The Health Care Endgame

Clearly, Democrats and the White House are advocating strongly for a public health insurance option, as the only way to truly lower costs, both to the federal budget and for consumers. The polls show that the American people generally agree - they may have concerns about cost and quality, but they support competition and choices. And the ABC poll cited above arguably skewed the public option question the most of any; opinion appears to skew in favor of a public option. Republicans have called it a deal breaker.

There are a million rumors flying around about this Senator and that. And there are plenty of process stories about whether Democrats should have pre-compromised reform by taking single payer off the table (which normally I would agree with, but this is the most plausible rebuttal to that scenario that I've ever seen - basically that such a strategy could have arrived DOA at the Capitol, and doomed reform because there's no assurance of a deal at the end of the road). And there's going to be more outright lying from those on the right who basically want nothing to be done.

At the end of the day, this sounds right to me as an endgame:

The stimulus was a huge and important accomplishment. If you had told liberals in 2007 that they were going to pass an $800 billion dollar spending bill that made good on decades of promises about infrastructure rebuilding and comparative effectiveness research and train construction and broadband internet and green energy, they would have laughed at you.

But by the time the bill actually wound its way through Congress, most liberals were frustrated by the outcome: A few Senate moderates had lopped $100 billion in spending off of the total and done so for no apparent reason. Top economists said that the legislation, though helpful, would not be enough to close the output gap and should thus be larger. The stimulus was a historic legislative accomplishment that nevertheless left liberals frustrated because they made concessions they didn't see any reason to make and ended up with a bill that they knew would not fully solve the problem.

That, I'd bet, is how health reform will close out as well. We will spend a trillion or a bit more covering the un- and underinsured. We will regulate a fairer and more decent insurance market into existence. We will expand Medicaid and build out subsidies to at least 300 percent of poverty and create health insurance exchanges. We will fund all this through sharply progressive taxes. We may even have a public plan. In 2006, it would have been a great deal. But as the legislation winds its way through the Senate, there will be unpleasant compromises, and unconscionable omissions, and the constant knowledge that though this is progress, it is not sufficient, and the people who stand in the way of a better bill are frequently incoherent or disingenuous. And that will be terribly frustrating for supports of the effort. The result will probably be a historic win when compared to the status quo, but I doubt it's going to feel like that for supporters of the initiative.

That's playing out as we speak. The Senate Finance Committee is trimming the subsidies to make health care affordable, reducing their availability to families at 300% of poverty instead of 400%. But they are NOT the only game in town. We have a solid House bill with a decent public option, which will reduce costs when factored in to the CBO score. We have the ability to keep insurers honest. We can implement a number of provisions to change the incentives for doctors to ring up more treatment instead of effective treatment. And we have allies like, amazingly enough, Jay Rockefeller:

Rockefeller estimates at least 100 million Americans face major problems paying for health care today.

"We can't count on insurance companies. They are just maximizing their profits. They are sticking it to consumers.

"I am all for letting insurance companies compete. But I want them to compete in a system that offers real health-care insurance. I call it a public plan," Rockefeller said [...]

On Thursday, Rockefeller admitted he expects little bipartisan support.

"There is a very small chance any Republicans will vote for this health-care plan. They were against Medicare and Medicaid [created in the 1960s]. They voted against children's health insurance.

"We have a moral choice. This is a classic case of the good guys versus the bad guys. I know it is not political for me to say that," Rockefeller added.

"But do you want to be non-partisan and get nothing? Or do you want to be partisan and end up with a good health- care plan? That is the choice."

In other words, we have a chance to reverse the dynamic, where bipartisanship is favored above everything and the policies are calibrated to the one holdout conservative, and instead have a dynamic where a public plan becomes the key for garnering support from enough Democrats to pass. We can keep pushing from the outside to ensure that dynamic holds.