The Obama administration’s commitment to the spirit of compromise in battles over the shape of health insurance reform has resuscitated a stale debate over political tactics. Some self-described pragmatic reformists encourage progressives to stick with the administration even when concessions to conservative Democrats dash the hopes for dramatic health care reform that once animated the presidential campaign. “Let’s get something passed,” they say. “Don’t let the perfect be the enemy of the good.” Other progressives—including some “liberal” Democrats—threaten to bolt if the final reform package doesn’t include a government insurance option. “The only way to get anything is to demand everything,” they say. “Be reasonable. Demand the impossible.” The two sides of this debate offer different answers, but they take up to the same question: How much reform is good enough?
The problem with this theoretical framing is that it tends to smuggle in a crucial assumption that warrants careful scrutiny: that various policy reforms exist along a continuum that runs from “the good” to “the best.” According to this construction, the disagreements only turn on a quantitative axis: that is, simply settling for less or more of a generically good reform spectrum. Any reform, then, would seem to be a victory for “the people” against powerful conservative elites.
But it cannot be overlooked that some of the considered reforms are different in kind, not merely in degree—and that some are not particularly progressive. The devil may be in the details of policy, then, and not in the tactics of reformists and revolutionaries. On the scorecard of history, has it made sense to celebrate a triumph of “people power” in the instances where a reform was championed by the very industries ostensibly “targeted” by those progressives? What does it mean for reformist incrementalism if the health care industry seems eagerly prepared to embrace a proposal of its own design, rather than reluctantly accept the “least bad” option promulgated by progressives?
This much we know: the commercial health insurance industry threatens nuclear war if the Obama administration even utters the words “single payer.” And the industry has called in all its chits among beholden Democrats in its (apparently successful) effort to shoot down the so-called “government option.” Not everything the industry opposes is automatically something worthy of support. But it’s probably a good place to begin. Both proposed reforms would directly threaten the basic corporate model that allows the current industry to jack up the price of policies while denying claims as a matter of course. And both reforms directly affect those who already have insurance.
Everything changes, however, when it comes to the policy that appears at first blush to be the most progressive of all: insuring the uninsured. In Massachusetts—considered a model for the national plan under consideration—the campaign to insure the uninsured was spearheaded, not subverted, by the insurance industry itself.
Insurance for the uninsured is means millions of new customers and immeasurable dollars more in premiums. For the insurance industry, the “crisis” of the uninsured is not that they receive no health care but that the uninsured do receive health care—in hospital clinics and emergency rooms. As the industry explains in its own literature, the care provided to the uninsured is paid for by federal government subsidies to states—and to a lesser extent, by charitable donations—in support of hospital clinics and emergency rooms. For insurers, the real crisis is that they don’t get a dime of that money. So what does it mean to insure the uninsured? In the current context, it means taking all that government aid that goes directly for care and sending it to the insurance industry. You can almost hear the insurers whispering to each other: “Ka-ching!”
So for those keeping score: be sure to code mandatory and/or government subsidized “insurance for the uninsured” as a victory for the commercial insurance industry.
Do the uninsured receive all the care they need under the current ad hoc system of hospital clinic and emergency room care? Not a chance. No, not automatically. Will the uninsured receive all the care they need? Not a chance. But the corporate and governmental defenders of insuring the uninsured explain why it should be coded as a loss for the uninsured.
The insurance industry has publicly committed itself to helping contain or even reduce the overall social costs of healthcare for the uninsured. Maybe they are just blowing smoke, but odds are there is something to that promise. Once all the money currently spent on care for the uninsured becomes corporate revenue, industry leaders would be in violation of their fiduciary responsibility if they didn’t do everything in their power to control or reduce the amount of money spent on care.
And there is no mystery as to the chief method by which the insurance industry reduces its expenditures: refusing claims. The result is a policy change that is arguably cost neutral or cost effective for the government and a windfall for the insurance industry. What is the source of that magical surplus? Who loses in the new math? If you guessed the formerly uninsured, advance to the head of the class.
Progressive reformers and incrementalists are understandably eager to claim something they can call a victory, but the other team still gets the point if you kick the ball into your own goal.
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