Tuesday, November 10, 2009

Should Single-Payer Supporters Oppose Obama's Bill?

Today's must read pieces, for liberals, are Jonathan Cohn and Ezra Klein responding to Dr. Marcia Angell, who writes in HuffPo that the House-passed bill is worse than nothing. I'm going to pile on here, on the side of Cohn and Klein.

I can't really argue the substance of it. Angell knows far more about health care than I do. But I don't think she makes a substantive argument; she makes a political argument. Her substantive argument is that the House bill would only make marginal progress, but fail to stem the current system's long term instability. If that's true, the question is: what should people do? That's a question of politics, not substance. And politics, I can speak to.

Here's Ezra Klein's response:

Failure does not breed success. Obama's defeat will not mean that more ambitious reforms have "a better chance of trying again." It will mean that less ambitious reformers have a better chance of trying next time.

Conversely, success does breed success. Medicare and Medicaid began as fairly limited programs. Medicaid was pretty much limited to extremely poor children and their caregivers. Medicare didn't cover prescription drugs, or individuals with disabilities, or home health services.

But once the programs were passed into law, they were slowly and continually improved.
And here's Jonathan Cohn:
To Angell--and to others on the left, as my colleague John Judis notes today--this is reason for ditching the whole effort. But what, really, would that accomplish? The immediate impact would be to undermine Obama and his allies in Congress, creating the (accurate) impression they are incapable of passing major legislation. The Democratic Party would lose seats at the midterms and then, quite possibly, suffer even bigger setbacks two years hence. That's not exactly a recipe for progressive revival.
I'll pile on a little, but I do recommend that anyone tempted to take Angell's side on this should really read both Jon and Ezra in full.

The question here is what should people do if they believe that a single-payer plan is the best policy, and that the current Democratic approach will only marginally help things. And the answer is clear: people in that group should enthusiastically support the House bill -- and they should strongly support final passage of pretty much any version of whatever emerges from the Senate and then from conference.

Look, there is no other approach, at this point. Angell's suggested alternative starts with expanding Medicare to age 55 and up. That may be the better policy, but it just isn't going to happen in this Congress. The realistic alternative in this Congress -- the realistic alternative for at least through 2012 -- is nothing. There will be no other bill that works its way through committee, to the House floor, to the Senate floor, to conference, to the president's desk. It's not going to happen.

It's not going to happen because the votes aren't there for what Angell wants; as I've said repeatedly, that was determined in the Iowa caucuses in 2008, when the three Democrats who emerged all had programs similar to what Congress is putting together right now. It's not going to happen because, if this thing fails, no one is going to be willing to put in the effort for smaller improvements (beyond the S-CHIP expansion that Democrats already put through earlier this year).

Moreover, if the current effort fails, and Obama is reelected, by far the most likely scenario is a return to incrementalism, similar to Clinton's second term. And a Democrat running in 2016 on Obama's success will, as Al Gore did in 2000, embrace incrementalism as the key to success. Of course, if the current effort fails and Obama is defeated in 2012, then there's no chance of a bill that Angell wants for the foreseeable future. Either way, I think it's safe to say that if this bill fails, it's not realistic to expect a new, comprehensive reform bill to have a chance to pass for at least twelve years, and probably longer.

If, however, some version of the current bill passes, the story is a lot different. Democrats have run on health care for sixty years; they aren't going to stop because this bill passes. If reform is law, then Democrats are immediately going to start campaigning on all the things the bill doesn't do. If consumers are losing benefits or paying more in deductibles and co-pays, as Angell predicts, then Democrats will devise policies to help those consumers. If the costs to the government spiral up, Democrats won't respond by seeking to cut benefits; they'll look for other solutions.

Basically, if the current bill (in any version, even the Senate Finance bill) passes, there are multiple paths that liberals should like. First, it might actually work the way proponents predict. Second, it might work only partially, allowing liberals to propose and (if they retain the White House and majorities in Congress) pass reforms, such as opening up the exchanges, expanding the public option, and/or expanding Medicare and Medicaid, that move closer to the system liberals prefer now. Or, third, if this plan passes and the system really breaks down, Democrats will be far more likely to move to proposals such as those Angell supports, because the current mixed alternative will no longer be available.

Bottom line: unless they believe that the current bill would actively harm people (and I don't see any liberals making that argument) compared to no bill, then liberals should -- after fighting hard for whatever they can get in the Senate and in conference -- strongly support the final bill.


  1. For one thing, this bill will effectively end funding for abortion. Guess you, Jonathan, are not worried about that, but millions of women are!

    And if the bill works the way Angell says it will, people will die for lack of healthcare.

    Being "realistic" should include that idea in the calculus.

    This bill is only helping the insurance industry. The public option in the exchange according to the CBO will have higher price insurance coverage than the privates and there is no holding down their prices now that they have control of EVERYTHING!

  2. Thanks for the comment.

    A couple things. First, I don't know what you mean by "effectively end funding for abortion." There is currently no federal funding for abortion. As for private insurance covering abortion, Stupak shouldn't affect people who get their insurance through their employers. Lots of people who have no insurance now would, if the bill passes w/Stupak, go from no insurance to insurance without abortion coverage. I don't see how a woman who currently has no insurance at all is worse off if she gets insurance, albeit without abortion coverage. I'm certainly not advocating Stupak, but I don't think it takes away abortion funding from very many people who currently have coverage (the exceptions would be people who currently have coverage outside of their employment and would qualify for the exchanges, so it's not no one. And I agree that the symbolic point is important, just not important enough to outweigh the rest of the bill).

    As far the broader point...anyone who genuinely thinks people will be worse off with this bill than without it, naturally should oppose the bill. That's not who I'm talking to. I'm talking to people who think that this bill is on substance better than no bill, but also think that passing this bill will make it less likely that a better bill will pass in the future. That, I argue, is mistaken.

    I'd add that in evaluating whether this bill is better for people than the status quo the question of how the insurance industry, drug companies, doctors, and hospitals fare is largely irrelevant. IOW, if you think that the bill will be neutral for current insurance-holders and marginally good for those currently without insurance, but great for insurance companies and drug makers, then, IMO, it's still better than the status quo, and therefore it's better to support the bill.


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