Health care reform rarely is accomplished in a process that is anything like a straight line. In 2009, for example, changing America’s health care system first requires addressing the nation’s tax system. That may not be intuitive, but it does seem to be the way things are working out.
President Barack Obama makes very clear that comprehensive health care reform is an integral part of his economic recovery program. Impressively, he has already accomplished a number of his goals, specifically inclusion of funding for health care technology as part of the recently passed stimulus package and the renewal and expansion of the State Children’s Health Insurance Plan (SCHIP). Those were just the start of his reform efforts, however. And now comes the difficult part.
President Obama wants to change the way Americans purchase and use their health care. He wants to achieve near universal coverage, reduce the cost of both health insurance and of medical care, and vastly reduce wasted spending on health care. This is not an easy task — just ask California Governor Arnold Schwarzenegger. Or Secretary of State Hillary Clinton, for that matter.
President Obama’s mission is complicated by the withdrawal of former Senator Tom Daschle to lead the Administration’s health care reform efforts. Senator Daschle had tremendous credibility in Congress and policy wonks alike. He was a superb choice to serve as President Obama’s Secretary of Health and Human Services and to be Director of the White House Office of Health Reform. His nomination withdrawn due to Senator Daschle’s tax problems, the Administration is unlikely to find a replacement of equal political heft, access to the President and in-depth knowledge of the issue.
Finding a leader for is the Administration’s second most pressing health care reform challenge. The first is passing a tax increase. Here’s how it plays out.
The stimulus plan supported by President Obama greatly increases the nation’s spending. At the same time, the Obama Administration inherited a budget deficit of about $1.3 billion courtesy of the Bush Administration. This week, in a White House summit on fiscal policy and in an address to Congress, President Obama will make clear his commitment to slashing the deficit to $533 billion by 2013. To do that, according to the Associated Press, he will: 1) reduce spending on the Ira war; 2) end “temporary” tax breaks enacted during the administration of President George W. Bush on those making $250,000 or more a year; and 3) increase government efficiency. Among those programs slated for streamlining is reducing Medicare Advantage subsidies to insurance companies according to the New York Times.
The Administration is also likely to propose treating investment income earned by hedge-fund and private-equity partners as ordinary income according to the Bloomberg Press. This income is currently taxed at the capital-gains rate of 15 percent. Ordinary income is taxed at as much as 35 percent (but could go up to 39.5 percent if the Bush tax cut for those earning $250,000 or more is repealed.
Without these savings, President Obama will be hard pressed to finance expansio of health care reform and his energy initiatives, increase education spending and enact his homeowners assistance program and send more troops to Afghanistan and reduce the deficit.
Of these, make no mistake: health care reform is near or at the top of the list. As Office of Management and Budget Director Peter Orszag puts it, as quoted in the New York Times, “He wants to present an honest budget, he wants to focus on health care ….” The Times quotes senior adviser David Axelrod as explaining, “The president believes there are essentially three areas that have to move forward even as we pare back elsewhere — health care, energy and education.”
It all comes down to the economy, however. And most objective observers would agree that America needs health care reform to have a sound economy. (The debate is not over whether reform is needed, it’s what kind of reform is required). So health care, taxes and the rest are all tied up in the Administration’s effort to right America’s fiscal ship.
We’ll have updated estimates as to how much revenue the tax increases are expected raise over the next four years when President Obama introduces a summary of his budget later this week. Clearly, however, it will be a critical component to the Administration’s fiscal goals. If the tax increases fail, it will be substantially harder for President Obama to finance a big ticket item such as his health care reform proposal. With the increases, he will have demonstrated his political acumen and bolstered his bargaining position with Congress while, at the same time, finding the revenues he needs to implement his plans.
So the first test of whether President Obama can pass his health care reform will not be a vote on creating a Federal Health Board or establishing a national purchasing exchange. It won’t mention guarantee issue or community rating nor even provider reimbursement levels. It will be a vote on whether a tax reduction scheduled to expire in 2011 will be allowed to so, then or sooner. Not a straight line, but a necessary course of action nonetheless.