Aaron and I are very interested in an honest, good-faith, evidence-based dialog on how to reform our health system. In order to make progress, we must also keep in mind what’s politically feasible. Compromise is necessary. But in the current climate, it seems impossible. Ezra Klein just expressed his understanding of why.
In a world where the two parties’ top priority on health care was providing answers for the uninsured and cost control, an argument over the best way to do health-care reform would be a very healthy thing. But that’s not what we’ve got. We’ve got the Democratic Party, whose top priority is to try and solve our health-care problems and who’ve shown their commitment to that by moving steadily rightward over the last century in a bid to pick up Republican support for some sort of solution, and the Republican Party, whose top priority is that we shouldn’t do whatever the Democrats are proposing and have proven their commitment to that by abandoning previously favored policy proposals as soon as the Democrats demonstrated any interest in adopting them.
And that’s the fundamental problem here: It’s easy to compromise when both sides are committed to solving a problem, because the appeal of solving the the problem is enough to persuade both sides to make concessions. That’s why Democrats gave up on single payer, on an employer mandate, on a public option. But it’s impossible to compromise when one side is uninterested in solving the problem, as they lack the incentive to make any concessions. That’s where the Republicans are on this, and it’s why they’ve not been interested in joining onto a bill even when Bill Clinton moved to the right and adopted the core of Richard Nixon’s plan and Barack Obama moved even further to the right and adopted the core of Mitt Romney and Bob Dole’s plan.
Taking the debate in the comments on this blog as further evidence, I am in general agreement with him. I’m sure not everyone sees it this way and will tell me so in the comments. However, if you can put aside whether you see it this way or not, perhaps you can at least recognize that this is the source of frustration for many who care deeply about health care and our system(s) of financing it. For some of us, this is not politically motivated posturing. We’re not happy with the nature of dialog. We yearn for something more healthy and productive.
You know what would help? Stop the meta-debate. Just cut right to the politically feasible compromises. Cut out the accusations of obstruction, threats of repeal, obsession with legal challenges, claims of illegitimacy, and so forth. You can wag your finger at me and say the same thing. You can be frustrated too! Go on, vent. And then let’s move on.
How do we move on? How do we just get right down to work? Perhaps one way is to just lay our cards on the table. What are our goals? Universal coverage? Cost control? How are they to be achieved in a believable fashion? What are we to do if your goals and mine conflict (as if either of us had any power to do anything)?
It should be clear that my chief goal is addressing the deep problems in our insurance markets. I think people who would prefer to be insured, or insured in ways not tied to employment, are not and for reasons that can be addressed. (The ACA is very slow to address some of the issues here, but is a start. I would have preferred something that moves faster. It couldn’t pass.) Addressing these problems will move us closer to universal coverage, or even achieve it. But, to me, that’s not a goal in and of itself. However, I am concerned about “gaming” the system, which is the justification for a mandate or something that serves the same purpose. (There are alternatives here.)
I also have some concerns about cost, but I’m not convinced we are ready to “bend the curve,” or that we really should. Yet, there are deep problems related to how health care is financed. I am absolutely committed to identifying and removing “waste” and inefficiencies from the system, but view these as likely shifts of the curve, not long-term changes in its rate of growth. I will note that “waste” is not well-defined.
I’m among the skeptics in the believability of the ACA’s cost controls or revenue generators. Alternatives or enhancements I’ve considered on this blog (competitive bidding, all-payer rate setting) don’t seem politically viable, not yet anyway. My skepticism doesn’t go so far as to claim the ACA can’t begin to address issues of cost, in addition to going a long way toward addressing some insurance market failures.
I live in Massachusetts. I supported the reforms here when they were backed by a Republican governor. If I thought repeal or removal of the national law made sense, I’d argue for the same for Massachusetts. Instead, I’m supportive of the ways Massachusetts is trying to build on its reforms and to address the related and unrelated cost issues.
If I thought striking the mandate would better remedy problems in insurance markets or better address cost issues, I’d support just that. I just don’t see how doing so would help. But I’m willing to listen to alternatives or enhancements. In fact, I think they’re required.