http://www.prospect.org/cs/articles?article=the_health_care_ultimatumThe Health-Care Ultimatum
Some progressives have called health-care reform without a public option worthless. Here's why they're wrong.
Paul Waldman | December 22, 2009 | web only
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Now that the public option is dead, many of the progressives who have turned against the bill have focused on the bill's individual mandate, the requirement that everyone buy insurance. There is something to the argument that it's unfair to force people to sign up with an industry that has repeatedly demonstrated its greed and indifference to human suffering -- particularly when you aren't giving them the option of a government plan. Unfortunately, there is simply no alternative. If you're going to get everyone covered, you have to expand the risk pool so it includes everyone. Keep in mind also that one of the core goals of this reform has always been forbidding insurance companies from denying people coverage because of their pre-existing conditions. But without a mandate, people could just wait until they get sick to sign up for coverage. If that were allowed, premiums would skyrocket to levels even more unaffordable than what we have now. It may be distasteful to deliver the insurance companies millions of new customers, but there's just no way around it.
I say this as one who throughout this debate has been as vociferous an advocate of the public option -- and as harsh a critic of the insurance industry -- as almost anyone who writes about this topic (see here, and here, and here, and here, and here). Progressives rightly condemned Joe Lieberman for arguing that he would rather see someone go without insurance than see them get insurance from a public plan (he didn't put it quite that way -- he said that reform with a public option was worse than no reform at all -- but the effect is the same). So we can't say that it's better that someone go uninsured than get insurance from a private company.
We have to remember that the currently uninsured will be getting their insurance not through the abomination that is today's individual market but either through an expanded Medicaid or through the newly created insurance exchange (or exchanges -- the superior House version creates one national exchange, while the Senate version creates state-based exchanges). The exchange is the most important feature of health-care reform as it now stands. If progressive opponents of the bill think the regulatory protections in the exchange are inadequate to forestall insurance company predation, they have to explain why, and how the exchange ought to be improved.
For all its weaknesses, even the Senate's version of health reform, which would hopefully move more in the direction of the House's version when the two are merged in conference, contains an extraordinary number of beneficial features. (You can find an excellent summary of both bills here, from the Kaiser Family Foundation.) It insures over 30 million more people. It expands Medicaid coverage. It outlaws denials for pre-existing conditions, rescission, gender discrimination in premiums, and both annual and lifetime coverage caps. It provides hundreds of billions of dollars in subsidies for low- and middle-income people to buy insurance. It makes it so if you lose your job, you don't lose your health insurance. It forces insurers to allow people as old as 26 to stay on their parents' policies. It establishes dozens of pilot programs to test new ways of saving money and improving care. All of these provisions, and many others, will substantially improve people's lives. And the insurance exchange puts in place the structure through which further improvements can be made in the years ahead.
I'm not arguing that the point has come -- or will ever come -- when progressives should say, "OK, that's good enough" and stop arguing for improvements to the bill. Quite the opposite: They should keep criticizing the bill's shortcomings and continue to argue for what it could be. But it would be a terrible mistake to conclude that because of the loss of the public option, the bill now does more harm than good. There is no starting over. If the bill dies now, it's dead, and we won't get another chance for reform for at least a decade. And what will happen in the meantime?
Last week, a friend of mine wrote to tell me about some of the people in her life waiting for health-care reform. A friend of hers, after a long stint of unemployment, finally got a new job -- but one with a six-month "probationary period" before he could get health benefits. As she put it, the stroke he suffered "didn't wait for the probationary period." He's now in the hospital, facing both a long recovery and crushing medical bills. My friend's mother-in-law works for a small business that doesn't offer her health coverage. She seriously injured her knee six months ago, but couldn't afford the surgery to repair it. She recently fell and broke her other leg.
Progressives have every right to feel that they've been mistreated in this ugly process. They have the right to be angry, and bitter, and resentful, and disillusioned about what has occurred and what might have been. They have the right to feel that their dreams of a transformative Obama presidency and their election-night euphoria were naïve. But we shouldn't forget who this debate is really about.
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