By the Slice

"The time has come," pronounced Barack Obama in a speech last week, "for universal health care in America." Words to warm the heart of any liberal. True, as some observers complained, the speech was incredibly vague and wound up not even gesturing in the direction of an actual plan. But who could disagree with the sentiment?

Well, me.

In one sense, of course, the time most certainly has come for universal health insurance in America. The time came in the 1940s and has persisted ever since. The United States of America ought to have a system in which all citizens are provided an identical, taxpayer-financed, publicly administered health insurance system. In this system, patients might -- much like in private insurance plans -- incur some out-of-pocket costs, the plan might not cover everything a person might want to have done to them, and it wouldn't prevent people from buying additional private insurance or seeking medical treatment outside the public sector system at their own expense.

That's how things ought to be, and it's also the reason that the time has not, in fact, come for universal health care.

The trouble is that essentially nobody believes it's possible at this point in time to implement, all at once, a system like the one I outlined above -- known as "single-payer health insurance." Simply put, the political challenges are too daunting. The special interests would fight it like the Spartans at Thermopylae.

Consequently, health care advocates have designed any number of compromise measures -- steps other than single-payer health insurance that would nonetheless achieve the goal of universal coverage. One popular genre these days, seen in various forms in Massachusetts, a new proposal in California, and a bill Ron Wyden introduced in the Senate, is to try and co-opt the private insurance plans. This involves a triple-step. First you mandate that everyone buy health insurance. That, of course, might be too expensive for some people. So the government subsidizes people who can't afford insurance on their own. But that, of course, might cost the government an inordinate amount. So the government mandates "community rating" of insurance policies, making companies charge everyone the same rate regardless of medical history and other factors. This, in turn, creates incentives for companies to simply not cover a wide range of expensive treatments. So the government will legislate a mandatory minimum coverage package.

This has, I would maintain, precisely no advantages over the government simply legislating an insurance package and then paying for it out of tax revenue. Some people disagree with me; that's an argument for another day. Many, however, do agree with me on the merits, but are willing to embrace the mandate-and-regulate scheme as a compromise with political realities.

The problem here is a mistaken conception of the role of compromise in the policy process, one that is in fact driven by a dogmatic insistence that the time for universal health care is now.

Compromise is a vital thing in politics, especially in a country like ours where it's difficult to pass laws. What you want to compromise over, however, are the quantitative elements of a proposal. If you don't have the votes for an $8.00/hour minimum wage, you propose $7.70 instead. If you can't appropriate $3 million for your pet project, you take $2.6 million instead. Similarly, if we can't get single-payer health care right now -- and nobody thinks we can -- then take half a loaf. If we can't get that, take a quarter loaf. Take whatever slice of the loaf you can get. And then come back and ask for more. The point is that at the end of the process, you want to wind up with a loaf of bread rather than a pile of moldy saltines.

To put it another way, compromising on the quantitative aspects of single-payer health care means taking small steps to the social democratic utopia of tomorrow. Compromising on the qualitative aspects, by contrast, risks locking a bad system in place forever.

What does quantitative compromise mean in this context? Many things. But, primarily, it means building on Medicare and Medicaid. First, change the 2003 Medicare reform bill to give the government meaningful price leverage over the pharmaceutical companies and eliminate the role for private insurance companies. Beyond that, see what you can get -- Robert Kuttner laid out a few options yesterday. Propose that Medicaid cover everyone under 25. If you can't get that, take everyone under 21. If you can't get that, take everyone under 18. If you can get that, propose adding full-time students under 25. Then all full-time students. Then everyone under 25. Lower the threshold for Medicare to 50. Or to 55. Or to 60. Lower it to 64 if that's all you can get. Then come back next year and propose lowering it to 50. Or to 55. Or to 63. Keep coming back. Let people under the threshold "buy in" to Medicare on some terms. Enroll all federal employees in Medicare instead of the Federal Employees Health Benefits Program. In short -- keep slicing away.

This means giving up on the dream of achieving universal health care in the short term. But it also means preserving the viability of the best solution for the long term. It allows progressive politicians to combine grand ideals -- working toward national health insurance -- with pragmatic flexibility, expanding existing programs where viable and useful to snatch up populations in need of coverage. It means a bit less health wonkery and a bit more hard-boiled negotiating (which is why I think most health policy people seem to favor qualitative compromise). But it also means creating a situation where liberals are making promises -- an ever-expanding public health insurance system -- we can deliver on, instead of risking the dramatic failure of Big Bang transformational schemes.

Last and by no means least, it means the step-by-step defunding of the health-industrial complex that does so much to provide financial support for reactionary politics in America. The alternative -- sticking progressive necks out for the opportunity to direct customers to an insurance industry that hates us -- doesn't make sense.

Matthew Yglesias is a Prospect staff writer.

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