Hope and weariness rise together in the hearts of the faithful as the 2008 election season begins, with de-escalation in Iraq open for debate and a barrage of serious-looking health insurance expansion proposals reverberating on the domestic policy front. In a culture of consumer gratification, it will be risky for politicians to raise the issue of cost control as the bidding on coverage progresses. But without a coherent strategy to restrain spending, universal coverage may represent an impractical quest to buy the nation into a system it really can’t afford.

Or such is the message of a new, devoutly bipartisan collection of essays from the Brookings Institution, Restoring Fiscal Sanity 2007: The Health Spending Challenge. The Clinton administration’s reform plan failed precisely because it attempted to fund expansions by reining in spending on those already insured, according to a chapter written jointly by Judith Feder, who served in the U.S. Department of Health and Human Services (HHS) under Clinton, and Don Moran, who worked in Ronald Reagan’s Office of Management and Budget (OMB). “Reluctance to disrupt Americans who have health insurance,” they write, “has inhibited most politicians.”

Pelosi’s health adviser on the budget. The budget debate currently picking up steam on Capitol Hill can curb public spending. But cutting Medicaid or increasing consumer cost sharing only shift costs onto new payers, observed House Speaker Nancy Pelosi’s chief health adviser, Wendell Primus, at a March 19 briefing on the new book.

Many promising strategies for tackling costs are on the table, Primus said, but none offer a big-bang solution, and most are not well enough developed for widespread implementation. “That’s why you can’t just sit a bunch of members [of Congress] around a conference table” to start making policy decisions now, he said. “We’re not ready.”

Real opportunities. Instead, an effort is needed “to grow a political center” large enough to overcome polarization and to proceed with a broad array of cost containment strategies in tandem. Authors in the Brookings volume seemed to agree on some of the most promising tools. They include research on the comparative effectiveness of treatment alternatives; experimentation with bundled payments for treatment episodes, rather than unconstrained fee-for-service payments that drive up volume; disease management; chronic care coordination; pay-for-performance; health information technology; and gain-sharing arrangements for physicians who manage costs effectively. None of them is a magic bullet, said coeditor Joe Antos of the American Enterprise Institute. But “there are real opportunities for system improvement,” he said. “Silver BBs.”