Hacker urges Obama to shift risk back

Jacob S. Hacker, the economist who best described the erosion of economic security for the middle class over the past thirty years in The Great Risk Shift, makes a tightly argued case that an all-out push toward universal health insurance is at once the best short-term stimulus and the best long-term investment Obama can make right now.

First, the short-term argument: Hacker lays out the extent to which out-of-pocket healthcare costs are eating into the income of the middle class as well as the poor, the underinsured as well as the uninsured:

Today, however, the health care deduction is big and getting bigger. Despite widespread complaints about "overinsurance," the amount people pay for health care out of their own pocket has risen substantially as a share of personal income over the last generation, and especially in the last decade. The Commonwealth Fund recently completed two massive surveys showing that the proportion of adults younger than 65 with health insurance who spent more than 10 percent of their income on health care out of pocket (5 percent for low-income adults) skyrocketed from 13.8 million in 2003 to 21.8 million in 2007, as health plans hiked deductibles and co-payments, denied claims more aggressively, jacked up costs for out-of-network care, and so on. What's more, almost all of the increase occurred among families with higher incomes--meaning that high health care costs have become a standard deduction for the middle class.

The problem is, of course, far worse for those who lack health insurance. Indeed, if you add the ranks of the uninsured to those without adequate coverage, you have more than 40 percent of the working-age population in an immediate economic bind because of medical costs. About half these people--slightly more of the uninsured than the underinsured, but not much more--report severe problems paying their medical bills. These are the families accounting for the 40 percent to 50 percent of people in bankruptcy or foreclosure who say health care is the number one reason for their plight.

So fixing health care isn't just a recipe for better access to medical care. It's an immediate economic lifeline for working families, giving them back part of their income to use on other things. It's also a rescue package for state and local governments burdened by Medicaid and S-CHIP, for doctors and hospitals who treat the uninsured and inadequately insured, for community institutions that help people in distress--in short, for all the rapidly fraying threads of our health care safety net. Put simply, most of the money we spend upgrading coverage and spreading it to the uninsured is going to go directly into the pockets of people who need help now.

And then, the long-term: controlling healthcare costs is the most important known variable in the nation's long-term fiscal prospects:

The faster everyone is in the system, the faster money flows into people's pockets, and the sooner reformers start reaping the political rewards.

And the faster all that happens, the better situated we are to start the difficult but essential task of controlling long-term health spending. Without runaway health spending, as Henry Aaron of the Brookings Institution has shown, the future fiscal picture of the federal government looks surprisingly rosy, even if taxes stay right where they are as a share of the economy. With runaway health spending, it looks catastrophic. Plus, as bad as the federal picture looks, it's prettier than what businesses and workers are facing. According to Sarah Axeen and Elizabeth Carpenter of the New America Foundation, if employer-sponsored insurance premiums and family income rise at the same rate they have for the past decade, an average family health plan will cost more than 45 percent of a typical family's income by 2016.

Will Obama risk his huge store of political capital -- and the nation's long-term fiscal health -- on trying to effect an immediate major investment in healthcare? No question. As he put it in his Dec. 11 press conference introducing his healthcare team: “Some may ask how at this moment of economic challenge we can afford to invest in reforming our health care system. And I ask a different question. I ask, how can we afford not to?”

Indeed, Obama's long campaign was in large part an extended argument for a sustained national investment in rolling back the shift of risk from institutions to individuals that Hacker so thoroughly documented -- through higher taxes on the wealthy that would enable new investments in healthcare, alternative energy and education. To shift risk to the public sector is not to eliminate it. Obama's writings show that he is aware of the dangers -- of large deficits, of taxes raised to the point of crimping economic growth, of bloated and unaccountable government offering ineffective services.

In The Audacity of Hope, he acknowledges those underpinnnings of the Reagan revolution. His argument in the campaign was not that there is no legitimacy to conservative concerns about big government, but that the pendulum has swung too far the other way -- that tax cuts for wealthy have hollowed out programs that sustain opportunity and social insurance. As he put it in Janeville, Wisconsin last February:

when opportunity is uneven or unequal - it is our responsibility to restore balance, and fairness, and keep that promise alive for the next generation. That is the responsibility we face right now, and that is the responsibility I intend to meet as President of the United States.

The genius of his campaign was a bid to move the center back to the left - to cast new social investment as a restoration of balance, fairness, commitment to commonwealth. Now, he cannot afford not to.