But Is It Good Enough?

Lot of interesting feedback on the Wyden plan, some of which I want to explore a little further. But first, I want to ask a question: Can anybody truly see Congress passing a piece of legislation and a president signing a bill that, in one stroke of the pen, dissolves Aetna, UnitedHealthGroup, Kaiser Permanente, Blue Cross, and all the rest? We're talking about the full dissolution of multibillion dollar corporations that employ thousands and thousands of people, contribute heavily to a wide swath of politicians and provide massive tax revenues to a large collection of states, and have been the sole providers of health coverage for nearly a century now. Forget whether you, or I, think their demolition would be a good idea: Do you see it as a possibility?

I've tried to imagine it. Believe me, I have. But I can't. Not in the near-term, anyway. Which why I'm somewhat unimpressed by demands that Democratic proposals start from a single-payer stance and condemns any that don't as "signal[ing] a sell-out by the Democratic congressional leadership." Politics is the art of the possible, and so long as the health system is genuinely harming millions of Americans, the perfect can't continually be the enemy of the good -- the question must be whether what's achievable is good enough.

That said, insurers are a problem. But what you can't destroy, you may be able to reform. That's the strategy of the Wyden plan. Insurers long ago realized the easiest way to make money was to expend vast amounts of energy and resources figuring out who will actually use health care, then deny it to them. So they identify everyone who is sick, has been sick, or possibly, one day, will be sick, and price them out of the system. We're left with a system that excludes precisely those who need it. Wyden's plan imposes "community rating," which means insurers can't price discriminate between applicants. Instead, they have to cover everyone for precisely the same price. You could have an enlarged heart, a missing limb, and a lazy eye, and you're getting the same deal as the triathlete down the block.

Of course, this system could make the triathlete down the block opt-out while the ill and the old rush in, thus destroying all insurers and bringing the system to its knees. Thus the individual mandate: With everyone forced to buy in, the young, the old, the sick, the well, and everyone in between spreads out cost, ensuring no single group too heavily tilts the pool. Some folks don't like individual mandates -- I'm not one of them. Single-payer, after all, is an individual mandate too -- you just pay for it through income or sales taxes. The problem with such systems is affordability, but the Wyden plan has a genuinely robust set of subsidies, reaching all the way up to 400% of the poverty line. It is, in other words, determinedly progressive.

The real problem, as I see it, is cost containment, which will be better than our system's but worse than a nationalized system. That said, any sort of coherent, national structure opens the door to serious cost containment mechanisms down the road -- something we definitively can't implement in the current structure. Nevertheless, I'll get more information on the cost containment mechanisms as the day goes on, and report back what I find. Any other questions?

Also at Tapped