Wednesday, June 10, 2009

Single Payer/Public Plan

Healthcare reform can be complicated when it comes to writing legislation acceptable to all the bought and paid for representatives of the various special (as opposed to popular) interest groups -- the insurance companies, the drug companies, the for-profit health care providers and so on. But the solution to the many problems our health care system faces is simple: make health care a right, not a commodity; get for-profit insurance companies out of the health insurance business altogether, replacing them with a public agency (as in Medicare or the Veterans Administration); and have the One Big Insurer negotiate costs with the pharmaceutical industry and set guidelines for healthcare provision with a view to the patients’ interests, not the interests of those who would profit (and profiteer) off the healthcare system.

Thanks to popular pressure, this single-payer solution sketched above is no longer entirely excluded from the Congressional shenanigans now under way. Why just the other day, Max Baucus, chairman of the Senate Finance Committee, was bold enough to meet with a handful of single-payer advocates! Baucus had previously refused to do anything of the sort, and even had a number of single-payer protestors at his committee’s hearings arrested for disrupting the sham proceedings he was presiding over. Baucus has also stashed away more campaign contributions from the health insurance industry than any other legislator. Thus everybody knows that his gesture was window-dressing; that the point of it was to diminish criticism, not to improve policy. There is, after all, plenty of criticism going around. This is one of those areas where media hostility and indifference have not succeeded in steering public opinion the wrong way. Nevertheless, so long as Obama and the Democratic leadership of the House and Senate are adamant about not doing the right thing, single-payer will get nowhere.

But now it looks like a pale second-best to the obvious solution has a chance. Thanks largely to Ted Kennedy and a few other “progressives” in the Senate, support is growing for a plan that Obama might get behind and that therefore might pass. According to initial reports, the Kennedy plan, still a work in progress, is similar to what John Edwards, and later Hillary Clinton, proposed during the campaign: it would mandate insurance coverage for everyone (during the campaign, Obama opposed mandates) – with subsidies for those who cannot get insurance through their jobs and who cannot afford to pay for it on their own. And it would establish a public insurance agency, either Medicare or something modeled on it, to compete with private insurers. How the mandate would be enforced, how large the subsidies would be and, above all, what kind of coverage the public plan would provide are still unsettled questions. Nevertheless, with single-payer effectively out of consideration, this has become the least bad position in the current “debate.” Count on opposition to it from Republicans and many Democrats – the “blue dogs” Obama courts assiduously. For them as for nearly all Republicans, any kind of public competition with “the free market” is anathema. And don’t expect Obama to abstain from going bipartisan on this one either. As becomes clearer with each passing day, though still light years better than Bush, Obama seems constitutionally incapable of doing better than wallowing in the middle; thus he is fast becoming a past master at disappointing (indeed, betraying) Obamamaniacs. Even so, with public opinion clearly on the side of bold moves, the plan that “progressive” Democrats forge may get through without being too badly compromised. But it won’t be easy.

Remember, though, that this allegedly best feasible option is not much of a solution. How good or bad it is depends, in large part, on what the public plan it will include, assuming Democrats hold fast on that key point, would provide. But even if the public plan is generous, it would not do much to lower costs because, unlike with single-payer, there would still be wasteful administrative costs at both ends – for health care providers, who would have to deal, as they now do, with myriads of (private) insurance plans, and, at the other end, with the for-profit insurance companies. The executives of these firms are in the health insurance business to make as much money as they can for their shareholders and for themselves -- tasks that raise (inefficient) administrative costs egregiously.

Nevertheless, if the public plan offers benefits comparable to good private plans, it just might provide a mechanism for backing into the obviously better solution – for who, other than doctrinaire free-marketeers, would want to be privately insured if they had a public alternative as good? Surely, no one in his or her right mind. This, I think, was what John Edwards envisioned. If the Kennedy plan is fleshed out along the lines Edwards proposed, it could set in motion a process that might, in time, end well – while modestly improving the situation from the beginning.

Thus the Democrats’ plan might turn out to be – not awful. But one has to wonder why Democrats who know better, Obama among them, don’t just go for single-payer? It’s a good question. The insurance companies’ hold over Congress and the White House no doubt explains something, but not the whole sad story. The illness merchants have been generous indeed – to those able to do them favors. But the forces gearing up to fight against what Obama and the Democrats will propose, if their proposal is even minimally decent, will fight as vigorously against a flawed plan as they would against single-payer. If insurance company profits are threatened significantly, count on them to fight it tooth and nail, just as they would the far better, single-payer alternative it has effectively replaced.

Of course, if Obama and the Democrats come up with something insurance companies won’t mind too much, it’s a different story. Then, much like tobacco industry executives finally came to see, health care profiteers would realize that it is best for them to concede a little to keep a lot. But if the Democrats remain steadfast; if, to the end, they support the pale approximation of a solution that is now being discussed, there’s no rationally defensible reason why they shouldn’t just go for the obvious solution itself.

I suspect therefore that the explanation lies less with campaign contributions or opportunistic political calculations or any of the other usual culprits, than with the “mind set” of the POP, the Party of Pusillanimity, itself. The Democrats’ GOP rivals may be bereft of sound ideas and, in comparison even with right-wing Democrats, unusually “challenged” morally and intellectually. But they are magnificently obstinate. Ridiculous as their positions are, their pursuit of them – and their dedication to obstruction for obstruction’s sake – almost rises to the level of the sublime. In marked contrast and notwithstanding Obama’s celebrated praise of audacity years ago, the stalwarts of the POP are so wedded to inching forward cautiously, even in cases where a smidgen of audacity is plainly called for and likely to succeed, that they just can’t forbear from acting like the invertebrate creatures they are.

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