While this diary was originally written as a response to DemfromCT's item today (Senate Makes History Sans Republicans), that's certainly not because he has a particularly wrong-headed take on the matter. His item was just the springboard. If anything, the most useful disagreements are with people you really don't disagree with except on one or two details, at least when those details are the sort of thing wherein the devil famously resides.
What's not to like about 30 million more people covered?
Nothing at all. It would be a great good thing if this bill was actually going to make coverage possible for 30 million more. But that's not what this bill does.
Millions of those uninsured people who will be brought under coverage, are going to be so brought kicking and screaming. This bill isn't making anything available to them that wasn't already available to them. These folks looked at the crappy, hole-filled products that the industry had on offer at ruinous expense, and wisely decided to forego coverage. Now we're going, with this bill, to force them to ignore their own interests and buy the crappy product that they rejected when they had the freedom to act in their own interests.
I'm a socialist. I have no problem whatsoever with the govt playing nanny and forcing people to do things "for their own good", and for the good of society. But, you know, as a socialist, I actually respect the idea, and don't just use it as a matter of convenience. I think we have to actually prove that something really is for the common good, and the good of all of us individually, before we force it on people as a govt program. And buying the crappy, hole-filled product on offer from the industry, at whatever price, let alone the exorbitant prices on offer, is simply not in the interests of the people who buy the product, or the interest of society. Young, healthy people who choose to self-insure, rather than buy the industry product, are making an economically rational decision.
Sure, it's socially irresponsible to go naked, because part of the plan with that strategy is to parasitize off the people who do pay, when you need the emergent care that even our cutthroat society won't (yet) deny you in an emergency. And part of the plan is to stiff the providers who did provide you with perhaps life-saving medical services without demanding payment up front, if expenses from a medical catastrophe force you into bankruptcy.
But why do we expect only the working poor to be socially responsible? Why do we as a society, hang over the heads of the working poor the prospect that their kid, sick some 3:00 AM, will be denied care, perhaps care necessary to save their lives, unless they can come up with whatever exorbitant premiums the industry charges for coverage so crappy that they still have to worry about, even at 3:00 AM and even with a sick kid crying in the bedroom, will force them into bankruptcy, and thast while denying, if only by admin delay, treatment that their kid needs? Yeah, sick kids at 3:00 AM are a reality that a parent has to worry about, but, unless you're comfortably well-off, so is making the rent every month, and buying food and child care so that you and the spouse can both work those second jobs to keep all of that, plus the exorbitant premiums we are going to be requiring these people to pay to the industry, going. Sure, the health of your kids is another order of worry, so maybe, if the product we were making them buy were not hole-filled, maybe there would be some point, other than insuring the profitability of the industry, to making the working poor buy insurance. But the crappy product on offer will not even relieve those 3:00 AM worries. Part of the reason I'm against this bill, that I think it's a step in the wrong direction, is that, for this segment of those 30 million, it will not relieve those 3AM worries over health care, but will only add new worries about all of the other things for which they need that money that we are going to force them to spend on something that they have already decided, correctly, is a bad deal.
I'm not even going to ask why we don't expect the industry to be socially responsible. That's a non-problem, a non-question. The whole point of a corporation, the whole point of doing something as a society through a corporation, rather than managing it directly of, by and for the people, is that we have decided that the problem is better managed by entities that are responsible to their shareholders to maximize profit, and not to the wider society, to accomplish some broader good than profit. I don't blame the industry for doing what is to be expected of it, profit maximization no matter what the social cost. If profit maximization results, in this application of health insurance, in bad social outcomes, then it's our fault as a society for using the wrong tool.
The reason this bill is a step backward for the rest of those 30 million, is that we have decided to get them insurance through an industry operating for a profit motive, despite their being the group of folks for whom only the social insurance model makes any sense. Just as the other segment of the 30 million were the folks who decided that the industry product wasn't a good deal, this other segment of the 30 million are the folks whom the industry decided earlier weren't a good deal.
These people are the folks denied coverage for pre-existing conditions, or who had their coverage rescinded, or who perhaps can get coverage, but only under premiums so much higher than the low-risk pool, that they can't afford it. What this bill pretends to do is some mixture of forcing the industry to eat the unprofitability of covering these folks, and having the govt assume the extra costs of their coverage.
Well, one problem with this noble scheme of doing good for these folks who haven't been a ble to get insurance, is lack of credibility to the idea that a govt that didn't feel that it could just cut out the middleman and do single payer, or even just cut out the middleman for the currently uninsured and do a public option, will actually muster the nuts to force the industry to do anything unprofitable. We're going to forbid rescission (well, except for "fraud"). We're going to forbid denial for pre-existing. We're going to keep the MLR to 85%. Right. Absolutely. No way will industry lobbyists, and industry employees in Congress and the civil service block the most aggressive enforcement of every pie in the sky provision of this bill.
But let's concede, for the sake of argument, that despite all the evidence to the contrary notwithstanding, this fantasy scenario will hold, and the govt will find somewhere something we haven;t seen lately, the regulatory cojones to actually force all these noble behaviors on the industry. Insofar as we get the industry to assume the costs of doing the socially responsible thing for these unfortunate, unprofitable beneficiaries, we will be screwing the healthy working poor we have forced to buy their products, because they will have to pass on the costs of this beneficence to their beneficiaries. So, believing that the pre-existings are actually going to be allowed to buy affordable insurance, requires believing, not just that the govt is going to act against the interests of the industry, but also against the interests of the healthy working poor whom we have chained to the oars of the industry's crappy product. I'm sorry, but we concede all leverage, whatever pathetic leverage that Congress still has the will to exert over any industry, over the industry once we refuse to insure the working poor under a social insurance regime, but instead force them under the protection of the industry. We will have no choice but to give the industry the freedom to look after their interests under the indemnity insurance model. And that means dividing potiential beneficiaries up, to the max, according to their risk profiles, and charging the high risks more in order to be able to charge the low risks less. We're going to see more risk stratification under this bill, not less. And we're not going to even want to stop it -- even if we could, even if what we have let govt become were even capable of stopping the industry form having its way -- because the working poor, a big element of the the people we care about, are going to need the absolute cheapest, Walmart-cheap, deal possible if they are not to be absolutely crushed by this wonderful mandate to buy insurance we have gifted them with in this holiday season.
But that's alright. One of the do-goody things we're doing with this bill is providing both of these segments of that 30 million with govt subsidies to make up the shortfalls in what they will be able to afford. Lot's of luck maintaining what will be a welfare program, a welfare program in which the taxpayer (and in the US of A in 2009, the "taxpayer" means the working poor, because no way, especially in a recession, can we tax those job creators at the top of the food chain, no way). Welfare programs have done so well politically lately, have proven so sustainable, that surely, the taxpayer will forever be willing to fund the most massive subsidies for the healthcare of those who can't afford it, especially when their premiums, because the people who need subsidies will be disproportionally sicker, will be higher than those the bulk of the taxpayers have to pay themselves. No way will unscrupulous politicians be able to paint those subsidies as fostering a culture of dependency, as encouraging unhealthy lifestyle "choices" like obesity. Right.
Instead of getting everyone in the same boat, with a social insurance plan like SocSec or Medicare, where everybody is covered according to their needs (for healthcare, a true need if ever there was one), and everyone pays according to their means, this bill furthers our already insane commitment to dealing with a social need as if it were just yet another opportunity for an industry to make a profit. That's a step in the wrong direction.
And it's a crucial, probably irreversible, step in the wrong direction. I hate to burst the bubble of all you do-gooding progressives out there, but we're not doing health care finance "reform" this year because finally the progressive concern for the plight of the uninsured, all those parents with a sick kid at 3AM, is being addressed. We're doing changes in health care financing this year because the industry is in crisis. Our political system still doesn't give a hoot for people who neither contribute to campaigns, nor even bother to vote very often, so no, the system is not suddenly responding to the needs of folks who have been uninsured for decades. It's responding to the need that the industry has to keep healthy, young, low-risk people buying its crappy product despite the fact that it no longer makes any sense for them to submit to that exploitation. The mandate meets that need in the only way possible, by chaining people to the oars of the slave galley the industry has going. Sure, the industry and its employees conceded some do-gooder window dressing to get you progressives to fall in line. But once they have their mandate life-line safely in place, you will see soon enough the half-life of the do-gooder add-ons.
Don't believe this analysis? Think there's any substance and sustainability behind the do-gooder provisions? Then do we atheists this one little favor, humor us. Why not go with this bill, with all of it, except this one thing, the mandate. The rest of it, the restrictions on the industry to try to get it to act like social insurance, the subsidies to people who can't afford their own coverage, keep all of that, just get rid of the mandate. Sure, fewer people will be covered, but only insofar as they choose not to be covered. Can you really count the coverage of however many of these 30 million who fall in that category of being able to afford insurance as a good thing, when the bill as modified will still allow them to cover themselves?
What, you can't deliver on this slight modification? The industry won't let you? They won't let you pass a bill that only regulates them, and only provides subsidies to people who need them in order to buy insurance, but which doesn't give them their mandate? If you can't deliver on just the do-gooding by itself, but had to throw the industry a life-line to get their approval, why do you think that the industry that kept you from any better result will somehow be powerless to keep you from implementing the do-gooder parts of even the present bill, much less improving on it in the future? You have to concede that the industry is the enemy, not a negotiaiting partner, to explain why you can't do the better deal of just the do-gooder parts of the bill, sans mandate. Letting the enemy, the implacable enemy of the only workable way to do health insurance, the social insurance model, have the only thing that will keep it alive, chaining people to its oars, isn't a step in the right direction. It's the decisive capitulation, the surrender of all hope of ever moving in the right direction.