A few more thoughts on why I support the healthcare bill

David Brooks has several good reasons why people should support the healthcare bill – and in true David Brooks fashion, he also offers some reasons why the bill is not good.  Chief among these:

The first reason to oppose this bill is that it does not fundamentally reform health care. The current system is rotten to the bone with opaque pricing and insane incentives. Consumers are insulated from the costs of their decisions and providers are punished for efficiency. Burkean gradualism is fine if you’ve got a cold. But if you’ve got cancer, you want surgery, not nasal spray.

Well let’s flip this on its head, because I’m one of those healthcare bloggers who would have really liked to “fundamentally reform health care.”  You see, watching it all go down in Congress – and especially in the Senate – I realized that America was never going to fundamentally change the status quo, at least not in one fell swoop.  We weren’t going to implement the sort of free market the Cato Institute was pushing for, anymore than we were going to expand Medicare to cover every American.  We weren’t going to adopt a Singaporean or a Dutch system or even the French system that Matt Welch recently waxed poetic about.

No, we were going to pass something vastly compromised, far from perfect, but still pretty major.  It’s big enough and bold enough that conservatives are decrying it as socialism, and conservative enough that members of the further-left are calling for its demise.  But here are the things it does that I think are fundamental and important, and really overlooked by many proponents and opponents of the bill.

First – and I think this is extremely important – it answers the question about coverage.  Nearly all Americans who can’t afford to be covered will be covered by this bill.  There may be loopholes and problems with the subsidies and mandate penalties that make this less than perfect, but we move a giant step forward toward universal coverage.  This is important for two reasons. The obvious one, and the one that drives my own thinking on this issue the most, is that more people who need healthcare will have it.  The second and less obvious is that the universal coverage question will largely vanish from discussion.  It won’t be the motivating issue behind healthcare reform going into the future.

This is important because from here on out the only thing that our elected officials will need to worry about is cost.  So maybe this bill doesn’t address the cost issues, but it removes one final barrier to making that debate front and center.  There is no conceivable way that this bill will address all the cost-containment issues, after all, but it will make sure that more Americans are covered.

Second, this bill creates a real market for health insurance.  The exchanges aren’t perfect, but they are vastly superior to what we have now. Anyone who has attempted to purchase insurance in the current market (if it can be called such) knows how difficult and frustrating it can be. Some would argue that simply creating a freer market would do the trick – and they might be right – but I’m not holding my breath. At least this puts us on the road to nationally competitive private insurers within a regulated exchange. The subsidies (vouchers) for lower-income Americans can be used to purchase insurance from many competing insurers within this market, and insurers have to play by certain rules in order to be included.  That’s a market, and it makes consumers more confident that what they purchase has some modicum of quality and transparency.

Will this sort of exchange run the risk of crowding out small insurers?  It certainly could – but the current system is even worse.

One of the best concerns I’ve heard expressed over this bill is that it will limit the supply of medical providers – nurses, doctors, and so forth.  I think this is a more compelling argument than the stifling of innovation.  There are other reforms that might help this that we could implement in the future – like relaxing of medical licensing rules, and other attempts to bust up the medical provider cartel, or relaxed restrictions for health centers. Having cheap, efficient health centers set up in shopping malls and other convenient locations makes tons of sense. Tort reform may be a complicated issue, but there’s promise down that road as well. On the spending side, we could have programs like Teach for America set up for doctors who would work in low income, inner city, or rural areas and have tuition paid for.  We can even spend some money investing in community health centers.

And obviously there are many other fundamental changes that need to take place.  Fee for service is a problem.  Employer-insurance is a problem.  The distortion of the relationship between the provider and consumer of healthcare is a problem. And on and on.

But my larger point here is that after this is passed, we’ll have the coverage question out of the way and all these other ideas that revolve around cost can take center stage.  After this, all future healthcare reforms will be about cost – to the government and to the American taxpayer.  The exchanges will eventually expand into national markets and people will slowly drift from employer coverage to insurance via exchanges.  The important questions will be bandied about, kicked down the road, glossed over, pretended away – and eventually addressed and wrestled with and finally overcome.