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One lesson I learned early in my career as a pastor is that change happens much more smoothly when tackled in pieces. For example, if a pastor decides that worship should be more contemporary, the last thing he or she should do is walk into a committee meeting and announce that the service needs to be overhauled.
Instead, the smart approach is to work on one portion of the service at a time. Throw in a contemporary hymn in one service. Add a guitar to the mix a few months later. Change up the way Communion is done the next year. And week-by-week, gradually make the sermon style more conversational and less academic.
Done all at once, these changes would introduce a shock to the church system that would inevitably lead to resistance and conflict. But do it gradually over the course of a few years, and most of the congregation will not even notice.
The question I raise here is whether health care reform in the United States operates under the same principle. Would the Democrats be better off making a list of the ten most important things to accomplish, and then committing to getting them passed piece by piece?
Ending pre-exisitng condition exclusions would be a great place to start. I’d also proritize making it illegal to drop people from coverage when they get sick, followed by a ban on lifetime maximums. These measures would have a good chance of passing with bipartisan support, especially with mid-term elections on the horizon, and they would have an immediate impact on the lives of Americans.
At the same time, Congress could continue the debate over the public option and what to do about the millions of people who cannot afford insurance, with the long-term goal of creating a system much like the one Obama proposed last fall. As it see it, this is unlikely to happen with the "all or nothing" approach currently being used, as much as we might believe it should happen. In addition, the incremental approach would eliminate the abortion red herring that keeps hampering the process.
What do the Seminal readers think? Is incremental reform a better way?
20 Comments
The short answer to your title question is “NO, ABSOLUTELY NOT.”
The issue is you really can’t do this without doing everything else. Just banning denials of care for pre-existing conditions will cause premiums to skyrocket because insurance companies will have to shell out so much more cash to cover these illnesses.
If premiums skyrocket and there’s no mandate to carry health care, many people will take their chances and not purchase coverage, knowing they can re-purchase insurance as soon as they get sick and insurance companies will have to take them as customers.
If that happens, the only people who will have insurance are the sick, causing premiums to skyrocket further, causing more people to drop out because they can’t or don’t want to afford it. It’s called the death spiral.
To short-circut the death spiral, you need everyone to be in the system, and you need to offer subsidies so everyone can afford it. And of course you need to regulate that market to ensure real competition. Hence, you set up the Exchange to distribute subsidies and have a public option to compete.
And then you’ve basically got health reform in total.
The only real way to “go small” would be to not solve the fundamental problem. You could, for example, just expand Medicare and Medicaid for certain populations and not hit the death spiral issues. But you’re not making health care work better for everyone – a large portion of folks would still have huge problems.
Subsidies acknowledge that the premiums are unaffordable. That is NOT a solution. It merely transfers the peoples’ wealth to corporations. That is terrible policy.
That’s what the competition is for. And a lot of the delivery system reforms. And the mandated medical loss ratios. And the Exchange authority over rate hikes.
Subsidies are needed to make sure it’s always affordable to everyone.
Jason – This is the part I don’t understand. The insurance companies aren’t stupid. They’re not going to do anything that will limit their profits and potentially wreck the industry. If it’s true that they’re already overcharging for premiums, wouldn’t it be in their best interests not to drastically hike their rates to counteract a pre-existing condition ban?
I’d like to see a dramatic overhaul of the system as much as anybody else, but I’m starting to wonder at what price this will come. Forcing people to buy insurance, even if it is partially subsidized, doesn’t seem right to me at all. Neither does pushing through a bill that will further divide the country and lead to ugly fights to repeal it.
Is there hard evidence that incremental reform will lead to this death spiral, or is it just a political argument coming from those who are determined to get a comprehensive reform bill passed?
And please note the last part of my post where I argued that incremental reforms could be passed at the same time larger issues such as public option were being debated.
They don’t really have a choice. If the insurance pool gets dramatically sicker, which is what would happen if all the folks denied for pre-existing conditions suddenly have coverage for those conditions, insurers will have to raise rates just to keep up with expenses, plus their profits, of course.
I’m not sure what you mean by hard evidence, but every health expert and economist agrees that this is what will happen, no matter if they’re left, right, or center.
No. Incrementalism is a political ploy. What we need now is true reform so that the disease management insurance corporations don’t get further entrenched. Transferring the public’s wealth to private corporations is a terrible policy decision.
I agree with Kucinich that the current House and Senate proposals are building on a pile of sand.
Go for the gold, an improved, comprehensive, affordable Medicare for All type of national program. Improve Medicare and let any age buy in!
I would be an incrementalist if the first increment was to destroy the health insurance companies.
Jason has it on the money. There is no increment that gets us forward without enormous cost.
But I would point out we are taking an incremental step here. Getting this bill passed goes a long way to settling the argument over whether or not we should we should as a government be involved in trying to get health care for all our citizens. This way is not ideal, that is a fact, but it moves the argument to methods and not whether we should be doing it at all.
Once this is passed it becomes a question of how do we fulfill the promise it makes. It comes down the Oscar Wilde quote “We already know what you are, now we are just haggling on price.”
The insurance companies WIN EITHER WAY, they wrote the bill after all, do you honestly think they put anything in it that would help citizens? They are lying scum and can’t be trusted to do anything…fortunately they were smart enough to write a bill with no ENFORCEMENT MECHANISM so the Ins cos can leech off us for decades to come.
Kill the bill and eventually the Ins Co’s DIE
I am astonished that I still see discussions like this. Its should be apparent to everyone that you cannot guarantee insurance issue (ban pre-existing conditions) unless everyone is forced to participate.
I pay $1100 monthly for Florida Blue Cross. I would cancel in a heartbeat if I was guaranteed issue. In fact, with the weak mandates being offered I may cancel anyway if the Senate bill becomes law and the “death spiral” explained by Jason above might indeed happen anyway.
These is no health care reform without universal coverage of some type. Anyone who thinks so hasn’t thought it through or is just not telling the truth.
I’m not going to pretend to know more than economists and health care experts, but does anybody really know what would happen if incremental reforms were tried. It’s not like the experts have a great track record lately.
And it all makes me mad as hell. I just can’t accept a plan that is such a giveaway to the insurance companies, and I’m grasping at other solutions. Perhaps the only real answer is to start over and put single payer on the table and fight like crazy for it.
Like I said, you can do incremental, but that looks like basically doing comprehensive reform but just for a limited group of people. So you could give more poor people Medicaid by expanding the income level at which you’re eligible. Or you could lower the Medicare age. But you can’t do reforms that affect everyone unless you either have only one insurance company run by the government (single payer, or Medicare for 65+) or you have a mandate.
My point is that smaller reforms don’t preclude continuing to work on the big picture issue. If we can help some people now and still continue fighting for universal coverage in the long-term, why not – assuming we don’t create one of those dreaded death spirals.
To me, it’s analogous to feeding and providing shelter for homeless people while still fighting the larger issues that cause people to be homeless in the first place.
Jim there is a political cost as well. I know that ’round these parts the bill as it is written is not very popular, but cost of spending this much time on it and then backing away to do little increments (which are not really going to do a lot for the folks who need it the most) is going to be viewed as an epic failure by the general public. It will open the Dem’s up to the meme they can’t govern either.
At this point it is better to get the bill we can, with all the warts and then have to fix it than it is to retreat to incremental and largely cosmetic changes.
I hear what you’re saying, Bill, but I disagree. It seems that the Democrats are already paying a political cost, and will pay even more if they pass a bill that their base sees as a corporate giveaway. In my view, the Democrats that lose this fall will do so because progressives are upset over this bill and take their vote elsewhere. I know that I’m already considering third party candidates at this point.
See my post on polling above this.
Health reform might be a political problem in 2010, but I have a pretty hard time believe the bill will still be unpopular in 2012. Basically, popularity will only grow, just not sure if it’ll grow fast enough to beat the 2010 elections.
Dems are toast. Just watch.
I get that Jim the thing is the community here is far more upset about this than any other that I am involved with, both in cyber space and meat space. I don’t see most of them being willing to punish the Dems for doing as much as they will.
I even suspect that many (maybe not you) who are talking that way will come home to the party when the reality of losing the Republicans and what it means for governance hits home. Since the Dems are already paying the price, there is nothing to lose by going for the most comprehensive bill they can get.
Sure. You can do Medicaid expansion and in theory continue to fight for health reform for everyone. But you can’t do pre-existing conditions and continue to fight. I mean, you can, but you’re going to royally screw up the insurance market in the meantime, leaving tons without coverage.
But, I’d personally have grave reservations about just doing, say, Medicaid expansion. Medicaid and Medicare didn’t solve the problem when they were passed in the 60s, but they did allow us to kick the can down the road 50 years. I fear that if we do something small like that again, we won’t revisit the issue in the serious way for another 20, 30, or 40 years.