Tony Fratto: Behind The Partisan Divide on Health Care Reform


If you've been confused by year-long wrangling over health care reform, and the fierce differences between the parties, let me try to make it simple.

The fundamental difference between Republicans on one side, and President Bush and Democrats on the other side, comes down to the question of universal coverage for health insurance. Every other issue -- every law change and spending increase derives from how each party answers the coverage issue.

Democrats believe every American must be covered with a comprehensive health insurance plan. And since some Americans won't buy insurance or can't afford health insurance, then government will ensure coverage -- with an individual mandate, an employer mandate, with government-run health care (Medicare, Medicaid, children's health coverage), and with taxpayer subsidies.

Republicans believe every American must have ACCESS to health insurance -- choices that meet the needs of individuals, families and businesses -- including the choice to NOT be covered by insurance. Republicans prefer prices based on value and determined in robust, competitive markets for insurance. And government-run programs should only be provided for the elderly, the disabled, military veterans, the poor, and children of the working poor.

How the two parties answer the basic coverage question exposes the two major secondary differences between the parties: for Democrats, cost; for Republicans, how to create that robust market.

Mandating coverage is expensive: it requires a huge expansion of those government programs, higher taxes to pay for them, and new imposed costs for either individuals and businesses. A mandate, Democrats believe, requires either a progressive system of subsidies and/or a government-run program.

If you believe the benefits of mandated universal coverage are greater than the costs, then you're comfortable with the trade-off. (Arguments that universal coverage would lower costs are spurious: analysis shows that increases in health insurance coverage lead to greater use of the health delivery system.)

President Obama and Democrats believe Americans either (a) want universal coverage and are willing to pay for it; or (b) will want it and will be willing to pay for it once they begin to receive the benefits of coverage.

Republicans have tried to focus their efforts on reforming the market for health care in ways they believe would increase choices at affordable prices, thereby increasing access. The proposals are not designed to achieve the Democrats' goal of universal coverage, but would also not further expand government-run programs and increase the associated costs.

This fundamental difference -- access to coverage vs. mandating coverage is not trivial and should not be trivialized. It explains the legislative ambitions and stances of both parties in this debate.

But even after years of wrenching health care debate, that basic question -- with all its implications for costs and the design of our health delivery system -- has never really been put to the American people, leaving policy makers in Washington guessing as to what Americans really want, and talking at cross purposes.

The past year has largely been wasted by President Obama and Democrats trying to impose on Americans an answer to the fundamental question. It would be far better today to start over and focus the national debate on educating Americans about the implications of each option, and then put the question to them. Only then will follow sound legislation giving Americans what they really want.

Tony Fratto is a CNBC on-air contributor and most recently served as Deputy Assistant to the President and Deputy Press Secretary for the Bush Administration.