Health-Care Nation

Like a growing number of congressional Republicans, Herzlinger sees long-term benefits in replacing company health plans with individual policies, but the way she'd get there would give free-market Republicans heartburn. She posits a model for "consumer-driven health care" that would put money and tax credits in the hands of patients and the physicians of their choice, instead of insurance-company gatekeepers and hospital billing departments. It's an ideologically driven plan with a sensible side. She points to the Swiss system of universal health care as a model: It makes frank use of government power and money to create a health marketplace that favors "health-insurance entrepreneurs" rather than giant insurance companies and hospitals. Health insurance is mandatory and purchased in the private sector, with the rates overseen by the government, and the government pays the premiums of those who can't afford it. In Switzerland, insurance companies who benefit by signing more healthy patients find their profits reassigned to companies that cover sick people. It's a self-correcting mechanism that blocks the risk-selection process by which American insurers deny coverage to the truly ill.

I suspect that neither the political press nor many G.O.P. voters have realized how completely the party's leaders have embraced the concept of medical markets being guided by an extremely strong governmental hand.

Herzlinger-who stresses that she speaks for herself, not the campaign-and Republican thinkers like Ross Douthat and Reihan Salam, co-authors of Grand New Party, think they see a politically sellable economic tradeoff: The idea is to use sweeping governmental rules to open health-care markets to more diverse and efficient private companies.
A built-in clientele is essential to such plans. Rising party leaders like Mitt Romney and Arnold Schwarzenegger have already decided that health insurance, like Social Security, must be mandatory. That way, the young and rich can't hobble a state or federal system by opting out. Also widely accepted is the pragmatism of the government's picking up some or all of the insurance tab for as much as 20 percent of the population. For example, former G.O.P. Senate Majority Leader Bill Frist wanted the government to, in effect, reinsure the sickest patients by taking over for private insurers when an individual's medical bill surpassed a figure in the range of $50,000. Others like progressive cost sharing, in which the poor are fully subsidized and wealthier families' subsidies kick in on a sliding scale when medical expenses start moving toward 10 percent of total family income.

To Douthat and Salam, embracing old bugaboos is the cost of strengthening the G.O.P. in national elections. They note that the traditional conservative answer to health care-less regulation, spending caps, tax-code adjustments-will drive up health-care costs for the poor and the old, just as Republicans are trying to erase the memory of what Bush has done to average wage earners: "No working-class political movement can succeed, though, unless it makes a push for reform in what may be the greatest source of anxiety for working families-the country's health-care system."

Lieberman's sharp critique of McCain's assault on employer-based insurance does not mean that she's promoting Obama, who has yet to be put under the microscope on this issue. She faults Obama for being vague about how he plans to reduce average premiums by $2,500 per family, while creating a public option plan similar to Medicare for those not covered by an employer. Many experts doubt that he can, as blogger Williams puts it, "square the circle of cost, quality, and access" so easily.

There are encouraging signs that Obama's turn to be scrutinized has come. In the kind of dissection that has been all too rare so far, Kevin Sack of the Times cast doubt on Obama's claim that he can cut the government's health-care spending by up to $273 billion by 2012. In a short, sharp item for the Wall Street Journal's website, reporter Amy Chozick wrote that she caught Obama second-guessing his own plan to achieve universal access through private insurance companies. "If I were designing a system from scratch," he told a town-hall audience in New Mexico, "I would probably go ahead with a single-payer system."

Despite such bright spots, my guess is that voters who follow the issue via daily newspapers and network-news broadcasts aren't going to be well-informed by Election Day. The best information is in newly published books, medical blogs, and professional journals, and in specialized outlets like Lieberman's columns on the C.J.R. website. She's done the most useful medical reporting I've seen this year, but her columns are designed as tip sheets for daily newspaper-assignment editors. Reading them, a layperson can see how a good newspaper editor's mind worked in the latter half of the 20th century: You'd look around the newsroom and find a reporter you could spare for a couple of weeks, whom you'd instruct to dig into a candidate's position and ask the most awkward questions possible. This still works, but I agree with Lieberman that too many of the desks where those reporters used to sit are now unoccupied. As with so many benefits of the old newspaper world we once took for granted, it's time to say R.I.P.

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