Competition of ideas moves health reform in right direction

WASHINGTON — Here's an irony for you: The health-care bills in Congress are getting better, even as support for them diminishes around the country. It is just as well that President Obama has yielded to common sense and backed off his demand for quick action. It will take time for voters to become more comfortable with the changes he wants to make.

As the House and Senate prepared to head out on their summer vacation, a series of polls agreed that Obama's signature domestic initiative is in trouble, facing increasing skepticism about its costs and benefits.

A Wall Street Journal/NBC News poll taken last week found its sample split 41 percent approving and 46 percent disapproving of Obama's efforts on health-care reform. The numbers are almost identical to Bill Clinton's scores on the same question in June 1994, the month his effort failed.

The same survey offered a preview of the debate that now awaits us. When voters were asked to rate Obama's health-care plan, 36 percent said it was a good idea and 42 percent called it a bad one. But later in the poll, when the interviewer read an accurate, neutrally phrased description of the main features of the plan that Obama supports, it commanded strong support — winning approval 56 percent to 38 percent.

Coupled with the fact that all recent polls show Democrats with greater credibility on health issues than Republicans, these findings suggest that it is still possible for Obama and his supporters to halt the erosion and win the battle of public opinion — if they can get people to understand what is being proposed.

They plainly will get no help from the Republicans, who for the most part seem to be following Bill Kristol's urgings to "just kill it," or from the interest groups financing the ads that warn about "government control of your health care."

The danger to Democrats is that the final stages of committee work on the health-care bills have been depicted more as a war of factions — Blue Dogs vs. progressives — than as a concerted effort to tackle one of the most vexing policy challenges imaginable.

Actually, it is both. But the leaders have been too busy refereeing the factional fights to explain the substantive changes being made in the bills — most of which actually improve the chances of delivering quality care to more people at an affordable cost.

Here's an example: With almost no public notice, two backbench Midwest Democratic representatives, Ron Kind of Wisconsin and Bruce Braley of Iowa, have added to the House bills a provision that would mobilize the intellectual resources of the Institute of Medicine (IOM) for the task of delivering "high-quality, evidence-based, patient-centered care."

Coached by several innovative clinics in his district, Kind told me he had been following for years the work of the Dartmouth Medical School group on regional disparities in medical costs. Braley had a similar grass-roots story:

"A doctor in Cedar Falls, Iowa, Jim Young, gave me a book called 'Overtreated,' by Shannon Brownlee. I highlighted (passages in) the entire book and then I abstracted it. It led me to the IOM reports, and I started hammering on them in meetings with the leadership."

The IOM is a prestigious part of the private National Academies. For the last several years, it has conducted a series of workshops and issued a number of reports on "The health-care imperative: lowering costs and improving outcomes," under the chairmanship of Dr. Denis Cortese, the president of the Mayo Clinic.

Kind and Braley's amendment would give IOM a mandate to recommend changes in Medicare pricing and delivery to the secretary of health and human services, who would forward them to Congress. If not disapproved within 90 days, the changes would go into effect.

Obama has suggested a similar action-forcing mechanism, with the recommendations coming from a presidentially appointed, five-member commission of doctors and other health-system experts.

A spokesman for the White House Office of Management and Budget says, unsurprisingly, it thinks Obama's plan is better. Braley and Kind disagree. But the competition of ideas is moving the legislation in the right direction. Now the job is to keep public opinion well-enough informed to save all this effort from foundering once again.

David S. Broder's column appears regularly on editorial pages of The Times. His e-mail address is davidbroder@washpost.com