The debate over health-care reform has been many things. It has been an education in both the intricacies of public policy and the ease with which fears can be activated and deception accomplished. It has been a dispiriting exercise in the limits and pathologies of American politics. And it has been a clash of values.
Because progressives think government can actually solve problems, they tend to have at least a partially technocratic view of policy. At least in theory, it should be possible to analyze a problem, assess various solutions to it, select the one most likely to solve it, and then implement that solution. Yet so often in our country, this self-evidently sensible approach ends up feeling like an unattainable ideal.
In the course of this process, we've discovered -- if there was any doubt before -- just how deep conservatives' hatred of government runs, from the grass roots all the way to members of Congress. It's not just that right-wingers are suspicious of government or that they prefer the free market whenever possible. Their antipathy to government is so intense that they would rather see some of their fellow citizens die for lack of health insurance than see those citizens get government coverage. That may sound like a harsh assessment, but it is no exaggeration. In the system as it is today, 45,000 people die each year because they don't have health insurance. If you believe the status quo is preferable to an expansion of government's role in health care, you're supporting that.
Each week seems to bring a new proposal or compromise that inches us closer to a conclusion of this debate. The latest, announced in somewhat vague terms by Senate Majority Leader Harry Reid last week, would have traded the public option for a new system that would have included national nonprofit insurers in the exchanges. Perhaps most remarkably, the proposal would have allowed people over 55 who didn't have insurance from their employers to buy coverage from Medicare. Yesterday, Sen. Joe Lieberman withdrew his support for this deal, effectively ruling out the Medicare expansion and killing hope for any sort of public option in the process.This latest compromise may have failed, but it's worth taking stock of where the progressive values that are supposed to be driving this whole effort now stand.
While health-care reform is a subject of almost infinite complexity and involves hundreds of other important issues (like cost), I would argue that there are two essential value questions progressives should continue to ask themselves at each bend in the road to reform: Are we getting a system that is universal? And will Americans get the security that so many of them now lack?
The fact that the United States is the only industrialized country where many citizens don't have access to medical care has always been a major offense to progressive values. Conservatives believe in markets, with the understanding that markets seldom work out for everyone. Progressives, on the other hand, believe that there are some areas – health care being one – where citizens should not be left to the market's mercies. The idea of universal coverage is that everyone – and we mean everyone – deserves coverage, just as everyone deserves an education or the right to worship as they please.
The Congressional Budget Office estimated that both the bill passed by the House and the initial Senate bill would cover 94 percent of Americans when fully implemented. This is both very good and not quite good enough: Over 30 million people who wouldn't otherwise have coverage will get it, but around 18 million people will still be without it.
And what about security? As I've argued many times before, this was always the most compelling justification for the public option. The simple fact is that government health insurance offers security, while private health insurance doesn't. Most of the time, private health insurance works just fine for people. But people with pre-existing conditions can't get covered, people who get sick find themselves thrown off their insurance, and people who thought they had good coverage wind up being driven into bankruptcy by medical bills. None of these things happen to people who have government health insurance. Medicare doesn't deny people coverage because of their prior medical history. The Veterans' Administration doesn't have "lifetime limits."
That's the most critical fact separating government health coverage from private health coverage, and the essential reason progressives wanted even a watered-down public option. While an attempt to ensure security within the private system is certainly being made, most of us will still have no choice but to rely on a private insurance company now that the public option is on its way out.
So we need to consider whether health-care legislation sets the conditions for future improvements. How hard will it be to implement further changes that push the system in the direction it ought to go? If you establish one national health-insurance exchange instead of 50 state exchanges, for example, it will be much easier to deal with insurance-company abuses as they arise.
Health-care reform's ability to evolve is why the expansion of Medicare could be so important – and why conservatives are terrified of it. If we opened Medicare to anyone over the age of 55, it would change the nature of the program -- it would no longer be an insurance system just meant for retired Americans. If people from 55 to 64 turn out to like it (as they likely would, given that Medicare beneficiaries are substantially more satisfied with their insurance when compared to those with private insurance), it would become perfectly reasonable to open the program up to people over 45, or 35, or 25 in the future. Opening up Medicare would serve the progressive values of both universality and security, which is precisely why Joe Lieberman, who has made wreaking vengeance on progressives his twisted life's work, has now vowed to kill it.
Two fundamentally different visions of a just society are at odds in the debate over health care. Does that mean that if reform passes, the progressive vision will have triumphed? That depends on your view of the fullness of the reform glass.
Unfortunately, if it does pass, the United States will still have what is in many ways the worst health-care system in the developed world. It will still be the most expensive and the least able to control costs. It will still leave for-profit insurance companies with more control over citizens' lives than those companies have in any comparable nation. Even if the most optimistic predictions about coverage come true, it will still leave us with more uninsured than other countries have.
If we're lucky, reform will make it easier for those problems to be solved down the road. Whether a political and policy victory becomes a lasting triumph of progressive values is something we won't know for quite a few years.
