I’m talking about the health care bill, of course.
The people I tend to trust on these sorts of questions, such as Robert Reich and Paul Krugman (here and here respectively) say the bill does more good than harm, and sets us down a path towards further improvements later. They also point out, rightly in my view, that if this moment passes we will not have another shot at serious health care reform for quite some time.
The trouble is that Howard Dean is also pretty convincing when he writes
If I were a senator, I would not vote for the current health-care bill. Any measure that expands private insurers’ monopoly over health care and transfers millions of taxpayer dollars to private corporations is not real health-care reform. Real reform would insert competition into insurance markets, force insurers to cut unnecessary administrative expenses and spend health-care dollars caring for people. Real reform would significantly lower costs, improve the delivery of health care and give all Americans a meaningful choice of coverage. The current Senate bill accomplishes none of these.
Real health-care reform is supposed to eliminate discrimination based on preexisting conditions. But the legislation allows insurance companies to charge older Americans up to three times as much as younger Americans, pricing them out of coverage. The bill was supposed to give Americans choices about what kind of system they wanted to enroll in. Instead, it fines Americans if they do not sign up with an insurance company, which may take up to 30 percent of your premium dollars and spend it on CEO salaries — in the range of $20 million a year — and on return on equity for the company’s shareholders. Few Americans will see any benefit until 2014, by which time premiums are likely to have doubled. In short, the winners in this bill are insurance companies; the American taxpayer is about to be fleeced with a bailout in a situation that dwarfs even what happened at AIG.
Kevin Drum offers an impressive list of good things the bill does:
- Insurers have to take all comers. They can’t turn you down for a preexisting condition or cut you off after you get sick.
- Community rating. Within a few broad classes, everyone gets charged the same amount for insurance.
- Individual mandate. I know a lot of liberals hate this, but how is it different from a tax? And its purpose is sound: it keeps the insurance pool broad and insurance rates down.
- A significant expansion of Medicaid.
- Subsidies for low and middle income workers that keeps premium costs under 10% of income.
- Limits on ER charges to low-income uninsured emergency patients.
- Caps on out-of-pocket expenses.
- A broad range of cost-containment measures.
- A dedicated revenue stream to support all this.
An impressive list, and I could certainly support a bill that actually did those things. The trouble is that you know the insurance industry has already figured out how they are going to get around prohibitions against preexisting conditions and the like. The fact is that if there were anything in the bill that seriously inconvenienced the insurance industry, their shills in Congress would make sure it got stripped out before final passage. I think Drum is being a bit naive here.
Atrios with his customary style, cuts right to the heart of the matter:
The reason for thinking that without a public option or similar mandates are going to be a disaster is that without competition or sufficient affordability (due to not quite generous enough subsidies), you’re forcing people to buy shitty insurance that they can’t afford. Mandates aren’t bad in and of themselves, but they’re bad if they aren’t part of a comprehensive plan which is… good!
That sounds about right to me. The obvious counter, offered by Josh Rosenau for example, is that we already require people to buy car insurance:
The thing is, we do that already. To drive a car, you have to have insurance. We have an individual mandate for people to buy auto insurance. To my knowledge, there’s not a federal standard in place, nor subsidies to low-income drivers.
Hardly a perfect comparison. After all, you can opt out of the mandate by not driving. But as Atrios often observes, lots of people don’t have a viable option to avoid driving. So it’s a better comparison than it might first seem. Auto insurance isn’t perfect, but an individual mandate seems to do OK in that market, and this bill gives a lot more federal oversight of the insurance market, so there’s cause to think it’ll be better than auto insurance. At the very least, no discussion of the mandates in this bill should ignore the major mandatory insurance system
Sorry, but that’s a bad comparison no matter how many times you look at it.
For one thing, the moral case for requiring car insurance is a lot stronger than it is for health insurance. Why should you have to buy car insurance? Because other drivers need to be protected from you. Simple as that. You can do a lot of harm with a car, and there has to be some system in place to make sure you can pay for any damage you cause.
The only thing comparable to this with health insurance comes if you end up in an emergency room. Then all of us have to chip in to pay for your care. But to tell some twenty-something that he has to buy expensive health insurance because there is a microscopic chance he will end up in an emergency room hardly seems like an impressive argument.
Then there is the fact that the car insurance market is a lot healthier than the health insurance market. There is real competition among car insurers, and decent coverage is available at reasonable prices. Unless you are a truly rotten driver who is constantly causing accidents or racking up moving violations, you are not going to lose your insurance. Even the practice of automatically raising your rates after an accident is not so widespread as it once was.
By contrast, in many parts of the country, there essentially is only one health inusrance provider. The health insurance industry has also proven itself so unscrupulous in its business practices, that it is rather galling to force someone into it without ensuring that there is competition in the market.
And then there is simply the fact that this analogy is completely unresponsive to Atrios’ argument. That we force people to buy car insurance hardly implies that it is acceptable to force people to buy health insurance. As it is this bill places a huge financial burden on a lot of people who can not afford it. Don’t expect a lot of gratitude from them for “solving” their health insurance problem.
The fact is that a mandate without any serious measures to curb the worst excesses of the health insurance industry is repugnant. The benefit of broadening the insurance pool to spread out risk hardly seems like an adequate counter to this simple fact.
So what about the question in the title of this post? My answer is no. In the end, as awful as this bill is, I have to side with Krugman and Reich. The argument I find most convincing is that you have to pass something to get your foot in the door for future reforms. If the bill dies, that is it for health care reform for a good long time. Pass the bill, which does do some good things along with its more deplorable parts, and you establish the basic idea of universal health insurance. It will be pretty hard for future Republican majorities to take it away.
Of course, this could all be moot. Even if the bill gets out of the Senate it still has to go to committee. You could well have enough progressive members of the House willing to say they are not going to vote for a bad bill, political consequences be damned, to kill the bill in the House. A bill that is progressive enough for the House could be unpassable in the Senate, and a bill that could pass the Senate might be too right-wing for the House.