Back in the summer Ezra Klein wrote about what he thought the Obama WH strategy would be on health care reform, and why they were taking that path:
The central problem in health-care reform is that good policy and good politics point in opposite directions. Good policy proceeds from the understanding that our health-care system is a fractured, pricey, inefficient mess. Good politics, however, proceeds from the insight that a lot of people rely on this fractured, pricey, inefficient mess and don't trust Washington to change it. Good politics means, as Barack Obama frequently says, that if you like what you have, you get to keep it. But put those imperatives together and you have a strange problem indeed: How do you reform a system that you're not allowed to change?
The answer that reformers have come up with is that you don't change the current system. In the short term, you strengthen it with subsidies and regulations on insurers. You make it kinder and gentler. But you also build the beginnings of a new, better health-care system off to the side. You let it demonstrate its efficiencies and improvements. You let the lure of lower costs and higher quality persuade Americans to migrate over of their own accord.
This is what the health insurance exchange is designed to do. It is arguably the single most important element of health-care reform, because it is the bridge between the system we have and the system we want....
It's a single market, structured for consumer convenience, in which you choose between the products of competing health insurers (both public and private).... Consumers will benefit from more choice, from direct competition between insurance providers hungry for their business, from regulations meant to protect them from deceptive products, from efficiencies of scale, and from the sort of purchasing power that only a large base of customers can provide. They will benefit, in other words, from an actual, working market....
It's a very conservative strategy, both in its incrementalism and in its right-wing belief in the power of the market to deliver what people want and need, at a price they can afford.
I think it's less a matter of Obama's personal views (he did say if he were starting from scratch with the healthcare system he'd want to build single-payer, but that wasn't realistic now) and more a matter of keeping all those health insurance and pharma dollars flowing into Democratic coffers instead of into GOP ones. I think he thought it was possible to make a deal that benefited the existing industries and at the same time met the needs of the American public for better and more affordable health care coverage.
If that were the outcome, it wouldn't be the transformative change that people who voted for Obama hoped for, but it might be at least minimally supportable, as long as there were big subsidies with COLAs and strong oversight and regulation built in.
The question is, are the Exchanges really the beginnings of a new, better health-care system being built off to the side (even a national Exchange)? Can market forces alone really provide what's needed?
Personally, I don't believe so. Health care insurance that provides the public good of proper medical care for the entire population is never going to be the basis for a profit-making or even a non-profit business model. In financial terms, it's always going to be a cost and not a source of profit. The benefit comes in the health of the population, not in the provision of the insurance. Health coverage is something a society should put money into because a healthy population is needed for a country to prosper. It's a good like education. It costs a lot, but it's worth it overall, because otherwise your population can't compete with other societies that do educate their people. And the way to pay for it all is to subsidize it by means of strongly progressive taxation.
So that's why I'm so angry to see health care reform devolve to the point where it has. The current Senate bill may be good politics in terms of keeping the health insurance industry from turning its big guns on not just reform efforts but on the whole Democratic party. It may even be the timid incremental success Obama, Rahm, and the rest of the conservaDems had in mind all along. But even if it is, it's the wrong vision and the wrong solution, and no matter how well it works it won't work well enough to fix what's really wrong.