Second Opinions

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Hendrik Hertzberg: Second Opinions

http://www.newyorker.com/talk/comment/2009/08/03/090803taco_talk_hertzberg

Second Opinions
by Hendrik Hertzberg
August 3, 2009


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Pretty much everybody who believes that health care should be a human right, not a commercial commodity, and who makes a serious study of the abstract substance of the matter, concludes that the best solution would be (to borrow Obama’s words at the press conference) “what’s called a single-payer system, in which everybody is automatically covered.” But, by the same token, pretty much everybody who believes the same thing, and who makes a serious study of the concrete politics of the matter, concludes that a change so sudden and so wrenching—and so threatening to so many powerful interests—is beyond the capacities of our ramshackle political mechanisms. The American health-care system is bloated, wasteful, and cruel. Under the health-insurance-reform package now being bludgeoned into misshapen shape on Capitol Hill, it will still be bloated, wasteful, and cruel—but markedly less so. The House bill, for example, would make basic coverage available to tens of millions who now have none. It would curb the practice of denying insurance to persons with “preëxisting conditions.” (We’re all born with a preëxisting condition: mortality.) It would make insurance coverage portable, which would be a boon for both individual careers and the wider economy. Even one of these things would be a colossal improvement on the status quo.

The most consequential opposition to the reforms now under consideration is coming from a small group of Blue Dog Democrats, who protest that the plan does too little to control costs. To the extent that their concern is genuine, and not just a reflexive deference to wealth (they vociferously oppose a modest surtax on the top one per cent, whose effective tax rates have dropped by fifteen per cent since 1979, while their after-tax incomes have more than tripled), they have a point. But it’s a minor point. The prospective reform has more cost-containment provisions than past attempts, and, thanks in part to those same Blue Dogs, it is acquiring more such elements by the day—for example, the proposal for an independent commission able to set Medicare payment rates, which Obama has also embraced.

But the Blue Dogs are playing a dangerous game of chicken. Even if they’re right that reform would do too little about costs, the alternative—which, as the President has repeatedly pointed out, is the status quo—would do nothing. Ultimately, real cost control will require a strong push away from fee-for-service medicine. In Massachusetts, which three years ago enacted its own version of near-universal health insurance, the cost of expanded coverage has created pressure for just such a push. That state’s experience suggests that the cost problem, too, will be easier to solve under a reformed system, with all its other benefits, than under the one we have now.

As for the Republican opposition to reform, most of it has been, in a word, nihilistic. William Kristol, the editor of the Weekly Standard, last week offered the same advice he did sixteen years ago, when he masterminded the death of the Clinton reform effort: “Go for the kill.” Senator Jim DeMint, of South Carolina, elaborated on the theme. “If we’re able to stop Obama on this, it will be his Waterloo,” DeMint said. “It will break him.” Obama’s Presidency would survive the murder of health-care reform. But he would be greatly weakened, with dire consequences for his ability to meet many other urgent challenges. Whoever needs to be punished for morbidity, it’s not him. And not the rest of us, either. ♦