Parameciums have feelings too

Kevin Drum explains why we should still pass health care reform, even without any public option or Medicare buy-in. Basically Kevin's point is: if not now, when? Given the practical realities of campainging for midterm elections and a reduced Democratic majority in the Senate staring us in the face after those elections, what's the chance that any reform effort can get legs for another decade?

Kevin finds much to like in the remaining reform effort, including a ban on restricting insurance based on preexisting conditions. But I'm not sure about the other items that Kevin delights in: fixing rates within broad classes of people, mandates, subsidies to low income Americans.

Let's take mandates, for instance. Kevin's answer to arguments against mandates: "[H]ow is it different from a tax? And its purpose is sound: it keeps the insurance pool broad and insurance rates down."

Does billing it as a tax make it more palatable? Particularly where it is a tax that goes not toward the provision of government services, but instead to private insurers? The Teabaggers and the Naderites will have a field day railing on about government handouts. Does the reform effort collar insurance provider profits? If not, how does it keep insurance rates down? Do we now believe that monopolies are excellent vehicles for reducing prices? How do you keep rates down without a vibrant marketplace, a marketplace that Joe Lieberman's collusion with the GOP seems to have buried for good?

Moreover, how many are going to be grateful that they have access to insurance when they are in fact being forced to buy anti-competitive private insurance. Instead of having the right to choose what to sacrifice in the past, a subset of Americans will no longer have that choice. And when they're struggling to pay their other bills, are they going to feel really good about health care reform and the extraordinary efforts made on their behalf by some people in Washington? That's what it really means to most people when Kevin talks about keeing the insurance pool broad - to create animosity by forcing people into an imperfect system.

Mandates are essential to force those in "healthy" groups who would otherwise skip insurance - until they are no longer healthy and the insurance companies are forced to take them on - into the system and spread the cost to deal with those people who would have otherwise been excluded due to preexisting conditions but for reform's requirement that they take all comers. In short, we need mandates to eliminate health insurance free riders. Said another way, in any system which cannot reject a person due to preexisting conditions, basic economics means that no "rational consumer" would enter the system until they have a medical need that costs more than the cost of insurance; it's a system that would only have sick people in it. Having a mandate in a truly competitive system, which ensures and enables mobility and liberty and health security, where the mandate prevents free riding that could collapse the system, well, that's worth keeping. Yet the dilemma now is the existence of a a mandate which is perceived as corporate welfare. How do you sell that to a recession-weary America, even if it is the right thing to do?

Look, I understand the practical reality here. Health care costs already include the costs for the uninsured. Providers mark up the cost of services for the insured to account for their "losses" on those who do not pay. This reform essentially shifts the mandate away from the provider - who must provide emergency room care for indigent patients - and onto the insurer. And, the argument goes, the uninsured tend to require more expensive care because they do not take advantage of preventive care. (And preventive care means, generally, more pharmaceuticals. Conveniently for Big Pharma, the White House agreed to oppose efforts to allow the government to bargain for lower drug costs or to allow drug importation from Canada.)

But these are all hidden costs and subsidies in the health care marketplace.

This health care reform will make those subsidies explicit, and explicitly financed out of the insurance premiums paid by individuals and their employers. People are going to resent it when their insurance rates go up, as they will regardless of reform. It's just that now, Congress and the White House will be held responsible.

All of which is why it is horribly sad that we cannot have an honest, rational discussion about these issues. Kevin Drum is most likely right - we are much better with this reform than without it. The issue now is, how do you convey that to people when their instincts and the fear mongers are telling them otherwise?