It’s Too Late for Incremental Health Care Reform

[Updated below]

Conor Friedersdorf, a Republican whose opinions I greatly respect, lays out his case for incremental health care reform in a new column over at the Daily Beast. His central point is basically that liberals should essentially take a conservative approach to reform and advance smaller pieces of legislation rather than go all in under the guise of “comprehensive” reform so as not to arouse suspicion within the electorate.

That may be a defensible point of view, but I disagree with a few of the points he makes throughout the piece.

Conor writes:

Especially curious is President Obama’s decision to pursue comprehensive health care reform when it failed so spectacularly under the Clinton Administration. In contrast, “small bore” reform efforts initiated years later extended insurance to millions of children and afforded senior citizens a hugely expensive prescription drug benefit. Why are those who seek further reform so invested in a sweeping approach certain to provoke intense blowback? They’ve enjoyed their best successes using more incremental methods!

It took a lot of (partisan) work to get to these “successes”. Does Conor not remember how contentious the debate over reauthorizing S-CHIP was? President Bush vetoed two versions of the bill, arguing that the program would “federalize health care” (sound familiar?). It took electing a Democratic president with sizable majorities in both houses to get the extension signed.

The prescription drug bill is now generally considered to be financial boondoggle of immense proportions. The Bush White House hid the true cost of the bill, which now looks to cost upwards of a trillion dollars over ten years (which is in the neighborhood of what the entire health care system overhaul being pushed by President Obama would cost). Widespread confusion followed in the wake of its roll out. And let’s not even talk about the problems with dread “doughnut hole” in the Bush program that leads to a substantial gap in coverage for a lot of seniors. An August 2008 report by the Kaiser Family Foundation said:

From a health outcomes perspective, our finding that some enrollees stopped taking their medications or reduced medication use when they reached the coverage gap could be a serious concern. Individuals with diabetes, for example, risk immediate and potentially serious health consequences if they stop taking their medications. For individuals with other chronic conditions, such as osteoporosis or high cholesterol, the health effects from stopping their medications might not be immediately apparent but it could increase their risk of negative outcomes over time. On the other hand, switching medications to save money might be a clinically acceptable response to the coverage gap.

Physicians can play an important role in helping beneficiaries who reach the coverage gap identify opportunities to switch to lower-cost alternatives, but in order to do so, physicians and patients need to talk with each other about drug costs. Ultimately, both stopping and switching medications could result in higher costs for other parts of the Medicare program if beneficiaries have health issues that are not
being controlled by medication, or if they simply require more physician visits to prescribe and monitor changes in medications. Careful attention is needed to ensure that gains to Medicare beneficiaries from the addition of the Part D drug benefit are not undermined by the coverage gap—especially for those enrollees who are highly dependent on medications to manage ongoing chronic conditions.

Conor then writes:

Though an Obamacare skeptic, I am hopeful that some health-care reforms will be made, as is my family. This American Life, a favorite radio program in my household, recently aired a segment on rescission, the insurance industry practice whereby insured Americans, having paid premiums over many years, find their claims rejected when they get breast cancer or diabetes or some other costly illness—the insurance companies scour their archived applications hoping to find an innocent mistake, often unrelated to their condition, that serves as a pretext for cancelling their policy. Why don’t the Democrats draft, pass, and enact legislation that ends rescission? It would be wildly popular, even among Orange County conservatives. And it would rectify an injustice.

Conor surely knows this, but ending rescission is something that’s being addressed by the proposed legislation that’s floating around. Again, one can make an argument that this ought to be a standalone piece of legislation, but this leads to my final point.

Conor says:

Of course, some on the right will mistrust any legislation that President Obama backs, but even conservatives like me, who assume he is acting on the best possible motives, are right to be concerned by particularly complex bills. They are prone to capture by special interests, ripe for the sneaky inclusion of unpopular provisions, and more likely to result in unpredictable and unintended consequences. Talk of socialist plots is paranoia. The mundane reality to fear is that complicated measures benefit well-connected elites, who are best able to manipulate the legislative process.

I’m fine with debating whether a bill should be over a thousand pages long and I think the fear of corporate giveaways being placed in the legislation is appropriate, but the real issue is that moderate conservatives like Conor who actually don’t demonize the opposition (or have any real objections about some of the reforms being proposed) have no real way to influence the debate over this legislation. It’s not that “some on the right will mistrust any legislation that President Obama backs”, it’s that everyone a significant portion of the Republicans in Congress and their supporters in the conservative intelligentsia  have gone full in on the crazy to obstruct any reform. When the lead Republican legislator on the Senate committee with the most influence over the shape of the bill is now saying that people are right to be worried about so-called “death panels” and that there aren’t negotiations going on, just talks, there’s just no reason to believe that any Republicans are serious about working to reform health care. And it’s important to point out that the hysterical rhetoric is starting to show some concrete effects.

The bottom line is that it’s too late in the game for anyone to turn back at this point. The Democrats have put all their chits on comprehensive reform; anything less and they lose. Republicans have gone all in to oppose any reform and backing down on their overheated arguments as this point would cause considerable grief for elected members of the GOP.

The nation seems locked in a Kobayashi Maru situation. We seem to have our Mr. Spock, but where’s our Captain Kirk who will cheat the system in the name of the greater good?

[Update]

Let me be clear…I really understand and appreciate the notion of breaking down complex things into smaller parts that might be able to pass in an easier fashion than the large bills circulating for health care. By my gut tells me that it wouldn’t matter. Pushing incremental reforms when everyone knows that Democrats want to try to revamp the system as much as possible would only lead, I think, to charges of mission creep. The counter charge in that scenario would be that the Democrats are trying to backdoor their way to reform because they know they couldn’t get a monstrosity past the opposition, so it’s really a damned if you do, damned if you don’t situation for the major supporters of health care reform. Obama attempted to change the process (let Congress write the bill vs. dictate the bill to Congress the way the Clinton’s did in the early ’90s) with the hope that it might change the outcome. In reality, I don’t think there was any way to do this that was going to result in the kind of firestorm we’re seeing now.