of these proposals solves the overall problem of health cost inflation -- but neither do any of the other approaches under consideration. Obama would merely be expanding the reach of a broken system. But such a modest proposal might restart a productive health debate, signal the return of presidential pragmatism, and show Democrats a path to partial victory.
Michael Gerson
Michael Gerson writes a twice-weekly column for The Post on issues that include politics, global health, development, religion and foreign policy. Michael Gerson is the author of the book "
Heroic Conservatism" and a contributor to Newsweek magazine.
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