Health reform forecasts and the Great Society

Even the most die-hard NCAA basketball fans should concede that the major headline of the past weekend was not Northern Iowa upsetting Kansas or Cornell advancing to the Sweet 16, but the health reform reconciliation bill squeaking through the House of Representatives by a 7-vote margin. So should we be celebrating along with President Obama's crowd or throwing in our lot with the Tea Party? I'll dodge that question for now, but suggest that history provides a possible answer, or at least an analogy. In her acclaimed biography of President Lyndon Johnson, historian Doris Kearns (now Goodwin) wrote this about Johnson's relentless political pursuit of the mid-1960s social welfare agenda that would collectively come to be known as the "Great Society":

Even in the more familiar areas of public policy, the need for haste often resulted in a failure to define the precise nature and requirements of social objectives. Legislative solutions were often devised and rushed into law before the problems were understood. Since time was limited and agreement on ends could be assumed, since surely all reasonable men - especially those likely to be consulted by a liberal Democratic President - favored the elimination of poverty, the expansion of educational opportunity, and improvement in the delivery of medical care, most of the attention was focused on means. ... as if putting more money into a poorly conceived system will inevitably make it better. Pass the bill now, worry about its effects and implementation later - this was the White House strategy.

Sound familiar? A common critique that has been leveled at the health reform bill from both extremes of the political spectrum (those who want a Canadian-style single-payer health system and those who are basically fine with the status quo) is that it isn't real reform at all, but sinking billions of additional dollars we don't have into the current system. Of course, some will be quick to point out that one of Johnson's "hastily" enacted Great Society programs was Medicare, the health insurance program for senior citizens that is not by any means flawless, but has become so successful and widely accepted that opponents of "government-run health care" were forced into the paradoxical position of attacking the bill because it might threaten the generous benefits currently provided by Medicare.

Like picking who will emerge from this year's March Madness at the beginning of the season, it's much too early to correctly forecast whether this health reform bill - which may not survive the next round of Congressional elections - will turn out to be (like Medicare) a rousing success, an incremental improvement, or a catastrophic failure. Liberal commentators such as the Washington Post's Ezra Klein are already calling for additional reforms, while 11 states, fearing the possible effect of unfunded mandates on their battered budgets, plan to sue the federal government to prevent implementation of the bill. In the meantime, my thoughts on this topic are perhaps best summed up by the question I asked my wife (also a family physician) as we were listening to the final hours of floor debate while driving home on Sunday evening:

"So what are those 32 million newly covered people going to do when they get their health insurance cards and can't find a family doctor to see them?"