The Treatment

The House Bill Is "Worse Than Nothing"? Really?

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Marcia Angell, M.D., is one of the nation's most well-respected experts on health care issues. And with good reason. A board-certified pathologist who also trained in internal medicine, she's a former editor of the New England Journal of Medicine and senior lecturer at Harvard Medical School. Her writing credits include The Truth About Drug Companies and an award-winning article at TNR on the same subject. (She co-wrote that with Arnold Relman, a distinguished physician, writer, and intellectual in his own right.)

Angell is a well-known advocate for single-payer health care: If it were up to her, she'd simply expand Medicare to cover everybody. This is not, of course, the kind of health care reform we're going to get this year. Instead, we will--if we are lucky--get something that looks like the bill that passed the House of Representatives on Saturday night.

Angell is not impressed, as she explains today at the Huffington Post:

Is the House bill better than nothing? I don't think so. It simply throws more money into a dysfunctional and unsustainable system, with only a few improvements at the edges, and it augments the central role of the investor-owned insurance industry. The danger is that as costs continue to rise and coverage becomes less comprehensive, people will conclude that we've tried health reform and it didn't work. But the real problem will be that we didn't really try it. I would rather see us do nothing now, and have a better chance of trying again later and then doing it right.

I'm a longtime single-payer supporter myself. If Angell could get her way, I'd be thrilled. But Angell can't get her way.

Blame the composition of the U.S. Senate, where North Dakota has the same representation as California. Blame the power of special interests like the drug industry, which virtually own large swaths of Congress. Blame public opinion, which remains stubbornly skeptical of big government even as it cherishes programs like Medicare. Or blame somebody else. The numbers in Congress simply don't provide enough support for anything remotely approaching single-payer. Just look at how hard it is to pass a scaled-back public insurance option.

To Angell--and to others on the left, as my colleague John Judis notes today--this is reason for ditching the whole effort. But what, really, would that accomplish? The immediate impact would be to undermine Obama and his allies in Congress, creating the (accurate) impression they are incapable of passing major legislation. The Democratic Party would lose seats at the midterms and then, quite possibly, suffer even bigger setbacks two years hence. That's not exactly a recipe for progressive revival.

Perhaps Angell and those who agree with her that this would be a constructive failure--that eventually growing frustration with our health care system will help us elect even more progressives and pass more ambitious reforms. Well, maybe. But that's an awfully big chance to take. Progressives said the same thing when the Clinton health care plan failed and, before that, when efforts to pass universal coverage under President Richard Nixon collapsed. If anything, the conversation about health care reform has drifted the opposite direction over that span of time. You could plausibly claim that the reforms on the table today are more or less what moderate Republicans were proposing under Clinton, just as the Clinton reforms were not that far removed from what Nixon himself wanted in the early 70s.

And what would happen in the meantime? According to the Congressional Budget Office, the House bill would mean about 36 milion people get health insurance, reducing the number of uninsured by around two-thirds. People who had pre-existing medication conditions would, finally, have the ability to get insurance just like the employees of large companies do. The insurance would not always be as generous as it should be, but the government would prohibit lifetime caps, place some limits on out-of-pocket spending, and establish a basic benefits package that makes sure all policies cover a broad range of services.

The studies--which, I know, Angell has seen--suggests tens of thousands of people* die or go bankrupt every year because they can't afford to pay their medical bills. Countless more suffer. The House bill wouldn't stop such hardship altogether. But it would reduce it significantly--arguably, by as much as any single piece of domestic legislation since the Great Society. Surely that qualifies as something more than "a few improvements around the edges."

The House bill would do many other things, too, familiar to the readers of this space--from the creation of a public plan to the creation of pilot programs that would begin to change the way we deliver medical care. And while it wouldn't do nearly enough to make health care less expensive--the drug industry, among others, remains a source of untapped savings--the House bill certainly wouldn't cause the cost of medicine to go up even more quickly. If anything, it'll cause the cost to go up a bit more slowly.

As I've argued repeatedly, the House bill is not close to perfect. Neither is its Senate counterpart. But we don't pass perfect laws in the U.S. We pass imperfect ones and then do our very best to improve them over time.

It happened that way with Social Security and Medicare. It can happen that way with comprehensive health care reform, too. But only if we do something, rather than nothing.

*Note: I originally wrote "millions" of people die or go bankrupt every year. That's rather overstated. It would be more accurate to say "tens of thousands," as I've now rewritten, although one could plausibly argue it's more like "hundreds of thousands" depending on your definition of "medical-related bankruptcy." In any event, thanks to reader "adsprung" for correcting my error--and for reminding me that I should read over my blog entries a little more carefully before hitting "publish."

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