Thoughts on the state of health-care reform

By Michael J.W. Stickings

I'm not happy there's no public option, I'm not happy there's no Medicare buy-in, and, in general, I'm not happy it's not a single-payer system like the one we have in Canada.

But what to do? Oppose the bill because it isn't enough or support it because it's all we can get?

I've been mulling this over for some time, like a lot of you out there, and like a lot of prominent commentators in the blogosphere, and a conversation with a friend yesterday clarified a few points for me.

To wit: I think it's extremely important for those on the left, liberals and progressives alike, not to give in too easily. We have been largely dismissed by the White House and the Democratic leadership -- with Obama himself pushing Reid to make a deal with Lieberman while all but ignoring the protests of those on the left of the party, as well as of those within his, and the party's, liberal-progressive base -- as if we simply don't matter and are of little consequence. But why are we the only ones who need to compromise? Why do we have to give more than, say, Lieberman and Nelson? Well, we are told, because that's just the way it is, what with the Republicans apparently unanimous, for now, in opposition to reform. Either we give in or there's no bill, and no reform, and it'll apparently all be our fault, as we're the ones who'll be blamed. Yes, I accept that the bill will be more to the right than what we would like, but we should nonetheless withhold our support until we win at least some concessions. Okay, no public option, no Medicare buy-in? Then, if you want your individual mandate, which is what the insurance companies want, then put in sufficient subsidies to ensure that those required to buy insurance will actually have the means to do so. In other words, if it's the Dutch system you want, more or less, then give us the Dutch system, more or less.

Here's Jon Cohn:

Now, the reforms moving through Congress won't produce a system as comprehensive as what the Netherlands or Switzerland has. But that's not because of the individual mandate, which actually makes a lot of sense. (Read here if you want chapter and verse on that.) That's because the subsidies and regulation in these bills aren't as generous and strong as they could be.

The public plan would have helped make up for these deficiencies. That's why it's loss is truly regrettable -- and why its supporters should be angry. But the best response wouldn't be to demand the politically impossible -- that is, to insist upon a restoration of the public plan that simply doesn't have the votes it needs to pass. It would be to demand some other things, like better subsidies and regulation, that do have political potential and could actually make the final bill better.

I'm all for a loud, angry left. If nothing else, we need it to balance out the loud, angry right. But there's a fine line between being constructive and destructive. This latest gambit, I think, crosses it.

That "gambit" is opposing the individual mandate. I actually support the individual mandate, but I think it makes some sense to oppose it until "subsidies" and "regulation" are "generous and strong." At the very least, that should be our bargaining position.

So keep fighting. Don't just go along with Reid and the White House. Demand more. Demand concessions. It's quid pro quo. If Lieberman and Nelson need to be appeased, fine, but they should compromise, too, and not simply be allowed to determine the final version of the bill. Yes, we need to be "constructive" about it, but we can be constructive within the parameters of good-faith negotiating.

Ultimately, though -- as I swallow hard -- I think Kevin Drum (via Cohn) is right:

From any kind of progressive point of view it's hard to see how you could seriously argue that the current bill is a net harm. Sure, it makes compromises to powerful interests that are hard to swallow. But that's why they're called powerful interests: because they can kill your legislative priorities if you don't assuage them. In return, though, the Senate bill brings down insurance rates, expands Medicaid, offers the prospect of moderately priced insurance to tens of millions of the uninsured, forces insurers to take you on even if you have a chronic pre-existing condition, mandates minimum levels of coverage, and takes several small but important steps toward reducing the future growth of healthcare costs. That's an enormous advance for the progressive agenda.

There's an alternate universe out there in which you could get all this stuff without compromise based on the sheer force of progressive arguments. Sadly, it's not this universe. I sure hope we don't have to learn this the hard way yet again.

Of course, there is also much to be said for Glenn Greenwald's position (via Drum):

In essence, this reinforces all of the worst dynamics of Washington. The insurance industry gets the biggest bonanza imaginable in the form of tens of millions of coerced new customers without any competition or other price controls. Progressive opinion-makers, as always, signaled that they can and should be ignored... Most of this was negotiated and effectuated in complete secrecy, in the sleazy sewers populated by lobbyists, industry insiders, and their wholly-owned pawns in the Congress. And highly unpopular, industry-serving legislation is passed off as "centrist," the noblest Beltway value.

Kevin agrees, I agree, and I suspect most liberals and progressives agree. But what else are we to do? Yes, I wish it had all been done differently. Yes, I wish the bill currently in the Senate were more progressive. Yes, I see that "the worst dynamics of Washington" have triumphed yet again. Am I happy about that? No. But what I am happy about is that real reform is finally on the horizon.

And if it were to fail now, then what? It wouldn't be brought back next year, with the midterms, and likely not before 2012. And who can predict what Washington will look like beyond that?

Sad to say, but what we have now, compromises and all, is better than nothing.

We just need to keep fighting as urgently and as strenuously as we can, and to win as many concessions as we can, and to demand that the White House and the Democratic leadership take us seriously and pay us the recognition we deserve, before swallowing hard and signing on for good.