US health reform clears first hurdle

Passing healthcare reform in the US House of Representatives, where Democrats have a 258-177 majority, should have been easy. It was not. The House voted 220-215 for its bill, and only after frantic last-minute deals were struck. The party’s command of the Senate is weaker. Moving reform through that chamber, the reformers’ next hurdle, will be harder. The Democrats’ celebrations – Barack Obama called the weekend’s vote “historic” – are premature.

Healthcare reform, long overdue in the US, can still happen. But to be more confident of success, and to fashion a better bill, the Democrats’ leaders need to alter their approach. They must concentrate on essentials, around which a sufficient consensus can be built, and put their more divisive ideas aside. They must explain more honestly what reform will cost, and how to pay for it. Recalling that more US voters now oppose reform than support it, they must stop talking mainly to each other and convince the public of their case.

The House bill makes few compromises with moderate (let alone conservative) opinion, which is why it provoked 39 Democratic defections. It includes a so-called public option, a government-run scheme to compete with private insurance. Many advocates hope, just as many critics fear, this will break the private-insurance model and push the US towards a single-payer system. Most US voters, content with present arrangements, find that prospect unsettling.

The Senate is likely to pass a measure with a narrower public option or none – or else reform may stall altogether. Democrats should accept the compromise. A new public plan is inessential to the larger goals of widening coverage and assuring those who have insurance that they will not lose it.

The House bill is costly, at more than $1,000bn over 10 years on optimistic assumptions. It would impose heavy burdens on business, including small business, and add a new tax on those earning more than $500,000 to the hike they already face when the Bush tax cuts expire. The cost needs to be spread more broadly and more intelligently, preferably by curbing the tax exemption for employer-provided health insurance. This would raise the needed money and improve incentives for more efficient spending at the same time.

Reformers need to build public support by acknowledging and responding to voters’ concerns, which they have patently failed to do. Until that changes, the project is in jeopardy. It is a responsibility that falls especially to Mr Obama.