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Coalition Building and Political Reality

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Charles N. Kahn III, M.P.H., President of the Federation of American Hospitals

Short of ensuring domestic security, no more vexing challenge confronts Washington policymakers than the ever-rising number of Americans who lack health care coverage. Study after study shows that those who lack health insurance are at greater risk of poor health, and that when the uninsured become sick, they frequently face financial stress.

Over the last several years, many people and organizations have been involved in what initially started as a "strange bedfellows" coalition of groups from across the economic, social, and ideological spectrum. This coalition was formed to drive consensus on our nation's most pressing domestic issue: the development of public policy to address the ever-escalating number of uninsured.

Of late, the Robert Wood Johnson Foundation, along with numerous health care and health care financing associations, business and labor organizations, and consumer and other advocacy groups have partnered to do yeoman's work raising public awareness about this urgent problem. I am proud to say that I have been part of this process for several years, both with the Federation of American Hospitals and previously as president of the Health Insurance Association of America. The process has enabled me to find common ground with an old adversary, Ron Pollack, the executive director of Families USA.

Although on many policy matters Ron and I retain different world views, we agree strongly upon two points. First, it is unconscionable that so many millions of low-income working Americans lack any type of health coverage. Not only is lack of coverage linked to poor individual health, providing care to those who cannot pay adds considerable stress to our health financing system. When the uninsured become sick, their health care costs must be shifted to taxpayers or the insured in the form of higher premiums.

Second, Ron and I agree that making progress to get public policy that brings more people under the coverage tent requires working through our current health care financing structure, which is a combination of private and public funding. Currently, government provides coverage to seniors and the disabled, as well as to the indigent, while private employment is the vehicle for coverage for most working Americans and their families.

Within this context, we need to find ways to help fund—either partially or totally—the health insurance costs for Americans who lack the wherewithal to purchase it and who do not receive it through the workplace.

Up to this point, it has been my belief that the best way to proceed on this front is to bring together people with varying ideas about health policy and to work within the current context. Within this scenario, people with different perspectives but with similar goals can compromise on some policy principles, avoid the perfect becoming the enemy of the good, and achieve consensus about developing policy to cover more uninsured Americans.

I still have great hope for this approach, and I remain committed to working with Ron, the Robert Wood Johnson Foundation, and others to make solving this problem one of our nation's top priorities. But after many years of coalition building and consensus development, the number of uninsured Americans continues to grow, dramatically. Rather than risk inactivity and allow this number to escalate, perhaps we should adapt this approach to better reflect current political reality.

Republicans, who control the White House and both Houses of Congress, dominate the current political landscape. Therefore, if health policy advocates want to see progress on the uninsured, we have to look to President Bush and the GOP majority to take the lead.

President Bush spells out his objectives in his 2005 State of the Union address. "To make our economy stronger and more productive, we must make health care more affordable, and give families greater access to good coverage—and more control over their health decisions," he noted. In doing so, the president cited several components of his health policy agenda, including tax credits to help low-income workers buy insurance, association health plans, and expanded health savings accounts.

These are the policy items currently on the political table that relate directly to providing coverage for the uninsured. Rather than trying to achieve a sufficiently broad consensus, there is a compelling argument to be made that, to begin reducing the number of uninsured Americans, we instead ought to reach for what is already within our grasp.

I recognize that tax credits and expanded health savings accounts are not the preferred policy approaches for some members of our "strange bedfellows" coalition. However, these are the approaches most likely to be approved by Congress. Given the rising number of uninsured Americans, we owe it to them, and to ourselves, to work to pass what can be passed, and then allow these approaches sufficient time to work.

Building coalitions and achieving consensus is eminently worthwhile, but to make progress, we also must consider political reality. If we want to be effective and implement public policy, we who are involved with building coalitions and achieving consensus cannot afford the luxury of being prisoners of process. Rather than working toward a grand public policy compromise intended to be palatable to all but with no political legs at this time, let us instead look at the policy items already on the table, and work to implement them and thereby help reduce the number of uninsured Americans.

Charles N. Kahn III, M.P.H., is president of the Federation of American Hospitals, the national advocacy organization for investor-owned hospitals and health systems.

The views presented in this commentary are those of the author and should not be attributed to The Commonwealth Fund or its directors, officers, or staff.

Publication Details



Coalition Building and Political Reality, Charles N. Kahn III, M.P.H., The Commonwealth Fund, March 2005