The Washington Post Column

Medicare: Malaise…

Last week I spent the better part of two days trying to understand the Medicare bill. I called up the bill’s advocates. I called up the bill’s critics. At one point, I read the advocates’ declarations over the telephone to one of the critics. Then I rang up an advocate and asked him to respond to the critic’s criticisms, and so on. There was a reason why I went to so much effort. At issue, I had discovered, were not merely interpretations of the facts but the facts themselves. More distressingly, I also realized by the end of the two days that some of the people making vigorous arguments for and against the bill were not absolutely sure what it contained. Nevertheless, the U.S. House of Representatives duly passed the bill in the wee hours of Saturday morning, and the U.S. Senate followed suit. Now we have a Medicare reform law. And now Congress, along with the rest of us, can start figuring out what it says.

Is this a scandal? Most people around Washington seem to think not. One senior administration official pooh-poohed the very notion, pointing out that every one of the measures contained in the bill had been kicked around Capitol Hill for years: “We’ve been talking about this stuff for a decade.” Yet it is also true that the actual details — the level of the premiums, the design of the programs, the manner in which private companies are supposed to run the new drug benefit — were all worked out in the backrooms of the Capitol in the hours before the House voted on its passage. The uncertainty was enough for one former Republican health care official, a veteran of that decade of debates, to respond quite succinctly when I asked for a general opinion: “I don’t know.”

Others say that this is nothing new, which is also true. Congress has always liked passing vast pieces of legislation containing umpteen provisions designed to benefit all kinds of unrelated causes. Nevertheless, the nature of this bill — which will cost at least $400 billion over the next 10 years, which some officials think could cost as much as $2 trillion in the following decade, and which will have profound effects on our nation’s health — does seem to demand something more than a few hours of heavily partisan Senate debate and even less in the House. A month’s worth of public discussion, say, on television, on radio shows, in newspapers, in local legislatures, would have been more like it.

Yet I can’t imagine how that could have happened, and neither can anyone else. In part, the nature of the closely divided Congress precludes it: Republicans were so desperate to pass this legislation before anyone changed his or her mind that they preferred to keep all potentially controversial details suppressed until the last possible moment. In part, the deeply unideological nature of the subject precludes it too: Although many people talk of Medicare reform as if the argument were simply about “the free market” as opposed to “the state,” all of the proposed reforms in fact contain elements of both. Even traditional Medicare operates by paying set fees to doctors who are not state employees. That’s different from the way state health care works in other countries. As a result, the arguments for and against various reforms do not necessarily sort themselves out into neat “right” or “left” packages, as much as everyone would like them to.

But in part, I wonder whether something else is happening too. It’s as if we as a nation have lost our appetite for grand domestic policy debates. We have extended, national conversations about the fate of O.J. Simpson or Rosie O’Donnell, and after Sept. 11, 2001, we rallied around the flag. But only twice, in recent memory, have we come together as a nation and vigorously pushed Congress to act on an issue of mass public concern. The first time, it was to pass a “Do Not Call Me at Home” law. The second time it was to pass a “Do Not Spam Me” law. As a nation, we adamantly reserve the right not to be hassled. As for everything else that Congress does — it seems we are perfectly content not to know about it until the shouting’s all over.