The Beauty of Mediocre Policy

Responding to my health care post earlier, both Brad Plumer and Kevin Drum argue against incremental strategies and for a campaign towards single-payer. With such opposition, I think I should spend a few moments saying why I disagree. I recently read The System, an exhaustive account of the 1994 health care battle. Also recently, I've watched Bush's Social Security plan -- and yes, he has a plan -- get strung up by its thumbs. Taking the two together, I've basically concluded that it's impossible, in non-crisis (i.e, non New Deal or post-9/11) situations, to push sweeping legislation through Congress. The System, excuse my Broderian terminology, is really set-up, and at this partisan moment, primed, to resist and demagogue such change. And it succeeds.

Americans didn't want Clinton's bill to be defeated. Which is to say, they wanted Clinton's bill to be defeated, but only their perception of it. If you actually polled them on what they wanted in a health care system, it tracked their wishes quite precisely. And if you asked them whether or not we needed reform, they were all for it. But Clinton's plan was complex, hard to explain, and easy to destroy. After all -- selling a proposal like that requires explaining it, killing one merely demands you characterize it. The latter can be done simply -- big government! -- the former, not so much.

Similarly, I don't think voters are against Bush's plan. I think they would be if they understood the long-term economics of it, and they are when it's characterized as a benefits cut (which it is), but if you poll them, they repeatedly say Social Security is headed for a crisis and majorities continually support proposals allowing partial, optional investment of Social Security returns in the stock market. Which is what Bush is proposing. But Democrats have, without really trying, been able to destroy Bush's ability to push his ideas. Americans rightly don't trust him, and so anything that emerges from his desk or party faces enormous skepticism. Even though they still say they want what he says he's pushing. It's quite strange.

Which brings us to the CAP proposal. I agree that, as policy, it's less desirable to simply rejigger, rework, and expand what we have. But it's also simple. The beauty of FEHBP is less the program than the idea -- this is what the Senate uses. And if you want, you can have it too. It's easy to understand and it ties into the "classless" image people want to have of America, a land where the peasants are treated like the kings. Medicaid too is easily understood and already functioning, nothing new nor scary there. And the idea that the government will guarantee premiums don't rise beyond 7.5% of income, that's completely comprehendible and damn attractive. It all works rhetorically -- it can be sold as simply as it can be demonized.

Now, Kevin's fears are not misplaced. It's still a big program and it might lose. But I've become convinced that the only big programs we're able to pass are big expansions of old programs. So you can add a drug benefit onto Medicare, but you can't change Social Security or remake American health care. Down the road, I think, these changes can lead to others shifts: people become familiar with government involvement in their health care and so they're not as stunned by more government involvement in their health care. For now, I think this incrementalism using the familiar is all that can survive the PR wringer. Big, new ideas get shredded, with Social Security privatization and Clintoncare being examples of varying quality, but big, old ideas can be accepted, like the massive expansion of Medicare.

And that's why I support CAP's proposal -- it's a big, old idea that I think can lead to big, new ideas. Brad's no fan FEHBP, and I trust his judgment. On the other hand, what I've read on it has been different, so I'd need to see some pretty damning evidence. For now, I'm not convinced that it's an undesirable tent for health care -- though it's certainly not the most desirable tent -- and I'm quite impressed with it as a politically sellable program. And that, in the end, is what I'm looking for: a way to break the health policy deadlock. I think this sort of proposal is it.

Update: Sorry about the acronym confusion. For some reason, I mentally merged CHIPS and FEBHP to create CEBHP. The joy of alphabet soup. Anyway, the program is actually FEHBP -- Federal Employee Health Benefits Plan. Also, changed the last few sentences for clarity.