Just Because Things Should Be Totally Different Doesn’t Make Incremental Reform a Bad Idea
This Atlantic article on our badly broken health care system by David Goldhill is very good. It makes the case, correctly, that the entire health care system should be totally different from how it is. I agree with a lot of it. But I think Goldhill is deploying his insights to the pretty insidious purpose of arguing against the kind of health reforms that now exist in the congress. The simple fact of the matter is that defeating the current reform effort is not going to lead to the emergence of some alternative, radically different health care reform. Defeat of the current legislative effort will demoralize proponents of health reform, teach politicians that any talk of modifying Medicare is politically toxic, and basically result in another 10-15 years of the status quo followed by some kind of budget crisis.
Passing the kind of ideas that are currently on the table would still leave us with a system with a lot of problems. But it would ameliorate several of those problems, and solve a few. It would also, I think, teach politicians the lesson that it’s possible to change the health care system. And that might lead to more and better reforms down the road.
76 Responses to “Just Because Things Should Be Totally Different Doesn’t Make Incremental Reform a Bad Idea”
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August 16th, 2009 at 2:38 pm
Only if there is a strong public option.
Without that, it would be better to organize primary challenges for those that oppose substantive reform.
August 16th, 2009 at 2:48 pm
Hey BigY, you left out the part where it would CREATE a few problems and make us worse off than we are now.
August 16th, 2009 at 2:57 pm
Not unless BHO and his team — and supporters like MY, Benen, and Ezra — admit the strategy was fucking wrong from the beginning. And swear that future initiatives will NOT utilize the same approach.
In fact, without a mea culpa, passing what is “currently on the table” would do exactly the opposite: teach politicians and the right that change can be easily thwarted by a minority of crazies.
If Grassley and Enzi are still his buddies, if we’re going further down this fruitless bipartisan path, we must expect the same results across the board.
August 16th, 2009 at 3:01 pm
If the left is willing to fight for the public option, the easiest path for the WH will be to include the public option in the final bill.
If the left isn’t willing to fight for the public option, the easiest path for the WH will be to drop the public option in the final bill.
This WH likes the easiest path.
August 16th, 2009 at 3:06 pm
“passing what is “currently on the table” would do exactly the opposite: teach politicians and the right that change can be easily thwarted by a minority of crazies.”
I think it’s far worse than that.
Passing what the Senate Finance Committee is working on into law would teach this WH that they should spend the next seven years ignoring the left.
—–
Today’s revelations are a trial balloon, folks. Whether it flies or gets shot down will determine a lot.
Folks like Yglesias are going to lie like crazy to get it to fly, but the left ought to shoot it down.
August 16th, 2009 at 3:09 pm
I see Obama is going to give up Dem support in exchange for no Republican support:
http://news.yahoo.com/s/ap/us_health_care_overhaul
The more things “change,”…
And, what Petey said.
August 16th, 2009 at 3:12 pm
And, of course, the public option is incremental reform.
The public option was explicitly designed to scale up very gradually to avoid disrupting “stakeholders” in the short-term. That’s precisely why it’s passable if folks are willing to fight for it.
Yglesias isn’t in favor of incremental reform. He’s in favor of destroying reform and passing “something”. He doesn’t care about practical healthcare reform, he just cares about getting good optics for the WH.
August 16th, 2009 at 3:14 pm
The purpose of Congressional health care reform is to get Congress more practice? Pretty tortuous logic.
August 16th, 2009 at 3:19 pm
The public option is a good idea, but is an incredibly oversold policy. There’s no way that the public option will do much to control costs or lead to single payer, unless it was explicitly structured to do so. For instance, if employers were allowed to use the public option, instead of just individuals in the insurance exchange.
The logic of how you pass reform has always been that insurance companies won’t fight hard against community rating, guaranteed issue, consumer protections, etc. IF you also create a mandate on individuals and employers which will make their business secure.
If insurance companies feel reform will make their business less secure, they’ll fight like hell against the whole package. That means no public option that will end up enrolling more than a few percent of the public.
Support for reform has sunk because of a few lunatics screaming at town halls and a few e-mail chains about death panels. If the insurance industry decides they really want to kill reform, it’s dead.
August 16th, 2009 at 3:20 pm
All roads to “more and better reforms down the road” lead through the public option. And if we don’t get one now, it might easily be another 45 years before we get another chance.
For crissakes, I can’t believe we are actually losing to these “deather” lunatics. But look, if Obama wants us to come out and fight for health care reform, he’s got to promise reform worth fighting for. That means a public option. Nobody’s going to take to the streets to fight for co-ops.
August 16th, 2009 at 3:21 pm
I view the Goldhill article as a classic example of concern trolling. Thanks for noticing what public health experts have been complaining about for years; how do we actually get those changes implemented?
Shorter Goldhill:
If cap-and-trade hits the Senate I expect another article complaining that we shouldn’t bother limiting emissions until China, India, and Tanzania have done the same…
I had always viewed McMegan as the master of the concern-troll but Mr. Goldhill is showing real potential.
August 16th, 2009 at 3:23 pm
I can only imagine what you think a “strong public option” would be. And it was never on the table.
I am utterly baffled and dismayed by comments like this. The public option was never going to be anything more than a publicly run insurance company that would offer coverage at comparable premiums to the private insurers for those relatively small minority of people who couldn’t get coverage either through their employers or Medicare/Medicaid.
It wasn’t going to be insurance coverage for free or even at lower cost than the private insurers offered. It was intended to be revenue neutral. It was a market-oriented solution to the possible problems of some unforeseen and not-immediately-correctable breakdown of private insurance availability (or choice) and, primarily, to serve as an example lest the private insurers claim that they can’t provide the mandated coverage at the mandated cost. As was oft-stated, it was intended to keep the private insurers “honest”. It was not intended to be anything more than that. And there are more direct ways of keeping the private insurers honest.
They bitterly have opposed it because it necessarily means a smaller slice of the pie. But, more to the point, they oppose it because of that “example” part. With all the mandates by reform, you can bet your ass that private insurers will be complaining to Congress that they can’t insure these people in the private market, charging mandated small premiums and providing mandated expansive coverage. The “revenue neutral or positive” aspect of the public option is explicitly designed to be an answer to their complaints. If it were the giveaway that so many uninformed supporters of the public option thinks it is, then it wouldn’t in any way refute the private insurers complaints.
Indeed, insurance companies have been attacking it as if it were going to be a giveaway…that’s the basis of their complaints that they wouldn’t be able to compete against it. But this has been lies just as so much other things they’ve been claiming have been lies. The public option has always been intended to compete with private insurers on a roughly equal footing. The people writing the bills and the people who know better who have been supporting the public option have been saying this repeatedly.
In theory, if the system runs as it is intended to run, then an individual consumer of health insurance won’t see a difference between the publicly run insurer and the privately run insurer. Would the public option ensure this outcome? That’s a matter of debate and speculation. More than anything, the existence of the public option in this context is a political argument—and there’s no guarantee that it would be effective. It would take political capital to utilize its existence to answer private insurer’s complaints, and it will take political capital to answer their same complaints in the absence of a public option.
Meanwhile, all this will affect only a small portion of Americans. The bulk of the bills under consideration massively reform the insurance industry in ways that will affect almost every health care consumer.
More than anything else, this is health insurance reform and it’s never been anything other than this. It in no way is designed to dismantle the private health insurance market—indeed, it is designed to preserve it.
You or I may prefer a single-payer system or even a nationalized system, but those were never on the table and have no chance of being passed in the current environment (which is more favorable to health care reform than it has been in generations—so don’t hold your breath for that opportunity for single-payer).
Are people like you not aware that the private, individual insurance market (in which the public option is intended to compete) will be utterly transformed by the proposed reform? People at another site were talking as if the lack of the public option meant that someone who couldn’t get insurance through their employer will only have the choice of paying enormous, unaffordable premiums to a variety of private insurers. But that’s not the case. And if it were the case, the public option would be just as expensive because that’s how it’s been designed. At any rate, it won’t be expensive. And people will be able to get it, even if they have pre-existing conditions. There won’t be huge deductibles in coverage. There won’t be low caps on coverage. With the reform, even without the public option, people who need this sort of coverage will be much, much better off than they are now. But you want to oppose this because it lacks the public option? What kind of progressive calculus is that?
It means the status quo simply because of the absence of the public option. It means that the 50 million Americans without coverage will still have no coverage. It means that people will still suffer from recission of their coverage, of denial of coverage for pre-existing conditions, of enormous CORBA premiums and enormous private individual coverage premiums. This is the status quo you are willing to preserve if the reform doesn’t include the public option.
In my opinion, this position is as morally obscene as those of the right-wing oppositions to reform. It’s ill-informed, hysterical, and very likely putting partisan politics ahead of public health.
August 16th, 2009 at 3:29 pm
“For crissakes, I can’t believe we are actually losing to these “deather” lunatics. But look, if Obama wants us to come out and fight for health care reform, he’s got to promise reform worth fighting for.”
The “deather lunatics” have been a sideshow.
This WH had decided to go with the Senate Finance Committee’s “Gang of Six” in June, well before anyone had thought of the idea of “death panels”.
This summer has been about the WH doing its worst to marginalize the left on healthcare.
—–
Does anyone ever bother wondering why Obama told folks like Billy Tauzin to negotiate with Max Baucus instead of with Henry Waxman?
I didn’t think so.
August 16th, 2009 at 3:29 pm
What seems to be missing from the critique from the left is the acknowledgment that any reform will not simply be reformative, but actually revolutionary. It may not feel like that, and for a great many it feels like a sell-out. Mayhap it is, but I would argue that getting ‘any’ bill passed will be a miracle, because so many people are absolutely dead set against any health care reform.
Why? Money and particular ideas about government. Health care is exceptionally cash rich for the insurance industry, and thus they will never embrace reforms. Conservatives would love to simply admit that they would dismantle Social Security, Medicare and Medicaid if they could, but they can’t, thus they will fight that fight on this battlefield. Much easier to stop something than to revoke it.
Thus, any bill that passes will be startling. Like the Milwaukee Brewers winning the World Series. Many on the left have let the perfect become the enemy of the good (or even just the okay). No, it is not what we want, but we have to start understanding that getting the foot in the door is a major victory.
We can insist on all or nothing. Guess what we will get as a result? Right. Rush (the band) would have a better chance of getting into the Rock and Roll Hall of Fame than a pure, progressive health care reform bill has of being passed, or even getting out of committee.
I know it is all sorts of unsatisfactory, but you have to win the battles when you can, and with whatever gets you over the line. Practicality sometimes must win the day. (For those thinking I am simply an Obama apologist – nay – I really wanted Feingold to run.)
August 16th, 2009 at 3:29 pm
“The purpose of Congressional health care reform is to get Congress more practice? Pretty tortuous logic.”
There’s a reason why it took Democrats so long to agree to touch the idea of health care reform after the 1994 debacle. Political failure has consequences.
If this thing goes down, it will probably be, as Matt said earlier, that the conservative movement successfully positioned themselves as the protectors of lavish Medicare benefits. If it becomes political lesson from this year is that Medicare will tolerate no cuts, even in spending that is clearly wasteful, we’re going to continue on the unsustainable health care status quo, and we are headed towards a budget crisis. Passing a half assed reform will be a much better outcome.
August 16th, 2009 at 3:31 pm
“I can only imagine what you think a “strong public option” would be. And it was never on the table.”
Well, you can’t imagine it because you’re a fucking idiot, Keith M Ellis.
A “strong public option” was in the healthcare reform bills passed by three House committees and one Senate committee.
It’s not only “on the table”, but it’s actually passed out of committee multiple times this summer.
August 16th, 2009 at 3:34 pm
“Rush (the band) would have a better chance of getting into the Rock and Roll Hall of Fame than a pure, progressive health care reform bill has of being passed, or even getting out of committee.”
Good, progressive healthcare reform bills have been passed by three House committees and one Senate committee this summer.
It’s only the Senate Finance Committee (under instructions from the Obama White House) that have been unwilling to bring a bill forward.
August 16th, 2009 at 3:43 pm
The goal of the GOP here is to kill reform. Death by a thousand cuts. First end-of-life counseling (something they all voted for in ‘03); then the public option; and Murtha now making noises about delaying the legislation until January or later, virtually assuring it won’t pass.
The problem, Matt, is that you and Ezra are young. You haven’t seen this movie a million times; and Petey and the rest of us have. Just a couple of weeks ago on PBS Ezra declared unequivocally there would be some form of public option in the final bill. If the public option is gone (as it most assuredly is at this point), then he looks like a moron for saying such a thing on tv.
If anything passes, it will be less-than-modest; and don’t think the Republicans won’t change the law once they improve their margins in both chambers next fall. Depressing.
August 16th, 2009 at 3:49 pm
“What seems to be missing from the critique from the left is the acknowledgment that any reform will not simply be reformative, but actually revolutionary … I would argue that getting ‘any’ bill passed will be a miracle”
Spoken like a genuine shill.
It doesn’t matter whether the bill is good or bad. All that matters is the appearances of passing a bill.
You must have absolutely loved the Bush WH’s Medicare bill in 2003.
Who would’ve thunk that Billy Tauzin would be responsible for two “healthcare reform” bills in the same decade under Presidents of two different parties. Pretty amazing.
August 16th, 2009 at 3:49 pm
Rush (the band) would have a better chance of getting into the Rock and Roll Hall of Fame than a pure, progressive health care reform bill has of being passed, or even getting out of committee.
Also, thanks to Rock Band, Rush’s popularity has been soaring, and prog is no longer a dirty word — extremely proggy bands like the Dirty Projectors have become critical darlings. I would not be at all surprised to see Rush inducted into the R&RHOF within the next few years.
August 16th, 2009 at 3:50 pm
This piece softens the blow for the White House abandonment of public plans.
http://news.yahoo.com/s/ap/20090816/ap_on_go_pr_wh/us_health_care_overhaul
Over on TP Rep. Meeks describes corporate sponsored Congressmen. Many of the For-Profiteers sit on the Senate Finance Committee, the one’s pushing co-ops in place of government provided option. Corporacrats already won, at least BusinessWeek thinks insurers have reform in the bag.
August 16th, 2009 at 3:50 pm
If a strong public option doesn’t pass, then I support only politicians who vow to support Medicare-for-all next election.
August 16th, 2009 at 3:50 pm
“In my opinion, this position is as morally obscene as those of the right-wing oppositions to reform. It’s ill-informed, hysterical, and very likely putting partisan politics ahead of public health.”
The “public option is the key to reform” crowd coincides with the “anything less than single payer isn’t universal” crowd almost exactly. The latter misconception probably arises because due to common language, most progressives are aware of the Canadian and British examples of universal health care, but not the Swiss, German, and Dutch examples.
I’ve heard some talk about how Obama is supposedly scaling back his proposals by pushing for “health insurance reform.” Like you said, that’s all his proposal ever was. And nonetheless if it is passed, it will be by far the biggest liberal policy advance in 40 years.
Yes, you can get to universal health care if for once you agree to regulate the private insurers and come up with the damn subsidies. Look closely at Switzerland, because what’s being proposed is very similar to that model.
August 16th, 2009 at 3:52 pm
Petey says,
As much as I disagree with Matt on his point about punting when it comes to a strong public option, I don’t think it’s fair to say he’s arguing in bad faith (which is what you’re doing, Petey). I think Matt sincerely believes that getting something like the finance committee’s bill through the Congress is better than nothing. You and I disagree with him, but it doesn’t mean he’s a cynic or a mere White House cheerleader.
August 16th, 2009 at 3:55 pm
“Just a couple of weeks ago on PBS Ezra declared unequivocally there would be some form of public option in the final bill. If the public option is gone (as it most assuredly is at this point), then he looks like a moron for saying such a thing on tv.”
I’ll repeat that the WH is sending up a trial balloon.
If the left is willing to fight for the public option, the easiest path for the WH will be to include the public option in the final bill.
If the left isn’t willing to fight for the public option, the easiest path for the WH will be to drop the public option in the final bill.
This WH likes the easiest path.
August 16th, 2009 at 3:59 pm
Again Matt is talking like a politician or a “strategist” hack, not a journalist or an independent blogger. Jennifer Palmieri is back?
August 16th, 2009 at 3:59 pm
… And if the public option is the final bill, it might end up covering 2% or so of the public, and won’t be anything like the “stepping stone to single payer” that many progressives seem to be counting on.
The “strong public option” was always going to be limited to individuals in the insurance exchange, which will only be available to people who can’t get employer-provided insurance.
August 16th, 2009 at 4:00 pm
“You and I disagree with him, but it doesn’t mean (Matthew is) a cynic or a mere White House cheerleader.”
Dude. He’s on CAP’s payroll.
I think he’s 100% wrong on how to play this issue and think he’s a cynical White House cheerleader.
August 16th, 2009 at 4:09 pm
Senator Kent Conrad said:
“The fact of the matter is there are not the votes in the United States Senate for a public option. There never have been,” Conrad said on “FOX News Sunday.
Corporacrats win.
http://politicalticker.blogs.cnn.com/2009/08/16/democratic-senator-public-health-insurance-option-dead/
The crappiest job in the world has to be being a CAP apologist.
August 16th, 2009 at 4:13 pm
This is a very revealing comment. And: fuck you.
There’s a whole lot of things wrong with Part D. But it means prescription drugs for people like myself and my sister—both disabled and on Medicare because of a genetic condition—when we otherwise would have either gone without or spent a large portion of our incomes on them.
That the millions of people with Medicare can now get much-need drugs that they previously couldn’t afford is an unqualified good thing. It means better health and much less suffering.
But, hey, it was an ugly compromise with lots of giveaways to the insurance companies. Therefore, in the opinions of moral cretins like yourself, it was a bad thing that is worse than nothing. Just like the current reform without the public option (which, you ignorant fuck, in any of the bills wouldn’t have done any more than I wrote that it would have done).
Yeah, I want you to tell those millions of uninsured people who still won’t have coverage if the reform fails that they’re better off than if it had. I want you to tell that to someone who is denied coverage because of pre-existing conditions. I want you to tell that to people who have their insurance canceled when they get sick. All because, basically, you hate insurance companies, wish vainly that the US had a single-payer system (as do I, by the way), and because it really fucking matters to you whether or not the political left scores or loses points in a political battle.
August 16th, 2009 at 4:14 pm
What other topics at NetRoots Nation can be corporatized, courtesy of conservative Democrats and their corporate sponsors? Health care had the best chance of appealing to the public good.
Austin Netroots–Practical Politics
Pittsburg Netroots–?
August 16th, 2009 at 4:32 pm
“But, hey, (the Tauzin/Bush Medicare bill) was an ugly compromise with lots of giveaways to the insurance companies. Therefore, in the opinions of moral cretins like yourself, it was a bad thing that is worse than nothing”
I’m generally opposed to looting the public treasury to give to drug companies.
However, if I had been a Senator or Representative in 2003, I would have voted for the bill. It was the most that could have been accomplished with a GOP House, Senate, and WH.
But 2009 is not 2003. Now we have a Democratic House, Senate, and WH.
We can actually pass a good bill in the public interest, if the will is there.
The WH today sent up a trial balloon to see if folks care about what is in the final bill or not. I think folks ought to care.
“All because, basically, you hate insurance companies, wish vainly that the US had a single-payer system”
Dude. I’m in favor of the Hacker plan, which is mostly a private insurance based plan with a public option that would take a decade or more to scale up.
I’ve never thought going directly to single-payer was a practical or desirable policy choice.
August 16th, 2009 at 4:32 pm
Quiet Keith,
The game plan is to come up with an awesome clean bill with no corporate giveaways, watch the special interests launch a major assault against it and cause public support for it to plummet, killing any chance at passage. Then the Democrats can go into the 2010 elections with a massive policy failure on their hands, and now here’s the brilliant part: the after all that failure, public will surely elect a real progressive Congress that will get the job done, right? I mean, what else could happen?
August 16th, 2009 at 4:33 pm
Hey everybody, believe what Petey says! He so savvy! Remember, he was right about John Edwards and Hillary Clinton. So c’mon people, let’s torpedo anything less than single payer! After all, heightening the contradictions worked out so well for both Nader and the country as a whole in 2000!
Oh, and don’t forget to narrow our coalition as much as we possibly can by insulting those who might be persuaded to join us. The key to electoral success is to piss off potential allies. Petey will lead us to victory!
August 16th, 2009 at 4:51 pm
Petey, no, not the appearance of a bill, an actual bill. Now, the bill may not be what you want, but it is a start, and right now, that is the paramount objective. No, it is does not feel particularly satisfying, nor does it do all that we want it to do – but (and this is no small piece of the puzzle), it breaks the dam. It gets us to a point where we can actually maneuver.
August 16th, 2009 at 5:02 pm
You’re fucking full of shit and have a very short memory. Don’t vilify folks who took Obama at his word. He sold out his supporters — pure and simple.
If he wants us to accept this so-called compromise, he needs to admit he and his stupid, cowardly approach were at fault. If he does that, I’ll accept the compromise.
August 16th, 2009 at 5:08 pm
So your condition for support of a bill that literally affects the health of millions of Americans is whether nor not the President satisfies your need for an admission that he was wrong and you were right?
August 16th, 2009 at 5:08 pm
“Now, the bill may not be what you want, but it is a start”
I think it’s a weak bill that is a start with a public option.
Without a public option, it’s not the start of anything. Without a public option, the current problems in the system will be locked in for a generation.
Without a public option, the percentage of the population on Medicaid will skyrocket over the years. It’ll be a massive healthcare program for the poor, which is precisely what you don’t want in a program. Programs for the poor are poor programs. Universal programs are strong and healthy programs.
The type of S-CHIP on steroids that will develop without a public option will cause a huge amount of unnecessary misery that plays out over decades. And it’s all foreseeable and unnecessary.
Shills like Matthew have been trying to downplay the public option for months, but there is a reason that the public option has attracted the amount of interest that it has. It really does provide a path to fixing the problems in the system in a non-disruptive way.
August 16th, 2009 at 5:20 pm
This shows a deep ignorance of both the public option and the rest of the reform which involves it. Simply put, all the bills that have come out of committee include subsidies to the poor for purchasing health insurance through the exchanges, whether it be a publicly-run insurance company or a privately-run insurance company.
It is simply false to assert or imply that the availability of health insurance to the poor will rely upon there being a public option. It would not.
August 16th, 2009 at 5:41 pm
Without the public option costs will continue to skyrocket.
Private insurance boosts cost by 20 to 30%, plus there will be no control over provider waste.
August 16th, 2009 at 5:53 pm
LOL@”progressive movement.” If it consisted of something other than dumb fucks useless for anything other than mau-mauing the press and raising cash for hack politicians we’d have health reform; but it doesn’t, so we won’t.
Democrats: The Limp Dick Party.
August 16th, 2009 at 5:54 pm
Simply put, all the bills that have come out of committee include subsidies to the poor for purchasing health insurance through the exchanges, whether it be a publicly-run insurance company or a privately-run insurance company.
Why are you, like MattY, in favor of destroying reform? Why do you care only about about getting good optics for the WH?
I mean, no one could possibly disagree with Petey in good faith on this. Seriously, it’s obvious that you have a trust fund and we all know what that means, scumbag.
August 16th, 2009 at 5:54 pm
If there is no public option it will be Obama’s fault.
He could have said (still could) he wouldn’t sign a bill without the public option.
August 16th, 2009 at 6:03 pm
Obama hasn’t threatened to veto a fig leaf bill because… Obama doesn’t care about getting anything more than a fig leaf bill. Are people still having a hard time understanding that he actually isn’t a social democrat posing as a center-rightist, but rather an actual center-rightist?
August 16th, 2009 at 6:09 pm
It’s worth repeating that petey’s claim that the Senate HELP bill and the House’s Tri-Committee bill had a “strong public option” that is significantly different from the Finance committee bill with regard to the argument here is false.
The only real difference is with regard to cost controls. Now, those would be important and the fact that a strong public option would pressure the private insurers and control health care costs in this manner (primarily by limiting it to Medicare compensation rates) is of no small importance. It’s the best reason to support petey’s so-called “strong public option”.
But that’s not what petey and others have been arguing, explicitly or implicitly. All the arguments I’ve seen here and elsewhere involve access. There is some weird, contrary-to-fact presumption that the public option is equivalent to expanded access. Petey claims that Medicaid enrollment will balloon without the public option. But that’s not true: all the bills out of committee allow only those who don’t qualify for Medicaid to enroll in the publicly run plans.
Furthermore, none of the bills out of committee—including petey’s “strong public option” bills—allowed open enrollment in the public plan for Americans who can get coverage through their employer. All the bills create exchanges where those who can’t otherwise get coverage are able to get it from an insurer at comparable rates, with comparable coverage, and with subsidies available to the needy…with or without the inclusion of the public option.
The public option would very likely have long-term importance—in terms of controlling costs, being competitive with the necessarily higher-overhead private insurers, and acting as a blueprint for something that could someday become a single-payer system. It’s worth supporting the public options for all those reasons. I support the public option for all those reasons.
But it’s not worth opposing the entire health reform package because it lacks a public option, nor is it worth failing to support the reform against the attacks on the right because it lacks a public option.
If we get reform without a public option, it could still be added later. In fact, given the existence of exchanges and the political victory of passing reform in the first place, and in contrast to the political failure of no reform at all and no regulatory structure in which the public option could easily fit…then obviously we’re farther from what we want from the public option without reform than we are without the public option but with reform. It makes no damn sense to oppose or fail to support this bill if it doesn’t have the public option. If reform fails, it will result in something quite obviously and incontestably worse than reform lacking the public option.
Most of what we (realistically) want now from reform is independent of the public option. Sure, what we hope for in the future is arguably dependent upon the public option. But no one has explained to me why we couldn’t get that later—or why we would be less, rather than more, likely to manage to do so if this reform passes now. Failure of reform now will mean the death of reform for another three or more Presidential cycles, at least. Maybe, as some argue, without it things will get so bad that people will eventually want something more radically progressive. But maybe during that same time period other things will become at least as urgent and two major failures at health care reform will poison it politically for at least a generation.
Let’s not risk that: let’s make sure that we pass this reform now, with or without the public option.
August 16th, 2009 at 7:17 pm
mandates.
can anyone say mandates?
does anyone realize how devastating those mandates are going to be to millions of americans?
millions of americans, for a number of reasons, don’t have health care. voluntarily, or because of circumstances beyond their control, they gamble on the fact that they will have no real access to routine health care.
the gamble may pay off – if they are healthy enough to be able to get by with out of pocket payments when the need arises.
what is coming down the pike is going to change everything.
i’d be willing to bet that whatever passes – and i’ll also bet that the final bill does not have any sort of public option – is going to have an individual mandate. which will mean that every adult is going have to purchase health insurance. and without a public option, that will mean that he/she will have to purchase health insurance from private insurers.
most adults have the experience of buying car insurance. if you thought that process was bad, wait til you have to go through the process of purchasing mandated health insurance from private companies that know that every adult will have to purchase said insurance. all of the nice regulations that matt and others laud will not be worth the paper they are written on, as they will be shot full of so many holes that you will need to hire an attorney to make certain you will actually receive the care you expect.
imho, the bill coming down the pike will make matters worse, because of the mandate. a imposed mandate when a citizen can turn to a governmental agency as a last resort is one thing. a mandate where we are all left to the tender mercies of private insurers is going to be an ugly, exploitive situation.
i, for one, am getting angry just thinking about being put in that position.
at this point, i hope they do not pass ANY legislation, as the change that’s coming is going to be good for one only sector: the health care industry.
they are licking their chops, right now…
August 16th, 2009 at 7:23 pm
[...] up plan, if the blue dog democrats keep the public option out of whatever reform finally passes. Incrementalism seems to be a popular meme these days — could the public option do better as a standalone [...]
August 16th, 2009 at 7:24 pm
“Literally affects the health of millions of Americans?” I assume you mean positively — in both the short and long run? Assuming that you’re right — and it’s not at all clear that you are — my answer is yes. That’s a pretty small price to pay, wouldn’t you say? For a guy who broke his promise — a promise on the basis of which he was fucking elected?
I’m not alone in this. Millions who voted for him are fed up with this arrogant stupid bipartisan shit which is totally counterproductive. It is an insult to our intelligence. Many believe the cost will be loss of the opportunity to insure all Americans for decades and further strengthening of the insurance monopoly.
Enough is enough. Are we going to sacrifice our energy, environment, and other social/humanitarian goals on the altar of this stupid shit? Change we can believe in? This has been a fucking fiasco.
August 16th, 2009 at 7:32 pm
Let’s be clear on this: when you say “small price to pay”, you are referring to Obama apologizing to you and those like you that he was wrong? That, indeed, is a small price for him to pay.
On the other hand, you are not paying any price for anything at all. What you’re doing is asking those who won’t have health insurance because you didn’t support it in the face of opposition because Obama didn’t jump through your hoop to pay a price. And that price is in lives. Some of them will die that would not have died with the health insurance they would have had if reform had passed, in spite of your demand that Obama admit he was wrong.
So, effectively, your holding a gun to someone’s head, threatening to shoot them unless another person admits to you that they were wrong. And you say, “it’s a small price to pay, isn’t it?”
Are you sure you’re not some depraved, insane movie villain? Because you sure sound like one.
One thing today’s arguments have made crystal clear to me is that a large portion of people on the left are no more concerned about the 50M people who are uninsured in this country than are many people on the right. Screw ‘em if they don’t understand that their lives are pawns in a political battle. What’s important is who wins and loses, not lives.
August 16th, 2009 at 7:46 pm
Obama should in fact sign the bill that Congress ultimately delivers to him (assuming it is within the range of outcomes currently on the table). Doing anything else would be both bad for the country in the short term and bad for the prospects of additional timely health care reform in the medium term.
But I certainly think the “progressives” in Congress should consider pushing the process into reconciliation if there really are some Senate Democrats who would filibuster a bill with a public option if it emerges from conference. I actually don’t believe that is true, but if it was true they should think about it, because I do think a robust public option will help speed us along the path to a truly rational system.
August 16th, 2009 at 7:48 pm
I mean, no one could possibly disagree with Petey in good faith on this.
True. It’s a pity that Petey manages to convey his positions in the most assholish ways.
I’m not going to pay cash money to a private insurance parasite. If the final bill mandates it, they can stick their fucking mandate where the sun don’t shine. Cunt Kenrad may want to make sure that he’s covered for that.
August 16th, 2009 at 7:52 pm
You thought the bank bailouts were a disgrace?
Well here comes another one – but this time to health insurers and providers. Not only will the taxpayer pay insurance companies for medicare part D, now we can add all those mandated with subsidies.
August 16th, 2009 at 7:55 pm
Hey Matt, I read the Goldhill health care article, but I disagree with you: I thought his analysis was trivial at times, and his main proposed remedy was foolish.
Goldhill first and foremost wants to commodify– as much as possible– health care procedures, testing, and diagnoses. As do others who haven’t worked within the health system or considered real world medical practice, he imagines that the average American adult will become an astute consumer of healthcare and make decisions which will greatly drive down costs and improve quality. I think he is fundamentally overestimating the ability of most patients to evaluate medical questions with the degree of knowledge necessary for success. Goldhill also seems to ignore the severe limitations on patient choice which occur in the emergent and critical care settings.
In contrast, I think that if healthcare is commodified to the extent that Goldhill advocates, it will FUNDAMENTALLY alter the incentives and behaviors of doctors over a relatively short period of time. Goldhill does not seem to realize that his proposed remedy places patients and doctors into an even more intensely adversarial role than at present, with consequences that will be difficult to avoid. That is to say, if patients are going to behave like shoppers cruising the aisles at Wal-Mart or Target, or like a prospective customer at a car dealership, undoubtedly many physicians will behave more and more like car salesmen or marketing exec’s.
It’s bad enough that even in the current fee-for-service system, physician self-interest can lead to over-testing and over-treatment. Goldhill seems to think that from the ‘magic of the market’ consumers will continue with fee-for=service but still drive down prices for physician procedures and tests and other services, and simultaneously minimize the number of unnecessary consumer charges. Nothing could be further from the truth, in my opinion.
I think that as a medical salesman bidding for the dollars of John Q. Public, without the detailed oversight of an insurance company or government bureaucracy, I would be able to find many, many ways to stay a step ahead of the average person who sees my advertising and walks through my clinic door, and I would be quite successful at maximizing my income at the expense of the best and most efficient patient care. Sure, I’ll make certain all the necessary work gets done for each of my patients– but I’ll charge everyone just for the privilege of ’shopping’ at my store (even if they don’t in the end need what I’m offering), and I’ll sell a lot of medical ‘undercoating’ along the way.
Physicians will never be passive commercial agents in Goldhill’s proposed system, and in such an unrestrained and over-commercialized environment, why would you expect a different, less adversarial response?
August 16th, 2009 at 8:18 pm
Incremental is the way to go. Obama should have said, ‘let’s try specific diagnostics and preventative care via government funding and see what happens’. Those of us with brains know that it would work very well. That is what those who profit from the status quo dread the most.
August 16th, 2009 at 9:11 pm
“I mean, no one could possibly disagree with Petey in good faith on this.”
Emphatically disagree.
Nescience is often just as often the reason for disagreeing with Petey as arguing in bad faith is.
August 16th, 2009 at 9:46 pm
Nescience is often just as often[sic] the reason for disagreeing with Petey as arguing in bad faith is.
It’s a pity that Petey manages to convey his positions in the most assholish ways.
No further comment.
August 16th, 2009 at 11:16 pm
I am a resident physician and, from a factual standpoint, this article is one of the worst I have ever read in the Atlantic. On the medicine side of things, this guy has no idea whatsoever what he is talking about, and I was disappointed to see you link to it.
From the opening graph “American medicine killed my father,” everything is overstated and unsubstantiated… and I agree with the core of his argument! He should have written “American medicine made it more likely that my father would die,” (probably true) but instead he went for the grabbing lede. Does he think people don’t die of urosepsis or get hospital associated infections in Europe?
The section on the ER is one of the weakest I have ever read in a major publication. Speaking about the ED as a cost driver as a “statistic”… “Has anyone who believes this ever actually been to an emergency room? My sister is an emergency-medicine physician; unlike most other specialists, ER docs usually work on scheduled shifts and are paid fixed salaries that place them in the lower ranks of physician compensation.” I spend an unfortunate percentage of my life in the ED and I can state unequivocally that he is full of shit. His sister? Really? The literature on this is clear; good primary care is the cheapest way to do medicine, full stop. The ED is about the furthest you can get from primary care. No follow-up– ever! He even references the Dartmouth data that shows this! Every test gets ordered EVERY SINGLE TIME the patient comes in. Everything is done by algorithm, If you don’t believe me, anyone cane easily walk in the door and rack up a couple of g’s in medical bills by mentioning the word “chest pain.” Furthermore, ED physicians actually make pretty good money, way more than family docs or internists, for example, and certainly not the “lower ranks”. All this for working less hours and providing more expensive care. This isn’t a hard thing to look up. First link on google for “physician salaries,” for example.
The whole line about LASIK surgery is all well and good… for elective outpatient procedures. He makes absolutely no differentiation between these procedures and the type of care that his father received that is, by definition, IMPOSSIBLE to comparison shop for. His father presumably did not go to the emergency room saying “I have a pneumonia” and there is no conceivable system whereby he could shop around for the best deal. Also, sort of by definition his father was intubated and sedated (a precondition for most ICU level of care). At this point, is he in any position to haggle over the costs of his care? Are his loved ones? As that guy in the Gowande article said, “you don’t expect the sheep to negotiate with the wolves” (or, more aptly, carrion to negotiate with the vultures).
Furthermore, referring to collective payment of services for the old by the young as a “Ponzi scheme” is kind of odd for a for a self-professed Democrat. You could easily see George W. saying the same line about Social Security, no?
August 16th, 2009 at 11:23 pm
In general, people who think placing more spending decisions in the hands of health care “consumers” (meaning patients) is a good cost-control idea just make me laugh. Patients are the last people we should be asking to say “no” to the system, and relying on them to do it is just silly.
August 16th, 2009 at 11:52 pm
By the way, apparently the Obama Administration is communicating tonight that Sebelius did not intend to change in any way their message on a public option (which I suppose would be something like that Obama thinks it is a good idea but hasn’t claimed it is strictly necessary). Of course some people are still going to read this as some sort of trial balloon, but I assume they would further conclude that means the trial went over sufficiently badly with progressive Democrats that it is being reeled back in.
Regardless, none of that really changes the underlying fact that if progressives want the public option to be in the bill that reaches the President, it has to come out of conference committee. And while it may not be necessary to that end to have a public option in the Senate version, it certainly would help.
August 17th, 2009 at 1:01 am
You know, I have to admit that I’m still more than a little fuzzy on the core differences between co-ops and the public option.
As far as I can see, the core difference is that the public option would pay doctors lower rates (the Medicare 80% rate), and might not have to keep funds on hands to cover risk (since it’s backed by the US govt).
I often hear people say that co-ops would do nothing to control costs. But if they’re nonprofit I have to assume that they would have at least of a bit of an edge on costs, inasmuch as stuff isn’t being skimmed off the top for shareholders. But the public option, by contrast, would have a pretty big cost advantage (20%+).
Am I getting this remotely right?
August 17th, 2009 at 1:30 am
Only the Senate HELP committee bill included the public plan paying at Medicare rates. The Tri-Committee bill did not and the bill in the Senate Finance committee does not. It’s very unlikely that a public option, if it is included in the bill, would include such a provision. I’d prefer it, for the reason that you say: it would help control costs. But more than just the insurance industry is opposed to that version of the public option…doctors are opposed to it (for obvious reasons). Dean’s AAFP is opposed to it, by the way.
You’re correct that any realistic public option would essentially be the same as non-profit co-ops. But from the consumer’s standpoint, so would the private plans. The public plans are not going to be any less expensive for the consumer than the private plans.
The real benefit of a public option is long-term, not short-term. The long-term survival of co-ops is unclear while a public option would be guaranteed by law. The public option would act as a proof that the private insurers could do what they otherwise will argue they cannot; and it will be a foot in the door of building a government run insurance system that could eventually evolve into something effectively like single-payer.
But in the short-term, it will not do very much for anyone that the private insurers do.
August 17th, 2009 at 1:50 am
You know, I have to admit that I’m still more than a little fuzzy on the core differences between co-ops and the public option.
It really depends on the details on both sides. Frankly, if you have a national (or at least large regional affiliates) co-op system on the one hand, and a public option that has to negotiate rates on the other, the short term difference might not be terribly significant–it might be as little as just slightly higher administrative costs. In that case, my personal complaint would be that such a co-op system wouldn’t do as much to ease the transition to something like a single-payer system.
On the other hand, it might ease the transition to something like the German/Swiss/Dutch family of models. My complaint then would be that adopting something from the German/Swiss/Dutch family of models could be more expensive than single-payer for no particular purpose. Still, I actually wouldn’t be terribly upset if something like a national/large-regional-affiliates co-op system emerged as the alternative to the public option in the final bill. I just don’t see that concession as necessary right now.
August 17th, 2009 at 8:07 am
“You’re correct that any realistic public option would essentially be the same as non-profit co-ops. But from the consumer’s standpoint, so would the private plans.”
I will reiterate that you are a fucking idiot, Keith M Ellis.
All three of those things would be somewhat similar in Year One. But they will be unrecognizably different from one another in Year Ten and Year Twenty.
I understand that you are at an age that means you think you will be dead at that point, and I understand that you don’t particularly care about what remains after you are gone. But the nation’s citizenry will still exist in Year Ten. The nation’s treasury will still exist in Year Ten. The nation’s economic competitiveness challenges will still exist in Year Ten. So choosing between those three dramatically healthcare paths will have three dramatically different outcomes in a very real near-term future.
There is a reason that Billy Tauzin and Jeffrey Immelt are willing to spend millions to defeat a public option. They understand full well that a public option will benefit the public over their companies’ shareholders in the very real future, and that’s what they get paid to avoid.
August 17th, 2009 at 8:12 am
Thanks, KME and DTM! I found it surprisingly difficult to extract the facts about these two alternatives from the debate.
Got it. Totally agree. Maybe, taking a page out of the GOP playbook, our negotiating posture should be, “Health Insurance without Public Option = Corporations Harvest Baby Organs.”
We can moderate the tone later.
August 17th, 2009 at 9:42 am
All three of those things would be somewhat similar in Year One. But they will be unrecognizably different from one another in Year Ten and Year Twenty.
This may or may not be the case, assuming eventually everyone migrates to the public exchanges with a system of taxes and subsidies providing everyone with enough funding to purchase a comprehensive basic insurance plan. At that point, it really depends on the additional layers of regulation that get put on top: basically, with enough government regulation of the terms of the basic insurance plans available through the public exchanges (up to and including strict price schedules for procedures, as in Japan), you can make these systems fairly closely resemble single-payer except for the fact that people will have some sort of choice of insurance providers at some point. Whether, after all the regulation, that is really a meaningful choice is a different matter.
August 17th, 2009 at 9:45 am
Maybe, taking a page out of the GOP playbook, our negotiating posture should be, “Health Insurance without Public Option = Corporations Harvest Baby Organs.”
Consciously or not, that is roughly the tone that a lot of self-identified progressives have adopted. Again, right now I still think they can actually get a public option, so they might as well go for that. But even if all they are doing is making sure the final bill contains a pretty good co-op plan, that would be good too.
August 17th, 2009 at 9:50 am
“Maybe, taking a page out of the GOP playbook, our negotiating posture should be, “Health Insurance without Public Option = Corporations Harvest Baby Organs.” We can moderate the tone later.”
FWIW, the public option is not a negotiating posture.
It’s an actual policy measure.
The folks who are spreading misinformation that a co-op system would be vaguely similar to the public option are intentionally refusing to look past Year One of the plan. And given that pretty much all of what the public option accomplishes happens after Year One, they are making a purely strawman argument.
August 17th, 2009 at 9:59 am
“This may or may not be the case, assuming eventually everyone migrates to the public exchanges with a system of taxes and subsidies providing everyone with enough funding to purchase a comprehensive basic insurance plan. At that point, it really depends on the additional layers of regulation that get put on top”
The genius of the public option is that it will generate its own self-sustaining strong political constituency over time.
The co-op programs being discussed have been intentionally designed to avoid generating a self-sustaining strong political constituency.
If you look at the political history of entitlement programs in America, you’ll find that the program’s architecture in terms of whether or not it can generate a self-sustaining strong political constituency is its destiny.
If folks aren’t looking one or more decades out into the future on this issue, they are missing the entire point.
August 17th, 2009 at 10:08 am
[...] 17, 2009 · Leave a Comment yglesias: The simple fact of the matter is that defeating the current reform effort is not going to lead to [...]
August 17th, 2009 at 11:09 am
Petey is opposed to any bill that might possibly pass the current Congress (in which, let me remind you, people like Ben Nelson count as Democrats.)
There’s only a few ways to understand this:
1. Sometimes the simplest explanation is the best: Petey is opposed to bills that might pass because Petey does not actually want any bill whatsoever to pass and is concern trolling.
2. Petey thinks he knows what bills are passable better than all the Congressional and White House professional politicians, longtime political bloggers, etc. If that is so, then he’s entitled to make his case, but it better be one hell of a case. If you can’t name enough at least reasonably gettable votes for your “better” bill, then it is not a bill but a pipe dream and irrelevant to the discussion of what Congress actually might pass or what public activists or the White House should try to influence Congress to pass.
3. Petey believes that if a moderate bill is shot down from the left, resulting in an epic fail on the Democratic Party’s (and Obama’s) #1 legislative priority, the result at the next election will be a more progressive Congress that will pass a further-left bill. Nobody with any actual knowledge of politics believes this idea either (that’s why it’s the GOP that is so determined to kill anything and everything Obama supports), so again, he had better make one hell of a case if he expects anyone to take this idea seriously.
4. Petey is not thinking about short or medium-term politics at all and only cares that a public option will have better long-term effects. It will, but that doesn’t actually matter right now. Obama is not a dictator and can’t sign any bill Congress doesn’t pass first, so the merits of unpassable legislation are irrelevant.
August 17th, 2009 at 11:29 am
“Petey is opposed to any bill that might possibly pass the current Congress”
You can say this all you like, but that won’t make it true…
—–
Were you trying to accurately represent my position, you’d say:
The choice here is between a bad bill which can pass Congress with a bit of a margin and a good bill which can pass Congress narrowly.
Given the stakes, I don’t think the decision should be all that difficult. But I acknowledge we have starkly different priorities here.
August 17th, 2009 at 11:47 am
The co-op programs being discussed have been intentionally designed to avoid generating a self-sustaining strong political constituency.
That seems wrong to me.
First, holding aside this entire issue, what is undoubtedly going to generate a self-sustaining political constituency is the exchanges themselves. Indeed, I fully expect that it won’t take all that long before a lot of people starting thinking that they would be better off getting their insurance through the exchanges as opposed to through their employers. And that is why I think regardless of how this particular issue is resolved, this bill will spark a transition to at least something like the German/Swiss/Dutch family of models.
Given that, the question is then whether the co-ops would themselves be attractive options within the exchanges. I think they could be if they end up with enough negotiating leverage, and I also think as more and more people migrated to the exchanges, it would become clear that making the co-ops attractive options would be crucial to saving us all money. Again, all that would grow the constituency for a completed move over to the German/Swiss/Dutch model.
The folks who are spreading misinformation that a co-op system would be vaguely similar to the public option are intentionally refusing to look past Year One of the plan.
Bullshit. You may disagree with our analysis, but we were already discussing these issues before you wrote this. Shame on you.
August 17th, 2009 at 3:15 pm
@71: Please list the Senators that have supported, or plausibly will support, the bill you support. Otherwise, see my paragraph 2 of comment 70. The potential bills you consider “good” can’t pass the current Congress at all in the judgment of most professional politicians. If you want to argue the point, bring on your evidence.
@72: Indeed, I fully expect that it won’t take all that long before a lot of people starting thinking that they would be better off getting their insurance through the exchanges as opposed to through their employers.
Heck, I’m already thinking that and the bill hasn’t even passed yet. Why can’t I take however many dollars my employer is willing to kick in and convert it into a voucher I could take to the exchange (paying the difference myself if I want a more comprehensive plan)? It wouldn’t cost my employer an extra dime.
Right now I can only ask this question because I’m following this discussion closer than most people. But in a few years, everyone will know someone who got a better deal on the exchange than they are getting through their employer’s choice of plans. I think that will create a constituency for the right to shop around. (With preexisting condition exclusions banned, it won’t be only the completely healthy people who will be able to do so.)
August 17th, 2009 at 8:17 pm
“Given that, the question is then whether the co-ops would themselves be attractive options within the exchanges. I think they could be if they end up with enough negotiating leverage, and I also think as more and more people migrated to the exchanges, it would become clear that making the co-ops attractive options would be crucial to saving us all money.”
But none of this even begins to touch on my point that co-ops won’t generate their own self-sustaining strong political constituency over time while the public option will.
Healthcare reform is going to be a process of tweaks over many years, and without a self-sustaining strong political constituency in place to fight against the manifold devices the various “stakeholders” will have in play, those tweaks will make the overall program significantly less effective over time.
The public option was always designed precisely to be able to perpetuate its own political health, and even a well designed co-op system will lack that crucial element in determining future outcomes.
“Bullshit. You may disagree with our analysis, but we were already discussing these issues before you wrote this. Shame on you.”
I read the comments, and I have seen such concerns brought up only in order to be dismissed out of hand. Both the industries at stake and the WH are pushing very hard to get co-ops into play for obvious reasons. They’re just pretty directly acting against any conception of the public interest when they do so.
Tom Daschle wants to pass healthcare reform in the Senate with 80 votes (while he gets his checks from UnitedHealthcaregroup.) No wonder folks like him are so hot and bothered to get co-ops into the bill. They’d actually prefer an awful bill that is “bipartisan” (and satisfies their paymasters) to a good bill that, godforbid, only passes with Democratic votes.
August 18th, 2009 at 10:25 am
[...] you can admit Goldhill is mostly right, but advocate the passage of an asinine bill anyway, as Matthew Yglesias does with tortuous…what? You can’t call it logic, even tortuous logic: Defeat of the [...]
August 18th, 2009 at 1:11 pm
Geez, what an echo chamber here. And amazingly, you all think you represent something other than a handful of spoiled brats.
Why don’t you instead get real jobs in the private sector? Maybe as pharma sales reps… Then you’d have an inkling of how the other 95% of the country really lives and thinks — and what they really want.
It’s certainly not any of these wet dreams.