You have to be of a certain age to remember David Stockman (fame being fleeting and all).  Back in 1980, Stockman was a young conservative Congressman from Michigan, a true believer in supply side economics, who became Ronald Reagan’s first OMB Director.  Stockman thought that he could shrink the federal budget by “curtailing weak claims instead of weak clients,” a phrase he coined at the time to allay fears that he would trim the budget on the backs of the poor.

But powerful entrenched special interests repeatedly thwarted his efforts to cut down on their federal gravy train, eliminating even the appearance of balance to the cuts the Reagan administration made to on federal assistance to the poor.  “The Education of David Stockman,” a candid 1981 portrait of his efforts and growing disillusionment that ran in The Atlantic Monthly, kicked up a political firestorm and landed Stockman in the Reagan doghouse. In the end, Stockman found out it was much easier to curtail weak clients after all.

Enter health reform.  In an effort to keep the cost of reform down, keep powerful special interests at the table and unable to agree on sufficient revenue sources anyway, Congress has deferred the start of most of the coverage provisions in health reform for three to four years. Mindful that this is a weakness in the proposal, both Congress and the Obama administration have been working to identify provisions that could begin to make a difference for people in the short-run without running up the price tag of the bill.  Most of what they’ve come up with is improvements aimed at helping those who are un- or under-insured as a result of a major medical condition.  Admirable as these provisions are, they’re no answer to the tens of millions of Americans who lack coverage not because of their health status, but because they simply can’t afford the premiums.

One exception is a little remarked-on provision that would require non-profit hospitals—recipients in billions of dollars in federal tax advantages—to be more transparent in their provision of charity care and set some modest limits on what hospitals can charge the uninsured (for instance, non-profit hospitals would be banned from charging the uninsured more than they charge the insured – a common practice now).  The provision, added by the Senate Finance Committee, has been non-controversial until now, but recently the powerful American Hospital Association has launched an effort to kill it.

In polling conducted by Lake Associates in November 2008, Community Catalyst found that an overwhelming majority of the American public support requiring non-profit hospitals to provide charity care to those who can’t afford it, be held to price regulations, and to communicate transparently with their communities about their policies–all provisions included in the Senate health reform bill. These are small measures with big impact, since charity care often means the difference between getting treated or going without for uninsured people with serious illnesses and conditions. The Institute of Medicine and other researchers have found that 20,000-40,000 people die every year from lack of coverage while millions more suffer from unnecessary illness and financial distress—facts cited on the floor by Congressional leaders to support reform.

And yet, the uninsured are still standing at the back of the line when it comes to reform. These mostly low-wage American workers are the very definition of a politically weak client group, but one with a powerful moral claim.  Will what little short-term protection that remains on the table for them survive the legislative sausage-making process, or will the lessons David Stockman learned once again hold sway?

–Michael Miller, director of strategic policy