Kill the Bill!

I don't know how the Republicans do it. Sure, as an opposition party they've had little more to do this year than periodically consult the “Fuck Off” section of the thesaurus, but even when they were charged with the task of actually running the government not so very long ago, they made this whole business of policy-making look pretty easy. With the efficiency of a lightly regulated market, they were able to turn both chambers of Congress into well-oiled factories of catastrophic legislation. Even taking into account their post-midterm attempt at Social Security, I can't think of any major piece of legislation, 2000-2008, that made the party that particular party in power look quite so inept, divided, and easily manipulated as the Democrats look right about now as they squabble over the remaining uncompromisable remains of the healthcare bill. And this is still Obama's first year. And in principal, we have 60 senators.

That isn't to say that I do not understand the current dilemma. Progressives, Liberals, the remaining wing of the Democrat Party that has not yet disgraced itself—whatever you'd like to call the political community that wants to see meaningful reform of the American health system pass—is divided between those that have by now completely worn out the expression about the perfect being the enemy of the good and those that scratch their heads wondering where this allusive “good” might be found.

One of the easy things about being a progressive spectator of American politics, and something that usually leaves matters uncomplicated for lazy and relatively uncreative political minds such as mine, is that it is usually very easy to discern which is the right side of a debate with a cursory glance at the roster of pundits and politicians on either side. If you find yourself in the company of mustache-twirling oligarchs and the clinically retarded, you're conclusions may need rethinking.

But this debate is different. On the side of the self-proclaimed realists sit, to name a few, Paul Krugman, Ezra Kline, and Congressman Anthony Weiner. Occupying the not-good-enough camp, on the other hand, stand the likes of Howard Dean and Wendell Potter. These are all people with whom I usually agree and, in any event, respect enough to entertain their ideas. And so, before justifying my own thinking on this issue, I'll provide the caveat that I have by no means heard, listened to, or watched all the available analysis, that my mind is open to the notion of its own analytical shortcomings, and that, it goes without saying, I would love to hear what everyone has to say either in response to this post specifically or on the topic in general.

Having said all of that, I think the bill is horseshit. On Thursday, Paul Krugman wrote the following:

At its core, the bill would do two things. First, it would prohibit discrimination by insurance companies on the basis of medical condition or history: Americans could no longer be denied health insurance because of a pre-existing condition, or have their insurance canceled when they get sick. Second, the bill would provide substantial financial aid to those who don’t get insurance through their employers, as well as tax breaks for small employers that do provide insurance. (NYT)

Let me address the first point. As I'm sure many of you have already read, while outright discrimination from coverage of the elderly and those with preexisting conditions is indeed banned (and a big hurrah for that), insurance companies will not be prohibited from charging exorbitant rates to compensate themselves for the mandated assumption of that additional risk. This much should seem obvious: force a company to provide a good or service that it refuses to otherwise provide and, in the absence of additional competition or sufficient regulation, that company will demand a higher price. And while I may be overstating the point in this case (there are caps on how much a given insurance company can charge older patients and patients with certain common pre-existing conditions), at 300% and 50% above the average respectively, these provisions do not at first glance seem tight enough to prevent an ever-increasing number of high-risk American from falling into bankruptcy and poverty.

On Krugman's second point, the issue of financial assistance strikes me as a kind of band-aid over a fundamentally flawed and unsustainable system. Rather than the government providing health insurance directly to the public or at least making a government-sponsored option of some kind available to those who wish to buy-in, the best the bill has to offer is that it will spend hundreds of millions of dollars of tax revenue in order to help the uninsured purchase coverage at higher, private-sector prices. In doing so, the government will be spending more money on less (and certainly less reliable) coverage, a substantial portion of which will end up as private profit, rather than supplying the insurance directly at the lower prices that not any non-profit institution, but the biggest one around, would be able to provide. Don't get me wrong, I am glad that financial aid is included in the bill. But the fact that it needs to be included at all—that a bulk of the American population will not be able to buy insurance themselves and that there will be no government option made available to them—strikes me as a reason to reject and not endorse the bill.

Most insulting of all is the argument that with the mandate to purchase coverage, the United States will for the first time and at long last achieve universal healthcare. I don't think I need to elaborate on this point except to say that delivering a captive market to an increasingly concentrated industry without providing additional competition (and in some cases provoking further concentration) or price restrictions is not what most advocates of universal coverage had in mind.

As I see things, the strongest argument that supporters of the bill in its current form offer is a political one. Bernie Sanders made the case on Countdown the other night:

We’ve all got to deal with the reality that if this bill goes down, what does it mean politically in this country. When is the next time legislation is going to come up which will increase health care reform for 30 million people, provide insurance, deal with some of the major abuses in terms of pre-existing conditions. (ThinkProgress)

On a similar note, Krugman draws the familiar analogy to messy conception of Social Security:

Thus Social Security originally had huge gaps in coverage — and a majority of African-Americans, in particular, fell through those gaps. But it was improved over time, and it’s now the bedrock of retirement stability for the vast majority of Americans.

I understand, even sympathize, with this point of view. Legislative imperfection ought to be tolerated if it means getting a foot in the door. But based on my reading of the bill, the analogy is inappropriate. As awful as racial discrimination obviously is, the failure to provide black Americans with social insurance did not contradict or undermine the stated purpose of the institution of Social Security as a whole. The basic function of Social Security is to deduct contributions from the wages of current workers to pay the entitlements of the retired. That this mechanism was initially only available to white Americans is morally inexcusable, but from either a political or practical perspective, that exemption did not undermine the solvency or effectiveness of the system for its participants.

My worry is that in passing a bill that expands coverage without providing a release valve on either household costs (with increased competition of some kind, pricing caps on providers, or strict premium guidelines) or long-term debt growth (changing the way which Medicare pays for care, allowing younger and statistically less risky American to buy-into a government program), the Democrats will not only produce a piece of legislation that fails to adequately address (and perhaps exacerbates) many of the ills of the American healthcare system, they will undermine the credibility of the entire party and of all those who call for healthcare reform in the future. In other words, bad policy will translate into bad politics which, of course, means worse policy. I worry that this bill will not be a necessary baby-step in the right direction, but a substantial leap backwards.

Everything I've said so far strikes me as obvious, but then again, ideas tend to seem perfectly rational and well-thought out when they're coming out of your own mouth. And so here's to hoping that I am wrong, that I'm missing a key aspect of the legislation, that the Democratic Party really is on the verge of passing something great, and that Obama, who has all along seemed so deliberately fixated on snatching back meaningless legislation from the jaws of reform, is actually half the statesman he promised to be in 2008.