Dangerous, Dirty, and Unfun

I don’t mean to be flip in that title. Health care reform IS a big effing deal. I haven’t written much about Congress’s effort to pass comprehensive health care reform because honestly, things are changing every day, and while I get worked up about every little development in real life, I don’t feel compelled to expose you, my precious and treasured readers, to that sort of madness.

But it’s definitely worth taking a step back and looking at the larger effort, how it’s progressed, and what the consequences are. This is where my ambivalence comes in. Because, on the one hand, it’s become painfully apparent to liberal supporters of reform that most of the store has been compromised away. Even though any reasonable objective observer will recognize that a Canadian-style single payer system would be the most effective way to achieve both universality AND cost control (notice I said “reasonable objective observer,” which disqualifies pretty much every Republican critic of reform), that idea wasn’t even put forward as a serious starting point for debate. Consequently, the so-called public option, the next-most-progressive idea for reform, got whittled down and exposed to ridiculous right wing obfuscation and misinformation, to the point that even the most feckless shadow of the public option became anathema for conservative and moderate Democrats. Here’s the inimitable and heroic Matt Taibbi discussing the latest compromise, a proposed expansion of Medicare to folks age 55 and over:

I get that some people think this is a good idea, and it’s hard to argue that any kind of expansion of Medicare is a bad thing, given that the program has been popular and successful throughout its history. But this move just smacks of the bass-ackwards Solomonesque bargaining that has marked this whole health care effort from the start. If expanding Medicare is good for people aged 55 and up, why isn’t it good for everybody? Why isn’t it a good idea to provide cheaper insurance for people in their preventive care years, so that they cost Medicare less as they do get older?

Answer: because it’s a political non-starter, because hospitals and doctors won’t tolerate having to take Medicare rates from everyone, nor will the pharma companies or the insurance companies tolerate having to compete with Medicare for their most profitable customers.

So what they’ll do instead is expand Medicare for people aged 55 and up in exchange for the preservation of subsidies everywhere else in the system, as well as an individual mandate that increases the revenue flow for private insurers by forcing millions of new (and relatively young and healthy) customers their way. This isn’t a health care strategy, it’s a big baby that’s been hacked up into parts and fed in descending size order to the administration’s weightiest political lobbies. I almost can’t wait to see what the next “compromise” is.

It’s hard to argue here. If you start from a position where you have to appease doctors, insurers, the pharmaceutical industry, and the conservative members of your own party, it’s very difficult to construct meaningful, coherent reform.

But then you’ve got the equally inimitable Ezra Klein taking a different sort of long view, and discussing liberal ends versus liberal means:

The first year of the Obama presidency has been a long tutorial on the difference between liberal ends and liberal means. If I told you America has a president determined to pass large amounts of Keynesian stimulus spending (that’s particularly concentrated in impoverished areas), a near-universal health-care plan, and a bill addressing climate change, you’d say liberals had recaptured the White House. Ambitious liberals, even.

But though Obama’s program is quite liberal, he doesn’t seem to care much how it’s achieved. A public option would be nice, but if it’s not there, then that’s fine, too. Full auction of permits is a good idea, but if most get given away to corporations, then that’s how it goes. Infrastructure spending is good, but if tax cuts are the price of passage, then tax cuts there shall be. The best description of the administration’s ideology probably came from Rahm Emanuel when he said, “The only nonnegotiable principle here is success.”

He’s sort of right. The stimulus may not have been everything liberals hoped for, but it passed. Health care reform will pass, and while it may not include a state-run system, it will result in meaningful regulation of the insurance industry and coverage for millions more Americans. I’m a zealot, so I want the most liberal possible program with a trail of broken Republicans behind it. But at the end of the day, Obama is enacting a pretty liberal agenda. This is not to say that we should just sit back and be satisfied; Obama is a pragmatist who needs to be prodded from the left at every turn. But things might not be as bad as we think.

In the meantime, it’s important to look for silver linings wherever we can. In that spirit, here’s another writer with upper management written all over him, Atul Gawande, writing about how the Senate draft of health care reform, with its mish-mash of pilot programs and wacky ideas, might actually succeed in controlling the cost of health care. It’s not much, but it’s a tiny ray of hope. We’ll see what happens.