Obama needs to tell some harder truths on health care

WASHINGTON — A great speech is a combination of words and music, of content and color, of substance and emotion. When the speech is as important as the health-care address that President Obama delivered to Congress on Wednesday night, it is worthwhile to go back and analyze the parts.

So after watching it live on TV, I replayed it twice, the first time shutting out the argumentation and focusing on the tone and body language, the elements that communicate most directly with the audience. Then I listened again, weighing the assertions and evidence.

On the first run-through, I was struck again, as so often during the election campaign, by Obama's ability to move an audience through his actor's skills. At various times he conveyed deep-felt concern, anger, determination, reasonableness and firmness. The overall goal was to re-energize a slumping initiative, to summon and convey the determination to act — and act now.

The keynote was simple and almost substance-free: "The time for bickering is over."

The reaction among his fellow Democrats was all that he could have hoped. They came off the mat, full of fight.

When I listened again, this time trying to tune out the rhetoric and trace the argument, the impression was strikingly different. For the first time I realized how far Obama has shifted from the proposition that marked his successful race for the White House.

Then, his great theme was "change we can believe in." Now, the message is "change we need not fear."

It is certainly understandable why he has shifted. This summer has been brutal to his hopes. A variety of doubts — some artificially fed by his opponents, others reflecting genuine questions about the costs and consequences of his reforms — have put the president on the defensive.

The classic response is to offer reassurance, to promise that nothing important to you, the voter, will be lost if Obama gets his way. The problem is that by emphasizing what will not change, the president inevitably reinforces the status quo.

Consider the two main promises Obama made. First, he said, to the millions covered by their employer plans, "Nothing in our plan requires you to change what you have."

That sounds reassuring. But the reality is that the health-care system is headed for crisis precisely because those employer-based plans are foundering. More are being canceled, and more of their costs are shifting to workers. They are a drag on the economy and a major factor in our loss of international competitiveness.

Obama knows we cannot keep what we have. This is why he is pushing to create insurance exchanges where families can buy their health coverage in competitive marketplaces that will help drive down costs.

But Obama does not tell people: "I want you to get used to the idea that eventually you may not get your coverage from your employer, and you will have to be a smart shopper, looking for the best deal you can get from competing insurance firms."

The second big audience Obama addressed was Medicare retirees. Again, his message to this crucial constituency was: Nothing will change for you. The reality is even more at odds with the rhetoric.

Medicare is going broke. Health-care costs are rising faster than the rate of inflation, and within years Medicare will add billions to the budget deficits. What is worse, Medicare is the main engine for subsidizing the most wasteful, inefficient system of health-care payments in any advanced industrial country. It rewards practitioners and hospitals on the basis of the volume of procedures, not on the outcomes for patients. And because its reimbursement rates are below actual costs, they drive hospitals and doctors to do more and more — just to pay the bills.

Again, Obama knows better. He knows that unless he can fundamentally reform Medicare, he cannot achieve his goals. He knows he has to move it toward the models of the Mayo and Cleveland clinics and the few communities around the country where networks of doctors and hospitals have committed themselves to high-quality, low-cost medicine.

But he is not telling people that Medicare must change, so members of Congress will be reluctant to take the first steps in that direction.

I realize that what I am asking Obama to do is really hard. He has justifications for taking the easier path of reassurance. But his promise as president was to do the hard things, the big things. I wish he would try.

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