The Change We Need?

The President held a health care town hall yesterday, and reporters are cooing about the staged nature of the questions, but the President was asked why we can't have a single-payer system, why Congress wants to "tax health care benefits," why the whole thing isn't just about tort reform, and a pretty broad cross-section of the full debate. I didn't rally see the press corps get much deeper than that in all of their queries on this subject.

On the single-payer question, the President basically announced the triumph of politics over policy in the health care debate.

THE PRESIDENT: Sure. Well, it's a terrific question. I'm not sure if everybody could hear it, but the gist of the question is, why have we not been looking at a single-payer plan as the way to go?

As many of you know, in many countries, most industrialized advanced countries, they have some version of what's called a single-payer plan. And what that means is essentially that the government is the insurer. The government may not necessarily hire the doctors or the hospitals -- a lot of those may still be privately operated -- but the government is the insurer for everybody. And Medicare is actually a single-payer plan that we have in place, but we only have it in place for our older Americans.

Now, in a lot of those countries, a single-payer plan works pretty well and you eliminate, as Scott, I think it was, said, you eliminate private insurers, you don't have the administrative costs and the bureaucracy and so forth.

Here's the problem, is that the way our health care system evolved in the United States, it evolved based on employers providing health insurance to their employees through private insurers. And so that's still the way that the vast majority of you get your insurance. And for us to transition completely from an employer-based system of private insurance to a single-payer system could be hugely disruptive. And my attitude has been that we should be able to find a way to create a uniquely American solution to this problem that controls costs but preserves the innovation that is introduced in part with a free market system.

I think that we can regulate the insurance companies effectively; make sure that they're not playing games with people because of preexisting conditions; that they're not charging wildly different rates to people based on where they live or what their age is; that they're not dropping people for coverage unnecessarily; that we have a public option that's available to provide competition and choice to the American people, and to keep the insurers honest; and that we can provide a system in which we are, over the long term, driving down administrative costs, and making sure that people are getting the best possible care at a lower price.

But I recognize that there are lot of people who are passionate -- they look at France or some of these other systems and they say, well, why can't we just do that? Well, the answer is, is that this is one-sixth of our economy, and we're not suddenly just going to completely upend the system. We want to build on what works about the system and fix what's broken about the system. And that's what I think Congress is committed to doing, and I'm committed to working with them to make it happen. Okay?

I'm not saying that the President is wrong - except about France, where 86% of the public actually has supplementary insurance, mostly through employers. But it's true that upending the employer-based system would be disruptive and politically unpalatable, and firing everyone in the insurance industry en masse would be chaotic, and so on. The problem is that this further entrenches a fairly inefficient way of delivering health care, namely the employer-based system. In fact the goal of a reform with an employer mandate would be to get more people covered by their employers. So we move forward with a comprehensive incrementalism, building on the historical accident that is the present system, and trying to plug every leak in it, by encouraging employers to cover their workers, providing a health insurance exchange for those who don't, adding an individual mandate, forcing insurers to accept everyone, using a public plan to bring down costs, instituting reforms to Medicare and Medicaid, trying to get doctors to stop ordering up so much treatments that are unnecessary, etc. You're doing forty things at once to band-aid the current system instead of adopting a new one.

I agree, that approach IS uniquely American. But that doesn't make it terribly bright. I do understand the rationale - large majorities like the health care they get, so they perpetuate the system, and it's easy to demonize reform by saying "you'll get kicked off your current coverage." But the politics and the policy are not well-aligned. And the result is an uneasy compromise.

I do think that the President and the DNC are doing the right thing on the politics - highlighting the health care horror stories that bring this home and make it real, and demanding change. It's just a question of whether the change that ultimately will result is significant enough.