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How Progressive Groupthink Hindered Health Reform

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There's no point just blaming Max Baucus, Rahm Emanuel, or Barack Obama for the current unpleasant state of health reform - although they've each earned their share of criticism. The Left bears some responsibility, too, for failing to set the stage for meaningful change. By granting too much authority to "experts" and ceding their judgment to the resulting groupthink, many progressives laid the groundwork for the poor state of health reform today.

The public option's in trouble. And if Max Baucus and the other centrist Dems have their way Americans will be forced to buy health insurance that costs $12-14,000 per year. Progressives are finally raising a hue and cry about this burden, but a year ago they were busy promoting the idea that mandates were the centerpiece to meaningful health reform. Now, as the reality of this "reform" takes shape, it's becoming clear how badly this could turn out. Rational options are being proposed. But with the mandate issue all but resolved politically, progressives have no leverage left to push their agenda.

I can't have been the only one beating the drum about mandates (although it felt like a lonely position at times). It was clear long ago that any plan that imposes them on the American public without first creating significant savings would be a disaster, both politically and in human terms. As things stand now, a family of four without employer coverage trying to get by on $75,000 could suddenly be forced to fork over 20% of their income to a health insurer - or face government punishment.1

And according to the usually-reliable firm Martin E. Segal, those costs are likely to rise more than 10% on average in the coming year, even as benefits are cut back. Mandates? To buy that?

So perhaps those of us who have been sounding the alarm may be forgiven a little frustration when we read items like this one from Josh Marshall, which asks:

Am I the only one who thinks that if the Dems pass a bill with mandates and subsidies for poor and moderate income people to purchase it but no public option or competition with the insurers, that it will be pretty much a catastrophe for the Democrats in political terms?

His reaction's being echoed all over the progressive blogosphere, as progressives suddenly realize the idea's unfair - and a political loser. Jed Lewison at DailyKos called it "horrible political miscalculation" when Marc Ambinder reported that "the President continues to operate under the belief that liberals will warm to the bill when presented with a goodybag that includes an individual mandate ... "

How? How could the president get the idea that an individual mandate, especially without a public option, was a "goody" for progressives?

Because progressives told him so - over and over during the 2008 primaries. Supporters of John Edwards and then Hillary Clinton hammered Obama because his plan didn't include individual mandates, claiming explicitly (and wrongly) that mandates equaled "universal coverage" and were therefore more "left." And it's still happening, as in Joan Walsh's comment from a recent piece:

Let's remember that Obama opposed mandatory universal health insurance and backed the GOP fiction about the need for social security reform' - two social policy stands that put him to the right of all the leading Democrats in the primaries.

No! "Mandatory universal health insurance" is not a progressive position, as we explained here in 2007. And it's not even "universal," as we explained in early 2008. That's why Obama was able to score some points against his opponents in the primaries by rejecting mandates. That's a pledge he broke early on without drawing liberal fire, perhaps because of progressive misconceptions about this policy. But Paul Krugman, who battered Obama on this point during the election, understands what a wildfire the Democrats will ignite if they push mandates without a public option.

Context is everything. Virtually without exception, writers who are considered progressive leaders on health care pushed for individual mandates without considering the regressive and confiscatory form they could well take, and without emphasizing that they could only work fairly in the right context. As Ezra Klein wrote when the president met with all those "stakeholders," reflecting this progressive consensus: "Insurance market reforms can't happen in the absence of an individual mandate. Either everyone jumps together or no one will leave the ledge."

There is sound actuarial logic and economic calculation behind this concept. But a kind of groupthink took over. The group-thinkers decided to push Obama on mandates and assume that questions of access, fairness, and cost containment will be handled through a public option or some other mechanism. But nobody put those issues on the front burner, even though they were given lip service. The result is the potentially disastrous plan facing us today.

With mandates, the execution has to be practical and fair. Taxation's one such principle - the one I originally pushed - but it's apparently politically unsupportable. So Jacob Hacker came up with another (as discussed in my interview with him, here). But Hacker's plan, as with any meaningful reform proposal, requires a public option - both for cost containment and to serve as an insurer of last resort. If you're going to force people to buy something, you have to ensure they can afford it.

How did we get here? Josh Marshall's piece holds part of the answer. First he writes of Switzerland and Massachusetts, whose plans feature individual mandates and no public plan. But Switzerland created a rational system before things got out of control, so the Swiss aren't being forced to buy $14,000 plans. As for Massachusetts, its reform is only vaguely popular there, where the initial problems weren't nearly as complex as they are nationally, and is decidedly unpopular with those who have been affected by it (see summary about two-thirds of the way down the page, here).

And I have a sneaking suspicion that the people affected on the national level - independent tradespeople and contractors, for example - might just be swing voters in critical states like Indiana.

Marshall writes: "... many health care experts I have a lot of respect for still believe (these plans) would be a big improvement over the current situation." I have respect for those people, too, but we might be better off today if Josh Marshall and others had trusted their own instincts instead of relying on a group of people who appear to have reinforced each others' fixation on mandates. Now the progressive debate has been reduced to whether the likely final version (via Sen. Baucus) will be slightly better or significantly worse than today's status quo - and sadly, we can't know the answer to even that modest question yet. We could have had better than this.

So what now? Let's encourage the people who spoke with one voice in favor of mandates to speak with one voice again - this time, in favor of comprehensive and meaningful reform - while there's still a chance to influence this legislation.

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1The new Baucus draft bill limits out-of-pocket costs to 13% of income, but the draft seems jumbled and incomplete, and it's unclear how this would be achieved. See here for details.

RJ Eskow blogs when he can at:

A Night Light
The Sentinel Effect: Healthcare Blog

Eskow and Associates