That this bill is the status quo makes me very depressed
Before I go off and cheer up by watching the Japanese secular version of A Christmas Carol, Akira Kurasawa’s Ikiru, I want to vent. I’m pretty disgusted with what the health care bill contains, not because I think it will make the country’s health care crisis worse in practical terms, but because it illustrates the emptiness of our hopes for real progressive change in the current political configuration. I think this is driving most of that backlash against the bill, which is at least as much about what the bill represents as the bill itself, and I certainly feel it. This is the best that a large democratic majority in Congress and a massively popular democratic president in the white house can accomplish with their signature agenda after months of focus? Given the choice, I’d vote for the bill, should the health care industry decide to invest the requisite campaign contributions necessary to make me their mouthpiece as a democratic congressman. But why are we in this situation? Why do we have to accept this massively flawed, hopelessly impotent, unbelievably weak soup bill (coupled with a staggering handout to the insurance industry) as the best we can get? Those are the questions whose answers might help us.
What is not helping is the attempt by all sorts of liberals-ish to frame the issue as a choice between this bill or the status quo. Nate’s been drinking that Kool-Aid pretty hard-core; Scott Lemieux writes that “the only reason to oppose the bill is if you think it’s worse than the status quo on the merits,” and Ezra Klein and Matt Yglesias have been pushing the “something is better than nothing” argument for some time. We shouldn’t make the perfect the enemy of the good, as Evan Bayh (D-Health Insurance Industry) put it.
I’m somewhat convinced that this bill is better than the status quo in some important ways. But Klein’s argument that “This legislation is not perfect, but it can be moved in that direction” or Biden’s op-ed that “if the bill dies this week, there is no second chance to vote yes” presume a lot, and people nattering on about “the perfect and the good” are taking a tactically short term perspective, precisely because they don’t want to think about how, after this bill fails to substantively alter the currently catastrophic fundamentals of health care in the US, we can look forward to years of Barack Obama pretending that health care reform has already been accomplished, effectively destroying any chance of following it up with anything substantial. This will have been it. He’s already talking that kind of nonsense, going on about how senators are “standing up to the special interests” and moving “us closer to reform that makes a tremendous difference for families, for seniors, for businesses, and for the country as a whole.” I’ve given up on Obama being anything but a pure centrist, and if all the centrist democrats are going to adopt the position that this handout to the health insurance industry actually is reform — as it will be in Obama’s direct personal political interest to do, from now on — then they are going to do everything in their power to see that the issue never comes up again.
And one of the really troubling things about this bill is that the best argument that “liberals” have made for it is that it is deficit positive, that it will, in the long run, cost less than our present obscene hemorrhage.* But think about what a sandy foundation that argument will prove to be in the long run: this bill is a net-positive in financial terms only because anything would be better in almost any sense than the status quo. But this bill is nothing but the most painless reforms that republican politicians are too stupid to realize are actually good for business. So what there be to sweeten the deal with when the time comes to make actual steps towards an actually humane national health policy? Nothing, which is why this bill makes it increasingly unlikely that time will ever come. Not to mention that the supposed progressive left has wholeheartedly accepted the argument that lives can only be saved if it saves money to do so. But if that’s our standard, then liberalism is truly dead. It is disingenuous to pretend, for example, that this is “the largest social welfare program to be implemented since the Great Society,” when the entire premise is that we, as a society, can only spend money on poor people as long as it doesn’t actually cost money. As Obama put it, “for all those who are continually carping about how this is somehow a big spending government bill, this cuts our deficit by $132 billion the first 10 years and by over $1 trillion in the second. That argument that opponents are making against this bill does not hold water.” But that is not liberalism; that is neo-liberalism. If you start from the premise that a good bill is one that is spending neutral, you are going to find it very difficult to advocate for increased social spending.*
At the same time, the argument that this bill will, for a large number of low-income people, be worse than the status quo is a strong enough case that I don’t think anyone can really be sure it isn’t right. This anti-bill analyst estimates that a family of four making 66k will need to budget 14k for health while a family making 80k will need 20k. This pro-bill analyst argues that a family of four making 60k will be on the hook for around 12k of risk, while making 84k will need 18k. But while the worst case scenario is mildly to significantly better than it was for such families, making a health care plan a more affordable does not therefore make it affordable; after all, while the second set of numbers shows how people who are already paying for private health plans improves their situation, it only affects the uninsured if you assume that the marginal improvement is sufficient. But what if it isn’t? What if marginally cheaper health insurance isn’t enough for people who have already chosen not to buy private health insurance (having “chosen,” for instance, to pay rent)? For some people in this income bracket, the situation may be better and health insurance may siddenly become affordable; however, there are many people who will be saddled with a legal requirement to choose either to pay 9.8% of their income or a tax penalty for whom this will make an impossible financial situation worse. I don’t know, but my point is that neither can anyone else, and there are real reasons to be suspicious when a bill written by economists and insurance company mouthpieces determines how much a lower middle class family can afford to pay for health insurance and then gives it the force of law. Of course, again, that’s what neo-liberalism is: the state taking its responsibility to be maintaining a “friendly” environment for private industry.
But my point is not that the bill either is or isn’t worse than the status quo; like most people who haven’t already locked themselves into a rigid ideological position (and most of the analysts out there have long since cast their allegience one way or the other), I really can’t tell. I hope it’s better and I fear it’s worse. My point is that unless something fundamental changes about how politics happen in Washington, this bill is the best we’re going to get, and that’s horrifying. Because (as with climate change) the status quo is so far south of acceptable that a little better might as well be the status quo. In fact, exactly as with climate change. And this is what we were waiting for all those years wandering in the desert with President Bush, this is the centerpiece issue of a popular democratic president with a majority in congress. We will help people as long as doing so cuts spending? And encourages plans to cut costs by covering less? And degrades women’s access to abortions? And props up the health insurance industry? And so forth?
* Another pernicious aspect of the “we will save people’s lives as long as it is cheaper” logic is that the excise tax in this bill may significantly degrade the quality of insurance that people get from their employers. The Congressional Budget Office, for example, estimates that “those reductions would result from choosing plans that either pay a smaller share of covered health care costs (which would reduce premiums directly as well as indirectly by leading to less use of covered medical services), manage benefits more tightly, or cover fewer services,” while the Center for Medicare and Medicaid Services (a federal agency that administers medicaid and medicare) predicts that “in reaction to the tax, many employers would reduce the scope of their health benefits. The resulting reductions in covered services and/or increases in employee cost-sharing requirements would induce workers to use fewer services. Because plan benefit values would generally increase faster than the threshold amounts for defining high-cost plans (which are indexed by the CPI plus 1 percent), over time additional plans would become subject to the excise tax, prompting those employers to scale back coverage.” Ezra Klein points out that the excise tax will only tax health care plans above 23k a year (and only the portion above that point), but he also admits that the entire point of the tax is “to give employers an incentive to become more value-conscious purchasers of health-care insurance,” which is to say, to buy cheaper health care for their employees. And this is the means of making the bill more affordable: making the health care that people already get worse (and anyway, Jon Walker’s rebuttal of Klein’s numbers seems pretty strong to me).