The Mandate Fight Is the Wrong Fight

The health care “debate” among progressives has crumbled into a fight over the mandate to purchase insurance. This is the wrong fight. We all need to refocus and look at the bigger picture.

At Firedoglake, Jon Walker writes that the Senate bill with a mandate is unacceptable because the Senate bill’s provisions for insurance industry regulation are weak. Well, worse than weak. Jon Walker is right about that. And the Senate bill with no public option, no regulation of the insurance industry, and a mandate to purchase insurance would be a mess that would mostly benefit the insurance industry.

But the Senate bill would not be the final bill. There’s a House bill, remember? And the House bill is much stronger in the regulation department. The House bill strips health insurance companies of their antitrust exemption and outlaws price fixing, bid rigging and “market allocations” by health insurance companies. With those provisions, we’d end up with something that is closer to the systems in The Netherlands and Switzerland that Jonathan Cohn writes about at The New Republic.

No, it wouldn’t be exactly the same, but it would be close enough to be a big improvement over what we have now. It would be a big improvement over what Mitt Romney established in Massachusetts, because there would be much stronger regulations than a state could impose.

If by some miracle, someday, we really got somewhere with universal healthcare, it’s going to be some variation of single payer or some kind of mixed public-private system that mandates insurance purchase, as is done in The Netherlands or Switzerland. In other words, there will either be universal coverage provided by a government or through an individual mandate. Nothing else is possible.

Jon Walker is right to say that the Senate bill provisions are way different from what works in Switzerland. But if we ever did get a fair and workable system short of single payer, a mandate would be a necessary part of that. That’s because caring for the uninsured is one of the biggest factors driving up cost for everyone. And if a substantial part of younger, healthier people are opting out of the risk pool, it drives up premiums for everyone else.

So if hell does freeze over and we get a shot at passing a reasonable universal health care bill that is something like what they’ve got in The Netherlands and Switzerland, it will have to include the individual mandate. And all the arguments against the mandate progressives are making now will be hauled out of mothballs and used against it.

But insurance industry regulations are essential also. Without the regulations in the House bill there really is no reform, just a big social welfare program that funnels money into private industry.

So put aside the mandate for a moment. As I see it, there are three issues we should be discussing (in my order of preference):

1. Insurance industry regulations in the final bill. Instead of fighting to take out the mandate, we should be fighting to put in the regulations from the House bill. The Senate bill is completely unacceptable on that score.

The Senate bill even has the ridiculous “buying insurance across state lines” provision, which is an invitation for the insurance industry to set up shop in Texas and sell junk policies to the young and healthy. Older and sicker people would be left behind in higher-risk pools, driving up their premiums. And the young folks might pay premiums for years before making a claim and finding out they’ve been ripped off — Dear Policy Holder: This policy doesn’t cover whatever it is you have. Sorry.

If we can’t get traction with regulations, the next option is —

2. Go to reconciliation. I’d say do this before going to a final bill without regulations. However a healthcare bill passed under reconciliation would have to be rewritten so that it would reduce the federal deficit over five years by at least a billion dollars and be deficit neutral after that. Plus, any part of the bill that does not significantly impact the budget could not be included in the bill. Most people who understand how this works say you’d lose insurance industry regulations and other good stuff with reconciliation, although you could include the public option. So reconciliation is not a magic bullet that will make everything the way we want it to be, but it might give us something somewhat less obnoxious than the current Senate bill.

3. Kill the bill. This really is a nuclear option, because if the bill is killed it may be years before we get another shot at reform. But if the final bill is mostly the Senate bill as it is now, we’re better off without it. If this weakens the Obama Administration, so be it; the President might learn something, and he’s got three more years to change his modus operandi. But this has got to be followed up by a very strong effort to defeat every “centrist” Democrat up for re-election in 2010 and 2012.

These three issues are what we should be discussing, not the mandates.

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