Against Comprehensive Incrementalism

Nancy Pelosi understands that her place is in the home in the health care reform debate is to position her caucus at the left edge of what is possible to get 218 votes. Everything she has been doing recently has moved toward that goal.

Speaker Nancy Pelosi is not among those praising Sen. Max Baucus (D-Mont.) for bringing his healthcare bill in well under President Barack Obama’s $900 billion limit.

Pelosi (D-Calif.), an advocate of the government-run health insurance option left out of the Senate Finance Committee chairman’s bill, criticized the means by which Baucus kept costs down.

“The savings come off the backs of the middle class,” Pelosi told a closed-door caucus meeting. “This is why we need a strong public option going into conference with the Senate.”

By contrast, Blue Dogs want to "pre-conference" the bill, so they don't have to take a tough vote. That's ridiculous and a corruption of the legislative process. The House reflects to a far greater degree the concerns of the American people; there's absolutely no reason that it cannot stake out its priorities with a vote.

The problem with simply accepting and rubber-stamping the Senate Finance Committee bill is not only that it isn't generous and doesn't cover as many people as needed. The real problem is that it's not going to feel different to the vast majority of people. Maybe that's a virtue, in some respects, but in the sense that health inflation will continue to ascend, costs will still rise, medical bankruptcies will still not be avoided, and the whole thing will be a "comprehensive incrementalism" rather than a sweeping change, I think people might look back and say, "what was the fuss about?" Now, I think Ezra is right here:

Which is only to say that this is not the end. That's true also for the House and HELP bills. All these proposals are major improvements for the uninsured and those left out of the employer-based market. That means they're major improvements for those who are hurting the worst. And in constructing exchanges and beginning the hard work of delivery system reform and creating a system of subsidies and an individual mandate, they're building the foundation of a better health-care system. But as they embark on that project, they're leaving most of our current health-care system virtually untouched, which means most of the systemic problems will remain unsolved.

I think that project can start now, particularly in the area of competition with the insurance industry in the form of a public option. Until we discover that this is all that is possible - and I don't think we're they're yet - Pelosi is absolutely right to engage and strategically position herself at the left edge.

The House still doesn't seem to grasp how to pay for the bill, knowing simply that they don't want to piss off labor with the tax on high-end insurance plans. A tax on "windfall insurance profits" would have a similar effect, however. And a public option that could lower costs would decrease the amount of people hit by the high-end insurance plan tax.

The real danger here is that the comprehensive incrementalism is so incremental that the industry decides the plan doesn't cover enough people, and they start breaking their own promises. This is what's intimated here. While I do subscribe to the "if the health industry hates it, well it must be good" theory, I think there's a real danger of not controlling rising costs because of the thinner risk pool. And that could incentivize insurers to continue their worst practices. More reform is really a cumulative answer to these problems, and we should not stop halfway.