Wednesday, December 09, 2009

What's All That Subsidiarity For, Anyway?

So, the very latest is that the Senate has a compromise in the works: no public option--that is, no government-administered, publicly available alternative to monopolistic and price-controlling private and employer-based insurance packages--but instead, 1) federal encouragement (and perhaps financial support) for the emergence of nation-wide, non-profit insurance options (with the possibility of a "trigger" for an actual public option to be proposed if no insurance provider actually follows through with the creation of such non-profit plans), and 2) an expansion of Medicare, enabling an earlier buy-in to the program for economically disadvantaged folks of 55 years of age and older (a crucial, costly group for calculating the affordability of any subsidized plan), along with 3) other regulations and restrictions affecting the aforementioned insurance providers. Consider that we are dealing with a Senate that functionally operates in an environment which requires 60 votes for anything to get done, that's not bad, don't you agree?

My old friend Matt Stannard doesn't. He argues--not inaccurately, I must admit--that "non-profit cooperatives are to a 'robust' public option as a handshake is to a passionate kiss," and condemns the collusion of corporate power and weak-kneed Democrats who make it possible: "This is a failure of democratic deliberation brought about by the intervention of corporate resources...[and] because Obama himself, and even many 'liberal' democrats, fundamentally believe that a world where the rich get better care than the poor is...not worth the effort and risk of a foundational attack." And he cites a brilliant, radical piece by Alan Nasser, who argued that Obama's unwillingness to fight for a truly universal system of medical coverage--such as a single-payer system would likely provide--was a dodge, invoking the impossibility of achieving anything "perfect" and instead contenting himself with "the American way" of offering a "series of choices"...which, as things played out, would be provided by various private actors, of course.

I want to agree with Matt; I'm a believer that, for all it's faults--it's hardly a "perfect" system--single-payer, and a direct attack on employer-based private insurance, is the best way to achieve universal coverage in a marketplace where health care is inevitably concentrated and distributed in less than just ways. But I also wonder if his attack on the compromises coming down the pike, as worthy as it is, doesn't misunderstand the "perfect system" which Obama said he didn't want to try for. What's the relevant "perfection" here, anyway?

I went on (for too long, as usual) yesterday about why the Catholic--though really, just common sensible and Christian--principle of subsidiarity makes the broad theoretical argument in favor of national health care reform sensible to me, despite the unpredictable consequences such an expansion in federal involvement may mean. The national government can do something moral and just, which other levels of government cannot. And what is that thing it can do? It can get more people the medical coverage necessary for them to afford the health care they need. And that's really it. 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 if there are ways to do that without goring the much-deserved-to-be-gored oxes of private insurers--ways that, and this is crucial, can actually produce legislation that passes, rather than producing warm feelings of righteous indignation as bills go down in flames on the Senate floor--well, I can live with that.

Ezra Klein writes, "Health-care reform is not a competition between liberals and insurers. It's a question of outcomes....If there was some way the deal could be slightly changed so that the CEO of Cigna got a flat tire while rushing to an important meeting and would have to wait a long time for a tow truck on a cold day, that wouldn't really make it a better deal." He's right. It's a paltry--and, frankly, an un-Christian--form a justice, I think, which insists that getting an agency of government that can do something right, to actually do it, isn't enough if it does so in a way that makes use of another, existing injustice. That would be "perfection," maybe, but it's not the relevant perfection here.


Ross Bailey said...


How do you separate the injustice of insurance monoply from the injustice in inequitable provision of health care? Isn't Ezra Klein throwing out a straw man? Maybe no one wants to injure the insurance executive in some random way, but if his profits are unjustly obtained, from whom are they obtained if not from the individuals who give up the chance to get the health care they need?

Russell Arben Fox said...

Ross, perhaps Ezra's outlandish example is a straw man, but I don't think the point behind it--or, at least, the assumption supporting the point behind it--is. The point is, what will deliver more medical coverage to the people who need it now, next year, or ten years from now? The current Democratic proposals, with all their currying to avoid offending the interests of private insurers too deeply, will in fact do that, a little bit. But trying to jury-rig the present legislation so it's less friendly to insurance company interests will not, as things stand, do that...and there is little clear reason to believe that if the Democrats had come at this topic differently, that they could have even gotten to this point in the first place. And so here we are. I wish I didn't believe that; I wish I could believe the the injustice rampant in private insurance monopolies could have been attacked as part of achieving more coverage for more people, presumably by advocating something more socialistic, like a single-payer plan. But knowing what I know about the U.S. Senate, and its functional 60-vote requirement, I can't get myself to believe that. Which means, ultimately, that I find criticisms like Matt's, as worthy as they are, unhelpful at this point.

E.D. Kain said...

I think you're right Russell. Sometimes we have to accept imperfect results and then work with those - especially with something like health insurance because right now people really are going without, and that's simply not right. If we can cover more people now and then fix the other problems later, I say we do it. (Actually we should probably send out catastrophic coverage to all uninsured Americans tomorrow.)