The Future of Healthcare Reform

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Charles Pierce has some questions for me about healthcare reform:

I am not unsympathetic to the arguments made by Kevin Drum or Matt Y. here, even though I think the opprobrium heaped on Jane Hamsher is wildly disproportionate…..Ask me what I’d do, and I’d probably vote for the ongoing POS that is the Senate bill. However, I would like both Kevin and Matt [] to explain the “stepping-stone” argument to me. Why, precisely, should I believe that, that once we pass the POS, any opportunity to improve it, largely by the process of political evolution, will remain?

….After all, it’s unlikely that the new system proposed in the ongoing POS will become so wildly popular, and so seriously armored by public approval, that there will be a substantial political risk to having opposed it in theory, or to opposing it in practice. Not by next autumn, anyway….Why shouldn’t the Republicans run on a promise to repeal the new system, and then follow through by doing exactly that?….Can somebody explain to me how the surviving Democratic politicians, even if they hang onto their majorities, will muster the will and skill to move toward “further reform in the future,” as Mr. Drum puts it, given what we’ve seen of their performance with overwhelming congressional majorities?….Again, everyone, please show your work.

Obviously there’s no kind of geometric proof for this, but let’s take a crack at it anyway. There are two separate questions here.

First, if healthcare reform passes, what’s to stop Republicans from repealing it if they get control of Congress in November? That one is easy: Barack Obama’s veto pen. As it happens, I also think that Republicans will find that it’s far more difficult to repeal an actual existing bill with a bunch of popular provisions (pre-existing conditions, subsidies for the poor, etc.) than it is to make cheap, stemwinding speeches about onrushing socialism to tea party crowds, but that’s really secondary. They couldn’t muster 60 votes for repeal, and if they did, they certainly couldn’t muster 67 votes in the Senate and 290 votes in the House to overturn a veto.

Second, what’s the argument for longer term progress? This isn’t quite as black and white, but the historical evidence is pretty clear. Look at virtually every other advanced economy in the world. They started off with small programs and grew them over time. Germany spent over a century getting to universal healthcare. France started after World War II and didn’t finish until 1999. In Canada, national healthcare started in Saskatchewan in 1946, spread to the other provinces over the next couple of decades, and became Medicare in 1984. The trend here is pretty obvious: once people get a taste of universal healthcare, they like what they see and they don’t stop until the job is finished.

But the United States is different! Fine. Take a look at social programs in the United States. Social Security provided meager benefits and only modest coverage when it was first passed. Over the course of the next 40 years it became a full-fleged universal pension plan. Medicare passed in 1965 with a limited payment structure and has been improved ever since. Prescription drug coverage wasn’t added until 2003. You see a similar direction for things like federal home loan programs, civil rights measures, S-CHIP, gay rights, and practically every other social program ever passed. Progress is uneven, and sometimes even goes backward, but the general trend is pretty clear.

Once healthcare reform is passed, everyone will breathe a sigh of relief and move on to other issues. Republicans will huff and puff, but they don’t have the votes to overturn it and they know it. (Why do you think they’re resisting it so rabidly? They know perfectly well that entitlement programs practically never go away once they’ve been passed.) Then, down the road, future congresses will start to make changes. Maybe a Medicare buy-in. Maybe bigger subsidies. Maybe a public option outside of Medicare. It won’t happen overnight, but within 20 or 30 years the current bill will almost certainly turn into de facto national healthcare. It’s likely to be based on private health insurers in some way, but that’s how they do it in Germany and the Netherlands too, and it works fine. Eventually it’ll work fine here too.


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