Dr. Maccoby participates in a Weekly Forum on Washington Post.com called "On Leadership". I am compiling all of his responses to the weekly questions here.

Declining 'credibility capital'

Barack Obama came to office with a vision of raising the level of the national culture. By improving education, making the next generation technologically literate, investing in science and alternative energy, shoring up the national infrastructure, including high-speed broadband internet access for all, his administration would arm Americans to succeed in the competitive global economy. By providing health insurance to those who could not afford it, he would also take a large step to close the widening gap between rich and poor. But despite winning large majorities in Congress, Obama has found it extremely difficult to implement his vision. There are three main reasons why.

First, when Obama entered the White House, the economy was in shambles and he had to spend a big chunk of his "credibility capital" to pass a stimulus package that probably avoided a disastrous depression. In doing so, however, he increased the national debt, losing the support of some independent voters and, by saving the banks, losing some enthusiasm from the left.

Second, he knew he had to take on health care early, while he still had some political momentum and before Congress was focused on mid-term elections. But this is a complex issue, not just a matter of providing all Americans with insurance. Unless costs are controlled, Medicare is on a trajectory to bankrupt government. Adding appropriations to subsidize access to care without paying for them would be unsustainable and irresponsible.

Costs keep ballooning, in part, because the system is riddled with incentives to provide unneeded tests and medical interventions, while entrenched interests have leverage to continually jack up prices. Some in Congress have proposed new taxes to cover the added costs of subsidizing care. This, of course, increases opposition. But there are proven approaches to cutting medical costs and at the same time improving the quality of care. Some of these have been demonstrated at health care organizations like Intermountain, Mayo, Geisinger and Kaiser-Permanente, while others are spelled out in a white paper from the National Coalition on Health Care. But these solutions will take time to implement and will collide with interest groups.

Third, there are ideological pressures from both extremes of the political spectrum. The Republican leadership has decided they can gain from defeating any legislation and not allowing Obama the credit for achieving a policy that has eluded presidents for a century.

Obama has been wise to involve Congress from the start in shaping health-care legislation so the legislators would have some ownership of the policy and not be able to just reject a package they had no part in making. But even though the Democrats have a majority in both houses, they represent different ideological constituencies, and they will not agree on everything.

To keep his vision alive, Obama and his lieutenants in Congress should keep their focus on the elements essential to providing affordable and sustainable health care for all Americans. This will not be achieved in one bill, but the legislation should provide the incentives and regulatory structure that allows continual improvement.

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