Health Care: Think Comprehensive and Practice Incremental Change

When I worked in policy development from 1968-70 one thing became totally apparent to me: It is nearly impossible for Congress to pass comprehensive policy.

When I worked in policy development, comprehensive took the form of PPBS or Program Planning Budgeting Systems. This concept evolved from the attempts by the Defense Department to get its budget to where results related to dollars spent. The problem, it required the Representative in Congress to gore the hides of a majority of its members.

The same is true for the bills passed by the Senate and House on Health Insurance Reform. No one questions the need for reform, but almost each step proposed in each of these comprehensive packages has an impact on individual representatives that necessitates him or her to register a no vote, or worse, get “paid off.”

As of the first of March 2010, passing a comprehensive change has been placed in the hands of Nancy Pelosi, Speaker of the House. If she could garner a majority, the very imperfect Senate package could be passed and sent to the President. An astute politician, she has decided the easy way out is to throw the ball back to the poorly operating Senate and let them muddle through. History has shown that this maneuver may be clever politics, but cowardly and likely to lead to no change for a health care system that is on its way to total disaster.

Comprehensive proposals rarely pass Congress. FDR barely did it with the Social Security Act in 1935 and LBJ squeaked by on the Civil Rights Act of 1964. Comprehensive reform of the Defense Department budget sought by Robert McNamara was DOA as it cut programs in too many Congressional Districts, programs that if considered separately would have won majorities in most aspects.

Republicans have been crude and gamey in their political attacks. But, underlying their arrogance is a political reality, expressed most effectively by Senator Alexander. The comprehensive nature of the House and Senate proposals cannot receive clear majorities. Their supercilious proposal of “shred and start over” is reflective of the political reality that the substance in each proposal can have an up or down vote that might lead to comprehensive change: to paraphrase Senator Alexander, incrementalism will garner bipartisan support for most of the pillars in each proposal, that the political fight will be over a small percentage of items that may pass or fail by narrow votes.

The late Senator Kennedy understood this political reality and worked diligently on structuring incremental change. He also publicly scolded himself for not working with the Nixon Administration when it proposed a comprehensive health care program in 1974 when the percentage of GNP spent on health care was only 8% (now 17% and growing). I would like to think that the Congressional leadership would have learned this lesson from history. It’s all right to think comprehensively on health care reform, but realism dictates that enactment will occur only through passing elements incrementally.

See my other writing on health care reform: Universal Health Revisited 1/27/09; Doctor Appointment: Wait 3 Months; Murray's latest writing on health care; and Nixon Health Plan Revisited.