IN a democracy, citizens are supposed to decide the major policy questions - setting basic direction, though not becoming expert on programmatic details. The record shows that for all the fussing about their not paying enough attention, the people usually speak clearly when a great question is brought before them.
Today's debate over health-care reform is a critical one, involving a sector consuming roughly one-seventh of the country's gross domestic product (GDP). But it will set the course for the even larger question of government's role in the America of the early 21st century. Where we turn at this juncture will have enormous impact on whether government's reach expands or is restrained.
The health-care debate has proceeded in earnest for several years now. Many Americans are still fuzzy on important details, but they've rendered an overall verdict on health-care reform that is about as clear and decisive as anyone friendly to it could have hoped, or any critic feared.
The question now is whether policymakers will heed the public's call and have the wit to translate it into workable programs.
The debate began in the late 1980s in response to an escalation of health-care costs and all the insecurities that hike prompted. Claiming just over 5 percent of GDP in 1960, health spending reached 12 percent of the far-larger gross national product in 1990. The public demanded that costs be reined in and security extended.
Some policy entrepreneurs wanted to hear more than this - wanted a call for a greatly expanded federal role in directing the nation's health system. But the majority never issued it. Most people plainly wanted something done, but they had become increasingly skeptical about government's role and record. A question posed by CBS News and the New York Times in January 1993 captured this mood: ``Do you think that ... the federal government creates more problems than it solves or ... solves more problems than it creates?'' Only 22 percent chose the latter. An extraordinary 69 percent saw government creating more problems.
Late in George Bush's presidency, and on into the start of Bill Clinton's, the political advantage on health-care reform tilted toward the Democrats. Though doubting the wisdom of expanding government, a decisive majority thought that something needed to be done on health coverage and saw the Republicans as too comfortable with inaction. As the debate has proceeded, however, the partisan advantage has swung sharply back. The GOP has gained, at times, it seems, in spite of itself. The government-centered character of Democratic approaches became clear, and well-established general skepticism about government asserted itself. The public no longer sees the Democrats as clearly better on health-care reform.
For example, in a survey taken in mid-July by Yankelovich Partners for CNN and Time magazine, just 21 percent said the Democratic Party ``can do a better job of reforming the nation's health-care system,'' while 17 percent picked the Republicans as better, and 53 percent saw no partisan difference. This is an extraordinary shift from the general pattern, which gives the Democrats an advantage on social-service delivery, just as the Republicans get the edge in foreign policy and economic management.
Solid pluralities think the kind of health-care legislation Congress is likely to enact would increase costs - without improving the quality of service. A Los Angeles Times survey conducted late last month found that just 16 percent thought their own coverage would be better ``if Congress passes health-care reform this year.'' In contrast, 23 percent thought it would be worse and 53 percent thought that it wouldn't get any better, an astonishingly negative verdict.
It isn't surprising, then, that a large majority now wants Congress to take more time to think through just where to go. A late-July survey conducted by Hart and Teeter research companies for NBC and the Wall Street Journal found only 34 percent saying that ``Congress should pass a health-care-reform bill this year,'' while 61 percent said it should ``continue to debate the issue and act next year.'' Posing a similar question in June, Gallup found 56 percent opting for not acting this year. The administration faces ebbing public support.
Public opinion on health-care reform will continue to unfold. Americans want effective cost control and want to be assured that they will not be left in the lurch through layoffs or job changes, especially in coverage of catastrophic health expenses. But they've looked at the approaches pushed by the president and ranking congressional Democrats, and so far they've said no.
Proponents of a more government-centered approach can and should try to get the public to change its mind on this. But right now the majority's prescription is clear: The US should not put government at the center of its health-care delivery system.