Finding Consensus (and defining it)

November 17, 2008

So Bob Laszewski and I completely disagree on the significance of the Max Baucus white paper, right?  After all, I said that it gave us a picture of the new “center” regarding health reform, around which the center/left is beginning to coalesce, and that it “may represent grounds for a new bipartisan consensus.”

Bob’s piece on the Baucus paper, on the other hand, is subtitled “Evidence There Is No Consensus On The Key Health Reform Issues.”  In it he chastises a reporter who suggested that Congress is coming close to consensus, suggesting that the journalist probably hasn’t read the full paper.

So we’re in complete disagreement, right?

No – and not just because I qualified my statement by saying the Baucus paper “represented grounds” for forming a consensus.  As with everything in Washington, it all depends on what the meaning of is is.  In this case the “is” – consensus on health reform – is really what’s up for discussion.  Bob says the paper doesn’t create consensus because it’s extremely vague on how the critical elements of reform will be carried out.  Whether it’s individual subsidies or provider payment programs, the Baucus proposal (as published so far) defers specifics.  Bob points this out, as do I.  My other critical concerns — minimum acceptable benefits, and the ratio of maximum personal costs (premium plus copays and deductibles) to income — are also left unspecified.

The devil is in the details, and the details haven’t been worked out.

But I’ll stick to my statement that a consensus is forming, because I’m using the word differently.  The American Heritage Dictionary defines consensus as “An opinion or position reached by a group as a whole,” or “General agreement or accord.” I think that’s coalescing in Democratic circles around six key ideas:

  1. Action is needed sooner, rather than later.  (Ted Kennedy has considerable influence in this matter, and his statement today will add weight to this position.)
  2. Mandated coverage is probably coming, but we should do whatever we can to control costs before imposing it.  (This is Baucus’ position, as I understand it.  Obama’s was somewhat different, but not entirely:  Let’s do all we can without mandates, and if we don’t get where we want to be we’ll revisit the issue.)
  3. Significant IT investment is needed.
  4. Premiums should be subsidized, to some multiple of the poverty income level.
  5. Benefits should be guaranteed – at some unspecified level.
  6. An insurance exchange or agency of some kind will be needed.
  7. Portability, and the elimination of pre-existing condition exclusions, is critical.

There are other important ideas, but these are the core principles around which the most powerful DC influencers seem to be gathering.

That’s all well and good, but here’s where I worry:  There was strong consensus around the Massachusetts reform initiative, too — so much so that the participants announced a successful solution before addressing the concrete issues that Bob Laszewski and others have been discussing.   The Massachusetts team is working hard to address some of the ongoing issues, and they’re coming up with solutions.  But they’ve been years in coming, and the roll-out problems they’ve faced there would be amplified enormously if they took place on a national scale.

Given the care and precision with which the Obama team has acted so far, it’s unlikely that the same thing will happen on a national scale. That’s good.  While we may be close to “consensus” on where we’re going, we have yet to draw the map which shows how we’re going to get there.  Should the Baucus paper prove to be a signpost toward the new center, that means that the hard work of design and prediction is just beginning.

As for Bob Laszewski, looks like he and I are having a “heated agreement.”  There’s a consensus forming about what health reform should look like.  Now we have to agree how to get there.


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