I have read Jon Walker’s answers to Nate Silver’s “20 questions for bill killers,” and I don’t find them very convincing. Many of them — like the ones about the likelihood of getting a better bill through reconciliation — are based on little more than wishful thinking.
Kevin Drum is blunt about this:
But there’s one argument that I find perplexing. Here’s Howard Dean:
This is essentially the collapse of health care reform in the United States Senate. Honestly the best thing to do right now is kill the Senate bill, go back to the House, start the reconciliation process, where you only need 51 votes and it would be a much simpler bill.
Here’s what I want to know: which one of us is living in dreamland? If you don’t like the Senate bill, fine. Don’t support it. But in what universe will healthcare reform get revived anytime soon if it dies this year? 2010? With the legislative plate already jammed, healthcare reform probably polling in the mid 30s, and midterms coming up? 2011? After Republicans have gained a bunch of seats in both the House and Senate thanks to public disgust with Democratic disarray? 2012? A presidential election year? 2013? 2014?
I have more sympathy for Walker’s opposition to the individual mandate (not because, as rightists claim, it’s unconstitutional, but because without the public option there is not enough help for people who would not be able to afford private insurance). Walker writes more about the insurance coverage requirement in a separate post:
Without the option of a government-run insurance entity or extremely tight regulations to guarantee everyone has access to quality, cost effective health insurance, an individual mandate is both immoral and bad policy. If the Senate refuses to provide Americans with the guaranteed choice of decent health insurance policy, it must not mandate people buy insurance. No public option, no individual mandate.
There are two ways that industrialized nations have achieved universal health care. The simplest is for the government to collect money through general taxation and use that money to directly provide everyone in the country with basic health care or health insurance. This includes single payer and socialized health care systems like the UK, Canada, Sweden, and Denmark.
The other way to achieve universal health care is with a strong social contract between the government and the people. The government promises to ensure that everyone has access to decent, effective, affordable health insurance, and, in exchange, the people agree to accept a mandate that they must acquire health insurance. The government does this by placing serious regulations on insurance companies and the rest of the health care industry. The government ensures everyone can afford a good health insurance plan. Normally, most individual are provided with generous subsidies to help afford health insurance and/or employers are mandated to help their employees pay for health insurance. This is how countries like Germany, the Netherlands, and Switzerland run their health care systems.
The current Senate bill only creates a sham imitation of these systems. This bill completely fails to uphold the government’s end of this social contract, but would still force Americans to buy expensive, poorly regulated, junk insurance. Insurance policies would only be required to have an actuarial value of 60 percent, a shockingly low number. …
This is a cogent and eminently fair argument, but Ezra Klein’s counterargument makes sense to me as well. The individual mandate, he writes, functions as a sort of pressure valve to keep costs down (emphasis is mine):
Kill the individual mandate and you’re probably killing the bill, too. The mandate is what keeps average premium costs low, because it keeps healthy people in the insurance pool. It’s why costs have dropped in Massachusetts, not jumped. It’s why every other country with a universal health-care system — be it public or private — uses either a mandate or the tax code. It’s why the Obama administration flip-flopped.
But maybe you’re willing to ditch universality. Add some subsidies, leave the mandate, and it’s a step forward, right? At least until the project is consumed by an insurance death spiral? And Congress will surely do something to stop that, right? Well, maybe.
Kill the individual mandate and you make it easy for Congress to let the country backslide to its current condition. In a world with an individual mandate, insurance has to be affordable. If it’s not, there’s a huge political backlash. That gives Congress a direct incentive to focus on cost. Remove the individual mandate and … eh. If insurance isn’t affordable, people simply go uninsured. It’s exactly what happens now. Same incentives, or lack thereof, to make the system better.
Yes, Obama rightfully should get the blame for putting Democrats in this horribly compromised position (although Lieberman remains a disgusting shill for the insurance industry who prefers to please CEOs and lobbyists, and stick it to the Democrats, than support an already greatly weakened bill that could save thousands of lives a year). But, as Paul Krugman wrote today, we cannot let bitterness, disappointment, and anger keep us from doing the right thing. Here is how he put it:
There’s enormous disappointment among progressives about the emerging health care bill — and rightly so. That said, even as it stands it would take a big step toward greater security for Americans and greater social justice; it would also save many lives over the decade ahead. That’s why progressive health policy wonks — the people who have campaigned for health reform for years — are almost all in favor of voting for the thing.
… As Ezra Klein pointed out a few weeks ago, we’re basically in a hostage situation: progressives really, really want to cover the uninsured, while centrists whose votes are needed can take it or leave it. So the centrists have a lot of power — which in the case of Joe Lieberman means the power to double-cross and indulge his pettiness.
Now, in a hostage situation there are times when you have to just say no — when giving in, by encouraging future hostage-takers, would be worse than letting the hostages perish. So the question has to be, is this one of those times? I don’t think so, given the history: as Kevin Drum points out, health reform has come back weaker after each defeat. I’d also point out that highly imperfect insurance reforms, like Social Security and Medicare in their initial incarnations, have gotten more comprehensive over time. This suggests that the priority is to get something passed.
By all means denounce Obama for his failed bipartisan gestures. By all means criticize the administration. But don’t take it out on the tens of millions of Americans who will have health insurance if this bill passes, but will be out of luck — and, in some cases, dead — if it doesn’t.