The Health-Care Ultimatum

There is a classic economics experiment called the "ultimatum game," which demonstrates how our decision-making process isn't solely determined by rational calculations. In the experiment, one subject is usually given a small sum of money and told to divide it however he wants between himself and another subject. If the second subject accepts his offer, they both keep the cash. But if the second subject rejects the offer, neither of them gets anything. Rationality suggests that the second subject should accept any offer, since even $1 is better than nothing. But in practice, offers that are perceived as unfair (like 80-20) get rejected most of the time, while offers near a 50-50 split tend to be accepted.

Our perception of fairness is so finely tuned that even in the context of an experiment, where nothing more than a few dollars are at stake, we will give up a potential gain -- in order to punish a person who has acted unjustly, or simply to make a statement about the standard of behavior we think ought to be upheld -- if we believe we have not been treated fairly.

Now take that idea out of the experimental context, put it in the real world, and up the ante. Here, you have worked, and advocated, and felt passion and anger and hope for a certain outcome, and you're being asked to accept a result that's not just unfair but one that undermines all that you want to believe about your own identity and sense of agency.

That's the situation many liberal activists are now confronting.

There has been a feverish debate in progressive circles for the last week or so about whether, now that the public option and the Medicare buy-in have both been sacrificed on the altar of Joe Lieberman's petulance, health-care reform is even worth passing anymore. Howard Dean announced that Democrats should "kill the bill" when the Medicare buy-in was removed (though he has since walked that statement back some). A number of prominent liberal bloggers, including Markos Moulitsas of Daily Kos and Jane Hamsher of Firedoglake, have said much the same thing. Keith Olbermann delivered a lengthy peroration against the bill on his television show.

I am not saying that progressive activists who have turned on the health-care bill are simply being irrational. They have some good reasons to be disaffected, with the administration in general and health-care reform in particular. And many of their arguments about the policy implications of some of reform's particulars -- and what has been left out -- are legitimate (though I disagree on some important points). We can't underestimate the frustration the left has experienced as it's been told to compromise, and compromise, and compromise some more -- all while watching the White House treat it like an irritant. Meanwhile, it seems as if the administration is ready to do anything any conservative swing senator wants. That'll leave an awfully sour taste in your mouth.

We've all heard the old saying that laws and sausages are the two things one should never watch being made. But this legislative circus has been truly appalling. Could the worst part be the despicable lying and fear-mongering of the Republicans? The self-important preening of the swing senators? The attempts to undermine reproductive rights? The spectacle that is the junior senator from Connecticut? Or the way industry lobbyists have laid siege to Congress like it was Helm's Deep (though this time, the orcs are being invited in to nibble hors d'ouvres while they write checks and amendments)? It's been utterly maddening, and no one could be blamed for being disgusted.

Unlike in the ultimatum game, progressives aren't confronting a narrow situation of fairness (I'm being offered $2, when I ought to be offered $5). When the public option -- and to a lesser degree the Medicare buy-in -- was stripped from the bill, it sent them a pretty clear message: "You don't matter." Progressives worked for Obama's election. They worked to get more Democratic members of Congress elected. They walked precincts and made phone calls and worried and sweated and labored. And none of it seemed to matter. They now believe that the things they cared about were always bargaining chips, to be traded away to win the support of people like Ben Nelson and Joe Lieberman, who love nothing more than to see them suffer. They've been told that centrists -- those supposed exemplars of compromise -- don't have to do anything of the sort. But progressives do.

That may not be the message the White House and congressional Democrats intended to send. They were hoping to deliver something that said, "Yes, we had to get rid of the thing you've placed your hopes on. But we want you to stay with us, because this is still worth doing." But instead progressives heard that they were powerless and inconsequential.

Now that the public option is dead, many of the progressives who have turned against the bill have focused on the bill's individual mandate, the requirement that everyone buy insurance. There is something to the argument that it's unfair to force people to sign up with an industry that has repeatedly demonstrated its greed and indifference to human suffering -- particularly when you aren't giving them the option of a government plan. Unfortunately, there is simply no alternative. If you're going to get everyone covered, you have to expand the risk pool so it includes everyone. Keep in mind also that one of the core goals of this reform has always been forbidding insurance companies from denying people coverage because of their pre-existing conditions. But without a mandate, people could just wait until they get sick to sign up for coverage. If that were allowed, premiums would skyrocket to levels even more unaffordable than what we have now. It may be distasteful to deliver the insurance companies millions of new customers, but there's just no way around it.

I say this as one who throughout this debate has been as vociferous an advocate of the public option -- and as harsh a critic of the insurance industry -- as almost anyone who writes about this topic (see here, and here, and here, and here, and here). Progressives rightly condemned Joe Lieberman for arguing that he would rather see someone go without insurance than see them get insurance from a public plan (he didn't put it quite that way -- he said that reform with a public option was worse than no reform at all -- but the effect is the same). So we can't say that it's better that someone go uninsured than get insurance from a private company.

We have to remember that the currently uninsured will be getting their insurance not through the abomination that is today's individual market but either through an expanded Medicaid or through the newly created insurance exchange (or exchanges -- the superior House version creates one national exchange, while the Senate version creates state-based exchanges). The exchange is the most important feature of health-care reform as it now stands. If progressive opponents of the bill think the regulatory protections in the exchange are inadequate to forestall insurance company predation, they have to explain why, and how the exchange ought to be improved.

For all its weaknesses, even the Senate's version of health reform, which would hopefully move more in the direction of the House's version when the two are merged in conference, contains an extraordinary number of beneficial features. (You can find an excellent summary of both bills here, from the Kaiser Family Foundation.) It insures over 30 million more people. It expands Medicaid coverage. It outlaws denials for pre-existing conditions, rescission, gender discrimination in premiums, and both annual and lifetime coverage caps. It provides hundreds of billions of dollars in subsidies for low- and middle-income people to buy insurance. It makes it so if you lose your job, you don't lose your health insurance. It forces insurers to allow people as old as 26 to stay on their parents' policies. It establishes dozens of pilot programs to test new ways of saving money and improving care. All of these provisions, and many others, will substantially improve people's lives. And the insurance exchange puts in place the structure through which further improvements can be made in the years ahead.

I'm not arguing that the point has come -- or will ever come -- when progressives should say, "OK, that's good enough" and stop arguing for improvements to the bill. Quite the opposite: They should keep criticizing the bill's shortcomings and continue to argue for what it could be. But it would be a terrible mistake to conclude that because of the loss of the public option, the bill now does more harm than good. There is no starting over. If the bill dies now, it's dead, and we won't get another chance for reform for at least a decade. And what will happen in the meantime?

Last week, a friend of mine wrote to tell me about some of the people in her life waiting for health-care reform. A friend of hers, after a long stint of unemployment, finally got a new job -- but one with a six-month "probationary period" before he could get health benefits. As she put it, the stroke he suffered "didn't wait for the probationary period." He's now in the hospital, facing both a long recovery and crushing medical bills. My friend's mother-in-law works for a small business that doesn't offer her health coverage. She seriously injured her knee six months ago, but couldn't afford the surgery to repair it. She recently fell and broke her other leg.

Progressives have every right to feel that they've been mistreated in this ugly process. They have the right to be angry, and bitter, and resentful, and disillusioned about what has occurred and what might have been. They have the right to feel that their dreams of a transformative Obama presidency and their election-night euphoria were naïve. But we shouldn't forget who this debate is really about.

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