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Is a flawed health-care bill better than no bill at all?

M1X00060_9.JPGMarcia Angell, a single-payer supporter and former editor of the New England Journal of Medicine, doesn't believe the House bill is better than nothing. She thinks, instead, that it "throws more money into a dysfunctional and unsustainable system, with only a few improvements at the edges, and it augments the central role of the investor-owned insurance industry." The fact that we need to do something does not mean we need to do this. "I would rather see us do nothing now," Angell concludes, "and have a better chance of trying again later and then doing it right. "

This is, I think, a misreading of not only the politics of this issue going forward, and also the history of health-care reform going backward. Failure does not bring with it a better chance for future success. It brings a trimming of future ambitions.

Truman sought single payer. His failure led to Kennedy and Johnson, who confined their ambitions to poor families and the elderly. Then came Nixon, whose reform plan was entirely based around private insurers and government regulation. He was followed by Carter, who favored an incremental, and private, approach, and Clinton, who again sought to reform the system by putting private insurers into a market that would be structured and regulated by the government. His failure birthed Obama's much less ambitious proposal, which attempts to reform not the health-care system, but the small group and nongroup portions of the health-care system by putting a small minority of private insurance plans into a market that's structured and regulated by the government, and closed off to most Americans.

Failure does not breed success. Obama's defeat will not mean that more ambitious reforms have "a better chance of trying again." It will mean that less ambitious reformers have a better chance of trying next time.

Conversely, success does breed success. Medicare and Medicaid began as fairly limited programs. Medicaid was pretty much limited to extremely poor children and their caregivers. Medicare didn't cover prescription drugs, or individuals with disabilities, or home health services.

But once the programs were passed into law, they were slowly and continually improved. They became more expansive, with Medicaid growing to cover not only poor families but also poor adults, and the federal government giving states the option, and matching dollars, to include more people under the program's umbrella. Medicare was charged with covering people with long-term disabilities, and it was eventually strengthened with a drug benefit, more preventive coverage, the option of supplementary plans and much more.

It is not hard to imagine health-care reform following a similar path. The exchanges can be opened to all employers and all individuals, creating a competitive insurance market virtually overnight. The public plan could be strengthened, or the government could begin to set payment rates for insurers who participate in the exchange (as is common in other countries). Subsidies could expand, and new funds could be used to encourage the development of integrated care organizations rather than simple insurance companies. The public option could be strengthened and the employer tax exclusion converted, as Ron Wyden has long advocated, into a standard deduction, which would strike at the heart of the employer-based market.

But all that is predicated on the creation of this new, flawed, insufficient system. As any scientist will tell you, it's much easier to encourage something to evolve in a certain direction than it is to create it anew. The idea that a high-profile failure in a moment where a liberal Democrat occupies the White House and Democrats hold 60 seats in the Senate for the first time since the 1970s will encourage a more ambitious success later does not track with the history of this issue, nor with the political incentives that future actors are likely to face. If even Obama's modest effort proves too ambitious for the political system, the result is likely to be a retreat towards even more modest efforts in the future, as has happened in the past.

For more, see Jon Cohn.

Photo credit: By Alex Brandon/Associated Press

By Ezra Klein  |  November 10, 2009; 11:43 AM ET
Categories:  Health Reform  
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I enjoy how Mr. Klein points to Medicare and Medicaid as "successes" even though they are now bankrupt and borrowing money from future generations to pay for the poor and the old today. I guess the definition of success has changed. . .

Posted by: octopi213 | November 10, 2009 11:55 AM | Report abuse

Unless of course people despise what you have created. This bill is forcing people to buy insurance and not guaranteeing they will get even decent coverage. This bill says that insurance companies now have to cover people with preexisting conditions but it leaves loopholes so the companies can deny claims. If people grow to hate the new system it will make it harder to improve it.

The fact the Medicare and Medicade were run properly and were successful made it easier for it to be expanded upon.

Posted by: jbou891 | November 10, 2009 11:56 AM | Report abuse

Fair argument. You might have bit of a luck with this line with Fred at WaPo.

Posted by: umesh409 | November 10, 2009 12:01 PM | Report abuse

I do loves me some Marcia Angell but yeah, I don't know why she's digging in her heels here. Her position that quitting now improves chances later is wholly indefensible by history. Truman, Kennedy, all had Democratic majorities in both houses just like Obama but in their case they were fighting southern Democrats instead of conservative Democrats. Safe to assume it'll always be something or someone you have to negotiate with and that negotiation will lead to incrementalism.

Posted by: ThomasEN | November 10, 2009 12:24 PM | Report abuse

Agree. Coming back later doesn't assure we will have the momentum we have now. It will be rough sledding the closer we get to elections (mid term and next Pres. election.)

Posted by: chiquita2 | November 10, 2009 12:28 PM | Report abuse

"But all that is predicated on the creation of this new, flawed, insufficient system. As any scientist will tell you, it's much easier to encourage something to evolve in a certain direction than it is to create it anew. "

That is exactly why this bill is worse than nothing: it pushes the country further down a path that cannot have a happy outcome. Private insurance in other countries is a component of an actual system; a part of a health policy. In this country, private insurance *is* the policy. Even though insurance companies do not deliver care, it's financial services products that have received all the "health care" attention.

Angell is right when she says that throwing more money into a bankrupting model a bad thing. Health care reform advocates in this country have focused almost exclusively on a fallacious binary choice between patchwork private insurance and single-payer. Like Jon and Ezra, most have folded in the face opposition to single-payer and convinced themselves that incremental "improvements" to a doomed model are better than nothing.

If anything, the Medicare experience -- in which CMS has been repeatedly forestalled from implementing cost saving, quality improvements by Congress -- should be a lesson in the dangers of depending upon legislative tweaks to yield coherent policy.

It is extremely frustrating to read self-avowed progressives call the current bills "reform" when it is no such thing. It represents continued affirmation of a patchwork, non-system of health care and as such, it guarantees that health care will be bankrupting even more families, companies, and government a decade from now.

Posted by: Athena_news | November 10, 2009 12:34 PM | Report abuse

talk to me when 40% of the country is liberal and 20% is conservative and not the other way around. Then you can argue that no reform now is better than incremental or "incorrect" reforms.

Oh and this is only going to get uglier. There's still that little issue of illegals being allowed to purchase on the exchange that the hispanic caucus has said they won't vote for a bill that doesn't allow that and conservatives will hold it up for that.

I'd love to hear Mr Klein's optimism/pessimism for reform passing now. I'm afraid what was 70%/30% pro reform passing is now 70/30 the other way.

President Obama needs to remind wavering dems that half a loaf is better than no loaf and three slices of bread is better than no food at all. Explain that to those with pre-ex right now. How easily the 44,000 that die every year without healthcare are brought up when it pushes a liberal argument but they're also as quickly forgotten when people jump off the reform bandwagon when its not "their version" of reform. They need to realize it was never going to be their version or reform.

Posted by: visionbrkr | November 10, 2009 12:41 PM | Report abuse

Since the final bill is far from completed, I think Marcia Angell is doing the right thing by trying to push the final bill to be better than the mediocre at best bill the House just passed. I realize the Dems never seem to do this, but even if Angell really thinks the current House bill is OK as a firs step (like Ezra seems to) saying that significantly before the overall bill is final is stupid. You don't negotiate from your final position, you negotiate to get something better than your final position.

Posted by: williamcross1 | November 10, 2009 12:55 PM | Report abuse

But doesn't your analysis assume that the employer-based health care insurance system doesn't completely unravel? I certainly agree that the past trends support your position, but on the other hand the pressure for reform will only become greater over the next several years if nothing happens. This is not an issue that is simply going to go away.

Posted by: valeskoi | November 10, 2009 12:58 PM | Report abuse

as i believe it was jon cohn who noted (and sorry, i haven't clicked through), if the same mentality had been applied to fdr's flawed version of social security, i doubt we would have social security at all today.

in short, if angell is doing her best to improve the bill, fine; if angell really believes that ripping it up and starting over at some unspecified future date is an intelligent position to take, she's wrong.

Posted by: howard16 | November 10, 2009 1:03 PM | Report abuse


You've been making some fantastic points lately -- even moreso than usual -- this being one of them.

I would add that social security for our seniors, unemployment insurance, and further back, free schooling for our children, started out weak and limited and over time were greatly augmented and improved.

Posted by: RichardHSerlin | November 10, 2009 1:13 PM | Report abuse

I don't understand the comparisons with Medicare and Medicaid -- they should in fact be lessons about how *not* to proceed.

Johnson bribed doctors with fee-for-service and thereby planted the seeds of our current financial problems in the health care arena.

The current legislation attempts to appease all the people who are responsible for the actual costs and bribe private insurance companies by delivering a captive market.

Posted by: Athena_news | November 10, 2009 1:14 PM | Report abuse

I couldn't agree with Ezra more. And I think the key with HCR this time around is getting coverage to approach true universality. IIRC the bills under consideration get us to something like 97% coverage. With those types of numbers, you should get the type of political critical mass that guarantees UHC will remain in place, which means the problems will have to be dealt with constructively, rather than dealing with them by dropping people from the ranks of the insured.

There's also a moral issue involved. It's true that we might have the votes for single payer some day -- let's be optimistic and call it eight years from now. The problem is, failure to adopt a universal coverage system now in favor of waiting for a better political environment for single payer means several hundred thousand Americans die in the interim for lack of health insurance.

Posted by: Jasper99 | November 10, 2009 1:19 PM | Report abuse

This bill is obviously only a single step, it is important as it basically can't be undone; like creating the DOE, SS, Medicaid, or a million other instances of growing the government.

Posted by: jhglassman | November 10, 2009 1:26 PM | Report abuse

I'm all for your logic, as long as the price is not setting reproductive rights back 25+ years.

Posted by: michaeljamesdrew | November 10, 2009 1:30 PM | Report abuse

I've crossed some kind of line, one that I never saw coming. I'm a 59 year old Democratic woman who's stayed with the party through thick and thin. I voted for Obama. As a former cancer patient I have a great fear of pre-existing condition and recission threats if I lose my current coverage before I'm eligible for Medicare.

The Stupak amendment finally put things into focus for me: I'm not falling for "making the perfect the enemy of the good" anymore. I will not sell out women's right to full health care for some ragged, half-assed shell of health care "reform." The likely form of what can pass both houses is not anything I can even imagine as "a step in the right direction."

The American people deserve the government they get. Some lessons just have to be learned the hard way.

Posted by: jslamen | November 10, 2009 1:45 PM | Report abuse

Ah, yes. This "let it all fall to hell and then we'll finally muster up the courage for a final solution" is a perennial favorite of the arrogant and the ignorant.

I believe that's how we handled AIDS. The Reagan administration wouldn't spend on education, research or treatment. So doctors just wouldn't tell people how to prevent the disease, in order to make sure it infected as many people as possible so that we'd make preventing and treating this disease a national priority. Or, wait, that's not AT ALL how it happened.

This is just magical thinking--that there's this perfect solution out there, everybody knows it, and those persnickety politicians are such horrible and corrupt losers that they won't just make it happen!

Would Wyden's bill or single payer be better than the reforms on the table? Sure, I think so. But I'm not going to romanticize payment systems. There's doubtless going to continue to be enormous problems in our healthcare system even if we pass single payer. And I'm sure it will create its own set of unanticipated problems. So, no, I'm not at all prepared to throw away coverage for 40 million people because I've got this romantic notion that a more intellectually appealing financing system will solve all our problems.

And for the trillionth time, Massachusetts is a pretty good indicator that a couple years after solving this coverage problem, you start solving the cost problem. Sure, doing this presumes we'll have a functional political process, but frankly EVERY approach presumes a functional political process. Absent a functioning political process, we can't solve ANY problems from banking to the environment to defense, so it's not really clear to me why people say "oh, we'll never get serious about the deficit" as an argument against making healthcare more accessible for millions of uninsured Americans. If we don't blow it on healthcare, we'll blow it on tax cuts, defense spending, corporate welfare, or something else that's equally stupid. At least with healthcare, we're not just burning the cash.

And frankly, healthcare isn't a problem we solve in 1 election cycle. It's not a problem we solve in TWENTY election cycles. It is something we chip away at steadily for the rest of this country's existence. PERIOD. Laws will have unintended consequences, and little things that seem not very important at the time (the born in the US clause of the 14th Amendment, for instance) can have massive repercussions. I don't care how smart you are, you've got to let this stuff play out in the real world, and EXPECT to have to go back and tweak it.

Good lord, we've amended the Constitution itself something like 27 times. If we couldn't get THAT right, I don't understand why anyone with a brain would presume we'd be able to fix healthcare in one fell swoop.

Posted by: theorajones1 | November 10, 2009 1:51 PM | Report abuse

"And I think the key with HCR this time around is getting coverage to approach true universality."

Universal health care means that everyone has the same access to the same level of treatment. Insurance is not coverage and coverage is not care.

Only in America would anyone think that extending a dysfunctional patchwork of private insurance by mandating insurance for the minority of people who don't have it constitutes some sort of "universal coverage." It truly is "uniquely American" to believe that this could be a good thing.

"And for the trillionth time, Massachusetts is a pretty good indicator that a couple years after solving this coverage problem, you start solving the cost problem."

Massachusetts is a very good illustration of what happens when people equate insurance with care and focus on tweaking the insurance market. Insurance is designed to see that providers get paid.

A national health policy should be designed to see that people get appropriate treatment, when they need it, without creating financial instability. IOW, the exact opposite of these bills.

Posted by: Athena_news | November 10, 2009 2:12 PM | Report abuse

"If anything, the Medicare experience -- in which CMS has been repeatedly forestalled from implementing cost saving, quality improvements by Congress -- should be a lesson in the dangers of depending upon legislative tweaks to yield coherent policy."

Our legislative process is certainly messy -- observation has lead to comparisons of sausage rendering -- but I’m not sure how else to allocate health care resources! The underpinning of representative democracies is the ability to more appropriately allocate resources, over the long-run, than other forms of governmental rule.

The reason Medicare has not been reformed has more to do with the Medicare Trust Fund than with the inability of our legislative system to address resource allocation. Currently, shortfalls in receipts from Medicare taxes are covered by the Trust Fund. When this runs out (2018, maybe 2016…it’s a moving target), expenditures exceeding receipts will be applied directly to the federal budget, and therefore the deficit. Right now the Trust Fund is like a credit card that does not come do for ~ 8 years – the members of Congress know inaction is not a viable strategy long term but none are willing to accept political flak at this point to change the system. Once Medicare’s bloated budget is not shielded by the Trust Fund and Medicare expenditures eat into every discretionary spending item in the federal budget, you will see legislators have a lot more enthusiasm for revising the Medicare program. (As an aside, health care should be funded in the general budget and subject to revision and competition with every other societal priority – then we will learn where public support can be found and its limits!)

Granted, this delays reform until its almost “too late”! But if the legislative process is ill-equipped to ever allocate health care resources, as Athena_news suggests, then I have to ask what color is your junta flag?

Posted by: bigDtex | November 10, 2009 2:19 PM | Report abuse


This is an excellent post, and something that needed to be said.

Tothose who worry that private insurers will take over the market, or that reform won't contain costs --or about many other things, let me just say this: No one piece of legislation could possibly overhaul a $2.6 trillion industry.

This is just the beginning. We will need separate legislation spelling out just how we will regulate insurers.

We have three years to do this. And we'll keep on refining and strengthening the system evern after 2013. Health care reform is a process not an event.

Posted by: mahar1 | November 10, 2009 2:21 PM | Report abuse

An important issue here is the power of experimentation and "trial and seeing".

I think a key reason why starting with even something very weak and flawed worked so well with Medicare, Social Security for our seniors, etc., is that that limited first attempt allowed the public to see how untrue the Republican lies were. They saw that Medicare didn't make us socialist as Ronald Reagan and the Republicans said it would (see here for proof: They saw that it was very valuable and made life a lot better, and so when a bill was attempted to make it stronger, there was strong public support. And then they saw that that made life better still, and so there was strong public support for the next bill to strengthen it, and so on.

Republican lies, misconceptions, and simple-minded sound-bite economics can be very stifling and harmful, but a fantastic way to expose them is to just try the plan and show how false they were.

And this is a key reason why I support abolishing the filibuster (which would only take 51 senators and the VP). It would allow for much more experimentation and learning. Very harmful Republican ideas that did get through as a result would be short lived, as public outcry, and only needing 51 votes, would reverse them relatively quickly. But good ideas would get tried much more often. This would quickly expose the Republican lies about them, and they would be permanent, like Medicare, Social Security for our seniors, unemployment insurance, etc. I have a post on this for more at:

There is also an outstanding guest post on the power of experimentation, trial and seeing, at Stanford economist Paul Romer's Charter Cities blog, at:

Posted by: RichardHSerlin | November 10, 2009 3:17 PM | Report abuse

I am absolutely appalled by statements that paint Medicare as an unmitigated success. It has definitely worked well in its goal of enabling seniors to access care and lift them out of poverty. It has not worked well for the federal budget and it has not worked for those who pay their own way. We have a situation today in which health care for seniors is bankrupting everyone else...that is not a good thing.

The problems with fee for service were evident to Johnson almost immediately -- and no one has ever been able to put that genie back into the bottle. Instead, the model was embraced by the private insurance industry and created more problem ever since.

Insurers are not the problem, it is the model in which they are working...and no one is talking about changing that. Talking about controlling costs later is simply denial. We have to reform the system now.

Posted by: Athena_news | November 10, 2009 3:48 PM | Report abuse

As a journalist, Mr. Klein, you really need to do more research. Contrary to what many newspapers report, Medicaid does not cover all poor people, or even most poor adults. It covers very low-income children and caregivers, disabled adults, and people over age 65. It has not been greatly expanded over the years, except in the increasing number of people who fit these limited categories, especially since discriminatory regulations that kept minorities from being approved were struck down.

Nor has Medicare been greatly expanded. The prescription drug benefit is an expensive joke. To my knowledge, home health care is still not covered -- I'm not sure what your sources are on that. Perhaps you are conflating Medicare supplemental plans, which not everyone purchases or can afford, with Medicare itself. And Medicare coverage for disabled adults doesn't kick in until they have been disabled for 24 months, which is a long time when you can't work and need to see a doctor regularly.

Furthermore, Medicaid and Medicare are entitlement programs. The difference between an entitlement program and a regular program is that people who qualify for an entitlement program must get the benefits, and cannot be deprived of the benefits without due process. The modern trend has shifted away from entitlement programs; no new health care entitlements have been created since the 1960s, and I'll bet the new health care "reform" is no exception. A program that can be changed or eliminated with a stroke of the pen, and which has no guaranteed due process to its recipients, is a poor foundation for future imagined expansions. You have no evidence that such expansions will occur or are even possible, except your own wishful thinking.

Posted by: linden2 | November 10, 2009 6:37 PM | Report abuse

I'm a strong single-payer supporter -- I believe that private insurance companies do absolutely nothing to contribute to the quality of health care in America. A middle man that profits off of denying people care is entirely unnecessary and should be eliminated -- the experience of dozens of other countries on this issue shows that single payer makes sense and lowers costs. So I sympathize with the intentions of Marcia Angell.

That being said, this post by Ezra Klein is precisely spot on. If this attempt at health reform fails, the Washington elite will say that the Obama plan was just too ambitious and that this country just isn't ready for such progressive reform. The next health reform debate (which will, in all likelihood, take place within a more conservative Congress) will start centering on conservative approaches to health reform such as vouchers for private insurance and buying insurance across state lines (i.e. killing all existing state-based insurance regulation), and the debate between Democrats and Republicans will merely be over how generous the tax credits will be.

The 2009 "Obamacare" idea that insurance companies can be "ordered by the government" on who they have to cover and at what (relative) price will be seen as some "failed liberal pipe dream". The 2009 "Obamacare" idea that lower and middle class Americans are entitled to affordable health insurance (via progressive government subsidies based on income) will be seen as some "socialist experiment". The 2009 "Obamacare" idea that millions of new working class Americans should be added to a single-payer system (Medicaid) will be seen as "old wealth redistribution politics".

Now yes, at some point, the bill could become so compromised that the status quo would be better. But the expected Senate bill, and certainly the House bill, are far from that point. And if you think otherwise, please take a moment to read some of the details of the bill -- the House Democratic staffers did a fine job summarizing the effects of the bill and when exactly they would kick in:

To my progressive friends: keep fighting to have your voices heard, support the good parts of the bill, and oppose the bad parts. But in the end, we need to pass the bill, and then we need to begin the fight to improve it. Rome wasn't built in a day. This would still be the greatest progressive domestic policy achievement in at least 30 years.

Conservatives know that once something like this exists (government policy based on the principle that no one should go broke because they get sick, and that no one should be unable to get coverage because of who they are or how much they make), it can never be undone; it can only expand to help more people and in more effective ways. And that strikes fear into conservatives' souls, as it should.

Posted by: vvf2 | November 10, 2009 7:05 PM | Report abuse


This argument made sense at the "Baucus Finance committee" stage, but the Stupak Amendment changes things considerably. We are not at "half a loaf" now, we are at moldy crumbs.

What are we doing here? The bill provides ZERO benefits to most people. It lumps onerous conditions -- effectively new restrictions -- onto the already-terrible individual market. It has virtually abandoned affordability concerns. And it's abandoned the clearest mechanisms for cutting costs.

Is effectively restricting abortion rights in the most extreme way in decades really worth that? Are the forthcoming Nelson/Lieberman compromises worth it? It's getting harder and harder for me to say "yes" to that.

Posted by: NS12345 | November 10, 2009 7:47 PM | Report abuse

I have been a critic of the coverage here of health care reform and of the public option as a lame excuse. I also think that this health care bill will potentially blow up the system with cost increases. That said, I cannot take Angell's position though I am also sympathetic to Kucinich not voting for it knowing that it will pass.

I believe Americans need to be constantly reminded that this bill will not get them very far at all. The efforts to pass this bill have largely MISINFORMED the public about what constitutes real healthcare reform and in essence once it passes, if it does, an entirely new discourse of healthcare reform will need to be introduced.

Maybe this is the type of bill that will so inflate healthcare costs that real reform will be it is progress in that way. I am however not going to criticize Angell for pointing out how straightforward a expansion of Medicare would be.

Posted by: michaelterra | November 10, 2009 11:51 PM | Report abuse

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