The good news is that, now that Democrats have won total control of the government, all Americans are likely to have health insurance.
The bad news is that the ranks of the uninsured, previously about 46 million, probably will swell by another 5 million to 6 million because of the recession, and a similar number will be added to strained public programs such as Medicaid and SCHIP. That means the cost of covering everyone will surge far above previous estimates - which were probably low to begin with - of $150 billion a year.
Health-reform plans advanced by President-elect Barack Obama, incoming Health and Human Services Secretary Tom Daschle and congressional Democratic leaders such as Sens. Edward Kennedy of Massachusetts and Max Baucus of Montana contain no certain cost-saving mechanism and specifically exclude the one advocated by Republicans: choice-making by individual patient-consumers. So, it wouldn’t be surprising if the 10-year cost of providing insurance to all who need it could be far more than $3 trillion, the figure some conservatives put on buying federal-employee-quality coverage for 45 million people.
And more bad news lies in the likelihood Democrats will adopt a government-heavy health-reform solution that might eventually result in the disappearance of private health insurance.
No one is seriously advocating imposing a Canadian-style, government-run, single-payer system in one fell swoop, but creation of a Medicare-like option for all Americans could lead to that result, especially if government policy drives up the cost of private insurance.
Moreover, Democrats such as Rep. Pete Stark of California want to revive the Clinton-era proposal of allowing people 55 and older to buy into Medicare, another step toward Canadian-style medicine.
Advocates say Medicare is more efficient than private insurance, but the fact is, the Medicare system is scheduled to go broke by 2018, and seniors express high satisfaction with one part of Medicare that’s private - Part D, the prescription drug benefit.
Democrats are likely to declare war on pharmaceutical companies, the people whose research produces the drugs that save lives and help people avoid costly chronic care. Almost certainly, Democrats will require the Medicare system to “negotiate” prices with drug companies - which means, set them - and some Democrats favor restricting seniors’ access to drugs the way the Department of Veterans Affairs does.
The purpose is to hold down Medicare costs, make drugs cheaper for seniors and prevent “profiteering” by drug companies. But, in the process, research and discoveries will be stifled. And seniors are likely to balk at having their drug choices restricted.
But back to the good news. Because Democrats won control of Congress so handily, the partisan warfare that has blocked health-care reform for decades is over.
When Mr. Obama takes office Jan. 20, Democrats plan to have passed for his signature the expansion of the State Children’s Health Insurance Program twice vetoed by President Bush. It will cover 3.5 million of the 10 million uninsured children. The economic recovery package he signs that day is also likely to contain money to help states bear the cost of providing Medicaid to low-income people - a number estimated to rise by 1 million for every 1 percent increase in unemployment.
Mr. Obama has said he wants energy and environmental legislation to be his and Congress’ second order of business, but Mr. Daschle reportedly is pushing for health reform to take priority. So is Mr. Kennedy, who is suffering from incurable brain cancer and wants universal health insurance to be his legacy.
Democratic leaders all favor maintaining the current employer-based health insurance system, and the likelihood is that a plan passed next year will require that every American have coverage - a device designed to bring down the average cost of a policy. The idea of mandatory coverage, which Mr. Obama resisted during the campaign, has been endorsed by America’s Health Insurance Plans, the insurance lobby that fought and defeated the 1994 Clinton health reform plan.
AHIP has agreed - if everyone is covered - to Democratic proposals barring insurance companies from refusing coverage based on a patient’s medical history and requiring that all people in a geographic area be charged the same premium.
Despite those concessions, Democrats still plan to offer a government-run competitive plan like Medicare. AHIP complains that, because Medicare underpays doctors, they shift costs to privately insured patients, driving up premiums.
If that continues and the costs of the public plan are low enough, people could flood out of private insurance, eventually leaving the government as America’s dominant health insurer.
If that’s bad news, good news is that - at long last - action is likely to come on a bevy of health reforms that have been delayed despite broad bipartisan support. They include investments in health information technology, greater emphasis on disease prevention, steps to pay doctors for keeping people healthy instead of just treating ailments and better management of chronic diseases. These are eventual cost-savers but will require investment and time to take effect. An idea of Mr. Daschle’s - creation of a National Health Board to evaluate best practices and diminish waste - is another eventual cost-saver.
Some studies indicate that between a third and half of all health outlays in the United States are unnecessary or ineffective. Mr. Daschle’s board is designed to reduce that cost, but it may be accused of rationing care.
And there’s one final problem: If 50 million or more people have health insurance, the nation needs more primary care doctors and nurses. The government must offer aid to reduce the $140,000 average debt incurred by medical school graduates.
It will all cost a lot of money, but it will be worth it if no one lacks for insurance - and if Democrats can correct the anomaly that the United States pays more per capita than any other country on health care but ranks 48th in the world in life expectancy.
Morton Kondracke is a nationally syndicated columnist.