Regarding Health Care Reform: It's the Philosophy, Stupid

Or, towards a general theory of why so many who support national reforms in our health care system, including myself, were so upset with Senator Joe Lieberman last week, and why so many of us are only moderately pleased with the reforms heading towards passage in the Senate this week.

It seems as though the final hurdles, at least insofar as the Senate is concerned, have been surmounted. Very early this morning, the first of several procedural votes were taken to move the shaky set of compromises which Senator Reid and other Democrats (plus two independents) had agreed to through a delicate, party-line-only window, and towards passage. It seems all but certain that before Christmas, the Senate's health reform bill will be passed and finished. After that, of course, comes the conference with the House bill, which itself is filled with all sorts of possibilities, both good and bad, regarding the ultimate fate of the bill...and only then will national health care reform go to this president's desk for signature. So clearly, there is a lot of fighting and debating yet to go. Still, getting health care through the Senate at all, with its sometimes astonishingly baroque factions and rules, was a huge accomplishment. More importantly, it is an accomplishment, what with the huge uproar which Lieberman's actions created, that underscores at least one of the key philosophical fault lines which run through those in support of national health care reform.

In this midst of all the noise and fulminations early last week, lots of folks, from Vice President Joe Biden on down, kept making the same points: this is not a great bill, but it is a good bill. It's not a mansion, but it is a "starter home", a good beginning for further developing universal coverage of basic medical costs in the United States. Few people, amongst those I read anyway, expressed this argument with more fervor than Nate Silver did: "At the end of the day, [the Senate bill is] a big bleeping social welfare program--the largest social welfare program to be implemented since the Great Society." Seen in that way, it's a huge success, correct?

Well, it's a huge success to liberal egalitarians and social welfare advocates, of course. What do I mean by those labels? Most of those reading this post who can guess where I'm going will probably already understand my use of them, but for the record: liberal (or welfare) egalitarianism is a way of talking about the demands of justice as equality, or as fairness, in terms of individual needs and rights. In the context of health care, it means this: there are some who, for reasons of hard work or inheritance or random luck are in a position of being able to pay for, on the private market, all the health care they need. And then there are those--a majority of Americans--who, for similar reasons, are at least able to cover the costs of all the health care they may need to pay far on the private market through insurance plans. And then, finally, there are those who, for any number of reasons (too sick or too old for private insurers to be willing to take on, too poor to afford insurance but too rich for Medicaid, etc.), can't pay for the health care they need. That's unfair. True, many of those individuals may have made some bad choices or foolishly missed some important opportunities, but just as many others may be stuck with illnesses and injuries and costs that exceed all of their plans. Individuals shouldn't suffer for bad luck, for things outside of their control, or even for things that, in some hypothetical situation, they might have been able to control, but didn't. So let's help them. It's the decent thing to do. Let's set up some welfare programs, let's engage in a little redistribution of opportunity and access, let's put some restrictions on what powerful actors are able to do. This will help more people be more healthy than previously they'd been able to be.

All well and good...except some of us want more than that. We wanted to see the distribution of health care to be run along lines which weren't dependent upon private actors (whether corporate or individual) making private decisions. In the same way that we, as a society, do not by and large see maintaining law and order, or defending our borders, or putting out forest fires, as a goal best achieved through private contracts (however subsidized and regulated!), some of us wanted to see the costs of providing health care made more deeply egalitarian: made more, yes, socialized. Now, we realized we weren't going to get that, for any number of reasons both defensible (the size and plurality of our national community, for example) and not (the corrupting power of corporate influence over our political process). But we did hold our hope for something, for some tinkering around the edges of our individualistic, private-and-employer-insurance-based system, for something that would cut into the role that various insurance monopolies (because that's what they are: for the majority of Americans, the choices their insurance plans provide them with are practically not real choices at all) play in how medical resources are bought and sold. That something could have been a public option, a government-run alternative to private insurers...or, failing that (which perhaps was always the likely result, though the Obama administration is at least partly at fault for that), it could have been a Medicare buy-in, which would have turned that federal program, however minimally, into a public option-lite. And we didn't get either one. Nate noted in the post above that "[this] bill is not 'real reform' in the sense of something that fundamentally alters the structure of the current, predominately private, predominately employer-based insurance system." And that pisses us off, because we were so close to something more--something less individualistic, something that treated health care less as a social welfare problem and more broadly as a social good.

As for what that means for the bill we actually do have, I'll admit to being torn, as most of the folks in my quasi-socialist category are; just a couple of weeks ago, while praising the Medicare buy-in option which briefly flourished in the Senate, I stated "My egalitarian longings want to see something more; they want to see social reforms that make for more democracy, and less corporate power. But, insofar as this debate is concerned, what I really want to see is more people insured." And that remains true, and that's why most of us angry people (even Howard Dean!) are willing to back the bill. But only grudgingly.

Here's my own weirdly localist/socialist beef in particular. Jacob Hacker called the public option "a means to an end: real competition for insurers, an alternative for consumers to existing private plans that does not deny needed care or shift risks onto the vulnerable, the ability to provide affordable coverage over time." By failing to create that, but still insisting on the individual mandate that all people purchase insurance, you pretty much guarantee that the only player who might be able to create regulations which powerful insurance corporations would be forced to obey--and to generate the level of subsidies necessary to make whatever the insurance companies offer all their new (mandated) insurees is affordable--is the national government. Unlike some on the left, I have no problem with the idea of the individual mandate; it makes perfect sense to me that, as a basic requirement of participating in a collective good whose costs need to be controlled and more equitably distributed, that everyone needs to be included in the pool. But of course, with no outright socialization (whether British NHS-style on one extreme or Canadian single-payer-style on the other) and no public option or anything like it, we don't really have, in the reforms being voted on, a vision of health care as a "collective good"; it's still just an individual good that we want to try to make the access to and distribution of somewhat more universal and fair. And that means making the most power actor of all--the national government--central to its provision and regulation. Wasn't that always what was going to happen? Yes, insofar as actually creating a new floor upon which everyone who needs health care could stand. But if we're not proposing a new, universal floor upon which all can stand--and the Senate bill does not--than it means that what's being proposed is potentially hundreds of millions of additional hand-outs to lift different individuals up. Which, again, isn't a bad outcome--it's certainly an important contribution to our nation's welfare. But I also wonder to what degree it will make the much-discussed Section 1332 of the Senate bill--the provision which would allow the states the freedom to innovate in any number of ways in how they subsidize insurance purchases from private providers--a bit of a dead letter. How long will state-based subsidized exchanges survive and flourish when set against the resources controlled by huge insurance conglomerates? Not long, I fear.

There was, in all of these debates, the real possibility, however remote, of removing from the American people a choice which, for the last century or so at least, has seemed to inevitably bedevil almost every public policy struggle which they have faced: a choice between increasing corporate power and a centralized federal government. Given a choice between the two, I'll go with the latter, and so would most egalitarians (whatever else might be said about the Senate bill, it's not designed to make the national government more money!). To get beyond those bad options requires dramatic, broad, social reform; it means a reconceiving of politics as something other than a handmaiden using the market to fairer ends, into seeing it as something more democratic, something that allows the people, and their agents, to directly involve themselves in supplying their own needed goods. But that's not where the Democrats are taking us; as Ed Kilgore put it (essentially making my own point about five days ago), "the Obama administration has chosen the strategy of deploying regulated and subsidized private sector entities to achieve progressive policy results." This is a philosophical divide amongst those who want more equality: you have the Clintonian "New Democrat" pragmatists, who accept that protecting the little guy means offering him as much freedom as possible in choosing which big guy is going to take care of him, and you have the "social democrats" (or whatever you want to call them), who would actually rather the sort of reforms which enable the little guy himself to be in charge.

We in the latter camp lost this round, as we will probably lose just about every round (no thanks to you, Joe!). We should be happy for what little additional equality we get, of course. But neither should we ever forget why pushing for what we did was important, and get ready to do it again next time.

[An update: a rather specifically Mormon bit of praise for Senator Harry Reid.]