• You Can Get There From Here

    Last week I argued that political feasibility is an essential consideration when evaluating policy proposals. That’s no more true than for health reform. The bills that have passed the chambers of Congress have survived more tests of political feasibility than any other comprehensive health reform bills in the past. Nevertheless, reasonable people can disagree over whether or not they will produce the “right” health care system.

    Or maybe not. Actually, I don’t think a reasonable person can say the health reform we may get this year will be the “right” one. Anyone who says so is overselling it. At best it will be a start. It won’t achieve universal coverage, though it will cover the majority of uninsured. It won’t achieve dramatic changes in health care costs, though it will implement new ideas that might set the stage for bigger changes later. So, it’s a good start, but a start nonetheless.

    So, if you’re thinking we can do better, I’m with you. But I would argue that the road from here to there goes through “this” bill. (Yes, I know, there is not one bill yet. But we know more-or-less what the final bill will look like if the Democrats do this the right way, by passing the Senate bill and modifying it via the budget reconciliation process. To a rough approximation and for simplicity, let’s just presume the Senate bill is the final bill.)

    But back to why this bill is the best way to achieve future reform. First of all very little of great significance will happen in health policy if it doesn’t pass. Ezra Klein made the argument in a November 2009 post.

    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.

    History has shown that each failed attempt at health reform has led to long periods peppered with far less ambitious proposals. The surest way to not get your preferred version of major health reform is to see the current effort fail. Success breeds success and change begets change. That’s not to say that everything possible becomes uniformly more likely if this bill passes. No. But, some health policy goals become more achievable after health reform.

    For example, suppose like me you favor the following:

    • Federalization of Medicaid,
    • Elimination of the preferred tax treatment of employer provided health insurance,
    • Severing of the link between employment and health insurance,
    • Greater transparency and uniformity of health care prices,
    • Less provision of unnecessary care.

    None of these will occur with the passage of health reform legislation this year. But all are far more likely to occur in the future if health reform does pass and far less likely if it does not. (*)

    That’s why I believe it is intellectually consistent to both find the provisions in health reform legislation lacking and still think them worthwhile to implement. As Obama said during his Q&A at the GOP retreat last week, if you expect to “get 100 percent or 80 percent of what you want, then it’s going to be hard to get a deal done. That’s because that’s not how democracy works.” That’s just another way of advising not to let the perfect be the enemy of the good (or good enough). The best way from where we are to where we should be on health care is through something like the Senate health reform bill (modified via reconciliation as necessary for passage). It’s an achievable first step along the long road from here to there.

    (*) See follow up posts on why I like these ideas and why they are more likely to come to fruition if health reform passes.

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    • I would be interested in why you like these ideas in part because they are similar to mine.

      To me, the ideal health care structure would be to completely privatize the insurance marketplace (eliminate Medicaid and Medicare) and to eliminate employer sponsored health care (although 525 and HSAs can be created so employees can pay for the premiums, but it is the individual’s responsibility to find and purchase a plan). Government would have to regulate policies to ensure a minimum level of coverage is met, how coverage and quality information is portrayed to make it transparent and comparable, make it easy to switch insurers, and that there is no discrimination. The Government would subsidize the purchase of low-income insurance via an HSA or 525. Although politically unfeasible, ideally the insurance companies could not know the subsidy amounts to avoid market disruptions. I consider this plan the “Wal-Marting” of health care and it will keep costs down as insurers compete for each individual. Once insurers have established a large market share, they can squeeze their suppliers to keep their costs down. Quality would be ensured via transparency and ease of switching insurers via government regulations.

    • It’s easy to see why you favor the reforms you mention. It is not easy to see why you think the current bill would make any of them more likely. Do tell.