Some in power are now may now be thinking of scaling back health care reform to a bill that "could attract bipartisan support." They must reconsider. A scaled-back health reform plan would be fatally flawed, both from a policy and political perspective.
On the policy, there's no way to make a "scaled down" health reform bill work. Our health care system is a complicated and inter-connected network of pieces and policies. Changing one or just a few pieces of that system - as a scaled down health bill would seek to do - will cause immediate and severe problems in the rest of the system.
For example, you can't just do "insurance market reforms" in a vacuum. You can't outlaw discrimination based on pre-existing conditions, for example, without having everyone in the insurance system. Why? As soon as insurance companies can't charge more because you're sick, the sick in this country who have until now been denied care will flood into the system. This will raise prices for everyone, causing another problem. If prices go up, more people won't be able to afford insurance.
So, now you have to solve the problem of people not being able to afford insurance. The solution? Give people subsidies so they can afford insurance. But that creates a new set of problems. How are you going to give out subsidies and make sure that taxpayer money gets to the right people? How are you going to ensure people buy insurance with that money, and that this insurance is good insurance, not junk insurance?
To solve those problems, you need an entity that will monitor the insurance market and deliver the subsidies in an effective way. That's what the Exchange is. But just having an Exchange creates other problems. What's to stop insurance companies from just raising their rates? How do you force them to play by the rules? That's what the public health insurance option is designed to solve. If reform is enacted without it, it will be up to Exchange regulators to make sure we get a fair system. Given the history of insurance companies gaming regulation, there's real reason for pessimism.
You can't solve one problem in health care without creating another. You can't just do insurance market reforms - if you want to stop insurance companies from denying care, the top goal of health reform according to officials in the administration and in Congress, then you have to do the whole package.
Let's say you want to buy a house from me. And at the last minute, your portfolio take a big hit and you realize you have less money than you think. "Pare it back," you say. What do I do?
I can't just rip out the foundation. Then there's no house at all. The frame is important, too. So is the plumbing and the wiring. I can't leave that stuff half-finished, or the place is unusable. I can downgrade the lighting fixtures, but they won't save you much money.
Fundamentally, the things that make the house expensive all exist in concert with one another. The things that exist on their own — track lighting, say — no one really cares about. You can decide not to buy this house and instead buy a cheaper house. But you can't just make this house cheaper and still expect it to function as shelter. So too with health-care reform.
That's the policy. What about the politics?
The idea that we'll have bipartisanship on health care going forward is ludicrous. The Republican party just won a massive upset by being the party of NO. They perceive this strategy as a winning strategy for them and their candidates. Unless we show them otherwise by passing legislation over their objections, they have no incentive to compromise. NO is working and winning them elections, why change?
Senators like Max Baucus spent months and months working for bipartisanship. That process resulted in the incorporation of some truly bad ideas into the Senate health care reform legislation - ideas like the elimination of the public option - and it resulted in no Republican votes for the final health care bill.
At this point, even if the entirety of the health care bill was the words "Health Care Bill of 2010," Republicans would still vote against it.
There will be no bipartisanship on health care, and chasing it will only cost more time and bring us more bad policies. Republicans are determined not to meet Democrats half way.
Democrats have only lost one seat in the Senate. They still have 59 seats. That's a lot of seats. I'll expand on the process by which health care can pass in a future post. For now, it's absolutely possible to finish reform right and pass a good bill through both Houses of Congress. The only reason not to pass such a thing would be a lack of political will. That's the challenge of leadership that's now in front of President Obama, Speaker Pelosi, and Majority Leader Reid.