The Structuralist Club
In my chat today, a lot of the questions were some variant of "what compromise could you support?" I could accept a lot of compromises. I could accept pretty much any compromise that makes people's lives better. But to actually merit support, the bar needs to be a bit higher.
Put simply, it's the structure, stupid. The health-care system is like a house. It's easy to add the furnishings later. It's not that hard to upgrade the kitchen, or redo the trim, or re-carpet the floors. Some of that might be expensive, but it's not actually hard. But it's really, really hard to add another room, or rip out all the wiring, or build a bathroom that wasn't previously included.
So too with health care. There's a basic structure that's been present in all of the bills, and for good reason. It's a structure that a lot of good and smart people have put a lot of time and energy into thinking through. It creates a universal system through an individual mandate and an employer mandate, and makes that system affordable and dependable through a mix of subsidies, insurance market reforms, and out-of-pocket protections. It creates health insurance exchanges that individuals and companies can choose to enter if they prove more efficient and consumer-friendly, and that offer an array of different insurance options, some public, some private.
If the cost of the bill has to come down somewhat, there are ways to preserve that structure. For example, you can't have an individual mandate without sufficient subsidies, but if the benefit plan starts out a bit stingy, then the subsidies could be pretty affordable. If that proved insufficient, the basic plan — and the subsidies — could grow over time, as has happened in Medicare. If the public plan isn't strong enough, or present, in the first incarnation of the exchanges, it would be a relatively simple matter to add it into the system at a later date.
But if you begin ripping out parts of that structure, you're doing damage to the bill that you might not be able to repair. If you're not willing to have enough subsidies for the individual mandate to work, then the insurance market regulations won't work either (insurers can't offer everyone the same price — or at least not an affordable price — if healthy, young people hang back from the system). If the exchanges are hobbled or can't grow, then they can never become the alternative we need, and there will be no existing market structure for a public plan even if one is introduced.
Once removed, it's not clear that these pieces can be put back. That's particularly true given that health-care reform that is missing key components isn't likely to work very well, and if it doesn't work very well, there's no reason to believe that voters will give Democrats another shot after a few years of experience.
It's become popular of late to talk about how reform is a process and programs grow. But they grow best, and most easily, upwards, not outward. Adding a prescription drug benefit to Medicare took 40 years. But creating a generous hospital benefit was a steady and dependable process. A good reform plan will take that lesson to heart: It will put the basic structure in place so future improvements are straightforward. A bad plan will sacrifice that structure, and just add some subsidies to the existing system. And that's how I'll be evaluating the administration's proposal: How much of the basic structure does it preserve?
September 3, 2009; 2:12 PM ET
Categories: Health Reform
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