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Saturday, 19 December 2009

Crunch Time in Health Care Reform

We're in the end game of health care reform.

As I said in my last post, we're seeing real debate in the Senate, but - unfortunately - only among the Democrats, since the Republicans have united around their goal of preventing the Democrats from passing a bill.

Yesterday two of our best commentators - David Brooks and Paul Krugman - discussed whether Senators should support the bill. Brooks (here) agonizes over the choice, but ultimately concludes that he would vote no. Here's why:
"...if this passes, we will never get back to cost control. The basic political deal was, we get to have dessert (expanding coverage) but we have to eat our spinach (cost control), too. If we eat dessert now, we’ll never come back to the spinach."
Krugman (here), I believe, would agree with Brook's analysis of the pluses and minuses in the bill. But he ends up encouraging a "yes" vote:
"With all its flaws, the Senate health bill would be the biggest expansion of the social safety net since Medicare, greatly improving the lives of millions. Getting this bill would be much, much better than watching health care reform fail...Bear in mind also the lessons of history: social insurance programs tend to start out highly imperfect and incomplete, but get better and more comprehensive as the years go by. Thus Social Security originally had huge gaps in coverage — and a majority of African-Americans, in particular, fell through those gaps. But it was improved over time, and it’s now the bedrock of retirement stability for the vast majority of Americans."
For three reasons I think Krugman got it right:

  1. The perfect is the enemy of the good. No matter where one falls on the spectrum from single payer advocate to market hawk, the Senate bill is hard to love. The legislative sausage moving through the reform process won't satisfy anyone's dreams. But the right comparison is with the status quo, not the ideal. It's been 16 years since the last serious effort at health reform. Senators should ask - "would we rather tinker with the status quo for the next 16 years or work with the framework created by the bill?" Imagining a better bill isn't a reason for voting "no." We're not going to see a better bill. Only those who (a) genuinely believe that tinkering with the status quo is the better course to follow from 2009 to 2025 or (b) expect that when we go further into economic hell in our health system handbasket we'll be readier to pass a better bill should vote against the bill we have.

  2. Wishful thinking won't control health care costs. The bill is rightly seen as doing little to contain costs. But many of those who make this attack are the same ones who shouted "evil rationing" and "death panel" when costs were dealt with more directly. We've made progress as a body politic in understanding that health care cost containment is a moral and economic necessity, but we haven't grown up enough yet to dig in to the cost problem openly, honestly and vigorously. In 1914 Freud introduced the concept of "working through" a "neurosis" - clarifying the elements of a conflict, identifying the basis of our resistances to change, and moving forward as best we can - as the pathway to change. It's a sloppy and slow process - "an arduous task for the subject of the analysis and a trial of patience for the analyst" - is how he described it. As it was with Freud's patients trying to cure neuroses in 1914, so it is with our population trying to cure the health system through political action in 2009. Alas, knowing that our system is profoundly wasteful and unjust doesn't create the will to to make bold choices any more than knowing the source of our neuroses erases our quirks. We have to take baby steps - working through!

  3. It's time to retire Reagan's sound bite that "government is the problem." In his inaugural speech in 1980 President Reagan said "Government is not a solution to our problem, government is the problem." It's still the central tenet of Republican theology. (See here for a video clip of Reagan's speech.) Because of our pervasive distrust of government, proposals like single payer insurance or a "public option," which would be mainstream ideas in most other developed economies, are seen as "radical" and "socialist" in the U.S. Our readiness to believe that support for doctor-patient dialogue about appropriate care for the elderly meant "death panels" showed just how powerful the grip of the perspective Reagan articulated so forcefully is in our national psyche. (See here for a discussion of the "paranoid style" in American politics.)

    Atul Gawande's characteristically insightful article in the December 14 New Yorker draws an analogy between the federal government's creative role in catalyzing development of U.S. agriculture at the turn of the 20th century to the potential impact of the many pilot programs promoted in the Senate bill. His argument won't convince the right wing mullahs, but I think anyone with even a partly open mind will see the many ways public action could foster positive change.

The Senate bill, and whatever comes out of the Senate-House conference, is the best option for change we're likely to have before 2025. It will be VERY imperfect. There will be LOTS to criticize. But voting it down and endorsing the status quo would be the wrong course for the country to take.


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