health care bill: good policy killed by bad politics?

Two of the most prominent progressive leaders in Democratic politics have just said that we should kill the health care bill the Senate is recommended, which has been freshly stripped of the Medicare buy-in for those 55-64 years of age as well as the public option trigger. It will likely also be stripped of the 90% "medical loss ratio" provision, which would have required insurance companies to pay-out 90% of their premium revenue in health care benefits. Given all these losses on big ticket and hotly debated issues, it is not surprising that Howard Dean and Darcy Burner are calling for abandonment of the abomination that they see a once promising reform effort having turned into. To quickly get the cost-savings that real health insurance reform requires, reconciliation may be a better idea.

One expert, however, disagrees. Health care cost guru Atul Gawande argues in his latest New Yorker piece that perhaps Frankenstein's Monster is exactly what the U.S. health care system needs right now: a poorly sewn together package of every innovation and policy proposal ever to cross a health policy expert's desk, all thrown out into the marketplace of ideas as pilot projects, may the strong survive. As Dr. Gawande argues, "if we’re willing to accept an arduous, messy, and continuous process we can come to grips with a problem even of this immensity."

The real question, then, seems to me to be not whether American ingenuity fueled by small-scale government-backed successes, gradually scaled up, can work--it seems very plausible that it can--but whether such a process can flourish in the political turmoil likely to follow from such a "weak" health care bill. Because the truth remains that even if there is a lot of "good stuff" in this bill, it will not reduce health care costs quickly enough, it will not create competition in the market where health insurers operate as an oligopoly, and Americans will see little short-term improvement in their access to or cost and quality of health care. There simply isn't enough big ticket stuff in the current health care bill that Democrats will be able to point to come 2010 and 2012, and too much risky stuff (individual mandates to buy insurance comes to mind) that may prove political liabilities. The possibility of a loss of Democratic control of government means that even the good policy ideas scattered throughout the bill may not have a chance to take root; a Republican government would undoubtedly lead to uprooting of pilot projects before they can demonstrate their success, and scaling up would be near impossible.

I have little faith that a Sen. Reid-led Senate will use reconciliation, as they should have from the beginning, to push through the most essential, cost-saving reforms. The final hope lies in conference committee and the possibility that the Medicare buy-in compromise with the public option trigger can be restored, and that this will provide enough short term relief for enough Americans that Democrats can hold on for the next 4 years at least.