Wyden-Bennett Vs. Single Payer: Fundamentally Different Views Of Health Care Reform

Last night, I mentioned this excellent post by Ed Kilgore. I want to delve into it a bit more and I will use Matt Yglesias's post on it as an entry point. Matt writes:

Kilgore writes that “sorting out these differences in ideology and perspective is, in my opinion, essential to the progressive political project.” I’m persuaded that acknowledging the existence and principled nature of this difference of opinion may be crucial. But I think the solution is less to sort them out, than to simply problematize the distinction. At the end of the day, no matter what people think they think, nobody remotely sensible actually holds a pure strain of either of these views.

This is absolutely true. Take health care for instance. No one who is for the public insurance program approach opposes the "regulatory reform model" because their ideology leads them there. They are skeptical that it will work. They believe that the government insurance model is the reform that will work for the U.S. Not the regulatory model (and certainly not the regulatory model proposed by the current bill.) More . ..

Kilgore writes:

This approach was inherently flawed to "single-payer" advocates on the left, who strongly believe that private for-profit health insurers are the main problem in the U.S. health care system. The difference was for a long time papered over by the cleverly devised "public option," which was acceptable to many New Democrat types as a way of ensuring robust competition among private insurers, and which became crucial to single-payer advocates who viewed it as a way to gradually introduce a superior, publicly-operated form of health insurance to those not covered by existing public programs like Medicare and Medicaid. (That's why the effort to substitute a Medicare buy-in for the public option, which Joe Lieberman killed this week, received such a strong positive response from many progressives whose ultimate goal is an expansion of Medicare-style coverage to all Americans).

Now that the public option compromise is apparently no longer on the table, and there's no Medicare buy-in to offer single-payer advocates an alternative path to the kind of system they favor, it's hardly surprising that some progressives have gone into open opposition[ . . .]

Precisely so. And gets at what has bothered me about the Village Wonks of late -- the failure to acknowledge that while they had confidence in the regulatory reform (the exchanges, the no preexisting conditions, the community ratings, etc.) - those on the other side (including myself) - simply do not. Given the BEST interpretation of the existing data, their case for the efficacy of the regulatory reform model is not strong. The short answer is the United States is not Switzerland, the Netherlands or Germany. The longer answer is the current bill does not create anything like the systems in place in those countries.

Incrementalism has always been the watchword of this reform effort. And I do not mean that in a demeaning way. Politics is indeed the art of the possible. But the key question has always been incrementalism towards WHAT?

When the bill contained both the regulatory reform framework (the new regs, community rating, the exchange) and the public insurance framework (the public option, the Medicare Buy-In), even in small, ineffective ways, at least you could feel that the bill was taking the system in the right direction.

But once the public insurance idea was completely eliminated, the bill no longer was taking the system in a way that public insurance reform proponents thought it needed to go. Not surprisingly, the public insurance reform proponents screamed bloody murder.

Not surprisingly, the regulatory reform proponents did not. Their ox was not gored. Somewhat surprisingly, the regulatory reform proponents were surprised by the strong reaction. They figured since they did not really care about the public option, neither would anyone else.

Of course that has lead to a lot of rhetorically bloodletting. But at the heart of it all (and this has been boiling up since the summer) has been the inability of regulatory reform proponents to accept, respect and grasp that there really was NOT agreement among Democrats and the progressives on the best way to reform the American heath insurance and care system.

Whenever I protested Ezra Klein going out and playing the public option proponent on television and on his blog - this was at the heart of it. I knew he really was NOT a proponent of public insurance reform. He was a regulatory reform proponent. His perfect reform was Wyden Bennett, not Single Payer.

Ed Kilgore is right - there is a fundamental policy schism on health care reform:

To put it simply, and perhaps over-simply, on a variety of fronts (most notably financial restructuring and health care reform, but arguably on climate change as well), the Obama administration has chosen the strategy of deploying regulated and subsidized private sector entities to achieve progressive policy results. This approach was a hallmark of the so-called Clintonian, "New Democrat" movement, and the broader international movement sometimes referred to as "the Third Way," which often defended the use of private means for public ends.

Normally, I am in this camp. On health care, after looking at the evidence, I have concluded it will not work. Health care requires the public sector model. I also accept that reasonable progressives can disagree on this.

Speaking for me only

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    Good post (5.00 / 1) (#1)
    by andgarden on Thu Dec 17, 2009 at 09:34:10 AM EST
    I especially agree with M.Y. that nobody falls perfectly into either camp. Certainly I do not.

    BTW, check your tags.

    There are and always were two camps (none / 0) (#5)
    by Big Tent Democrat on Thu Dec 17, 2009 at 09:43:01 AM EST
    on health care reform.

    Ezra Klein fell in one and would go on TV and pretend to fall in another.

    That bothered me a lot.

    And as Kilgore says, it is hardly surprising that the public insurance camp would be more inclined to oppose the bill now since their view of reform is what took the hit. It is disingenuous for the regulatory reform camp to not pretend they would not be just as upset if their programs were the ones getting cut.

    For example, I really hope someone in Congress proposes not using the Exchanges as the answer to Stupak. Watch Ezra go ballistic.


    Well, I think this may bring up another (5.00 / 2) (#12)
    by dk on Thu Dec 17, 2009 at 09:52:13 AM EST
    important ideological divide within the party, namely which is the higher priority, health insurance reform or gender equality.

    I understand that people of good faith who side with health insurance reform also care about gender equality, but as for me I sincerely believe that inscribing further inequality into our laws is just too high a price to pay.


    Indeed (none / 0) (#16)
    by Big Tent Democrat on Thu Dec 17, 2009 at 10:01:32 AM EST
    And we may soon find out (5.00 / 1) (#33)
    by dk on Thu Dec 17, 2009 at 11:42:48 AM EST
    given this development.

    WASHINGTON - Nebraska Sen. Ben Nelson -- the moderate Democrat whose opposition is holding up the Senate's health care bill -- says new language on abortion doesn't satisfy his concerns.

    Nelson told KLIN radio in Lincoln, Nebraska, Thursday that an attempt at compromise doesn't get to the fundamental issue of barring federal funding for abortions.

    Nelson says without further changes the compromise isn't sufficient.

    Moderate? In what respect? (none / 0) (#37)
    by oculus on Thu Dec 17, 2009 at 11:31:26 PM EST
    I really like that last point (none / 0) (#8)
    by andgarden on Thu Dec 17, 2009 at 09:46:02 AM EST
    I have to thank you for being basically the only person in the entire leftosphere willing to call out Ezra for his disingenuous.  

    Log rolling in our time (none / 0) (#10)
    by Big Tent Democrat on Thu Dec 17, 2009 at 09:48:30 AM EST
    Unlike poor Bowers, I can write whatever the hell I want. I do not depend on the DC Dems for my meal money.

    It's a tough spot.


    I don't know how the hell you find the time, (5.00 / 1) (#11)
    by andgarden on Thu Dec 17, 2009 at 09:49:17 AM EST
    but I sure appreciate it.

    Easy enough (5.00 / 2) (#18)
    by Big Tent Democrat on Thu Dec 17, 2009 at 10:03:47 AM EST
    People spend too much time "polishing" their posts as if they are works of literature.

    Write a few sentences, or better yet, quote somebody, so people know the topic. Lay out your case in a few sentences. Off you go.

    I think people OVERWRITE for the most part. I do too when it comes to legal stuff on a blog I think. And that might be what it is about. We want people to know that we know a lot.


    I think that's a pretty good model (none / 0) (#20)
    by andgarden on Thu Dec 17, 2009 at 10:06:40 AM EST
    As for the legal stuff, I think MaryB would like a word. . . ;-)

    Actually that makes my point (none / 0) (#21)
    by Big Tent Democrat on Thu Dec 17, 2009 at 10:08:11 AM EST
    I can not write a post on the preemption doctrine in 10 minutes.

    I have to set aside a couple of hours. This is true for most legal issues.

    I SHOULD be able to but when it comes to legal writing, I am not trained for that.

    Anything else? I can let it fly and do.


    Your professional colleagues might read you (none / 0) (#22)
    by andgarden on Thu Dec 17, 2009 at 10:11:10 AM EST
    on legal stuff. That would probably be my concern.

    I would probably not blog on anything resembling my practice.


    I don't (none / 0) (#28)
    by Big Tent Democrat on Thu Dec 17, 2009 at 10:16:54 AM EST
    I never did.

    Generalized discussions of antitrust law are not often a part of commercial litigation.

    Habeas corpus never comes up in my practice (preemption does pretty frequently, but in very specific ways.)


    That breakdown suits me better than (5.00 / 1) (#27)
    by ruffian on Thu Dec 17, 2009 at 10:14:27 AM EST
    those who try to break it into pragmatists and non-pragmatists. I would be in favor of the regulatory reform model if I thought it would work. However, I think the public insurance model is the only one that can really work - and I am joined by millions of people the world over, in most of the modern nations.  To me, that makes me a pragmatist. Yet the regulatory reform advocates implore me to be 'pragmatic' and support what can be achieved with the dolts who happen to be in power right now.  After watching the private insurance industry bend every rule imaginable to cheat their customers for all these years, they think these new rules will have any teeth? Sorry, it's just not pragmatic to think that way.

    the problem (none / 0) (#29)
    by CST on Thu Dec 17, 2009 at 10:37:44 AM EST
    as I see it is not the ineffectiveness of regulation.

    It's the lack of substantive regulation being passed.

    For example, if there was a cap on premiums, a minimum coverage requirement, and a profit cap, actually IN the bill, then you would have a much stronger argument for a regulatory system.

    The problem is, this stuff isn't there, not that this stuff doesn't work.


    Regulatory/public (5.00 / 1) (#34)
    by TheRealFrank on Thu Dec 17, 2009 at 11:59:15 AM EST
    Yep, regulatory can definitely work, but it needs strong regulations, and a situation out of which it can work.

    Therefore, the comparisons to the Dutch system are invalid. Given the situation in the US right now, it is very hard to map a path to where the Dutch system is, and it's questionable if it could ever work. It's much harder to correct a system that has gone wrong than transition an already working system.

    I think that's my big problem with the argument that the regulatory system can work in the US: you can't make a serious argument for the regulatory system unless you can make a convincing case for a path to a working system. How do you get there from here?

    What is happening now is that this bill will provide some insurance assistance and will get more people insured. That's a net positive. But it is a small, partial remedy for a symptom, not a structural solution.

    Good summary (5.00 / 1) (#36)
    by Lora on Thu Dec 17, 2009 at 12:27:57 PM EST
    Very concise and informative layout of the two major positions.

    I agree with your stand.

    I have never held out hope for any actual benefit to me and mine or to the majority of Americans in terms of health insurance and health care under this administration.  I hope I may be proved wrong in the near future.

    "there really was NOT agreement... (none / 0) (#2)
    by lilburro on Thu Dec 17, 2009 at 09:35:00 AM EST
    ...among Democrats and the progressives on the best way to reform the American heath insurance and care system."

    Which makes Obama's lack of coherent leadership on the issue even more of a problem, doesn't it.

    Mandate for what?

    I think the problem was that (5.00 / 1) (#35)
    by inclusiveheart on Thu Dec 17, 2009 at 12:15:49 PM EST
    there was no agreement about a specific set of goals effective reform would achieve.

    Well, there sort of was in a way, but that list was quickly deep sixed because an objective analysis of what it would take to achieve, access, affordability and efficacy would not be palatable to a lot of people in power.

    Objective analysis of existing data from the past two decades would lead to only one conclusion which is that a Medicare single payer model run by the government is the only system that could achive the highest return for our dollars in each of those areas.

    After the goals of reform were rendered moot, that's when all the wacky ideas could flow in and be treated as "serious" and "legitimate".  That's how Axelrod gets away with praising this bill.  The standards by which we might measure its value have been taken off of the table.


    Obama (none / 0) (#23)
    by me only on Thu Dec 17, 2009 at 10:12:05 AM EST
    wants to pass something.  He would like Republican support.  Does he really have his heart set on something that the average leftist wants?  Who knows, but the evidence appears to be "not so much."

    Form over function.  I still remember the SNL skit of H.W. Bush, "don't want to be a one term president."  Obama isn't going to sacrifice himself for a public option.


    I think much of Obama's behind-the-scenes (none / 0) (#24)
    by Anne on Thu Dec 17, 2009 at 10:12:06 AM EST
    deal-making puts him squarely in the regulatory reform camp; worse, he thought he could get the industry to regulate itself.

    What boggles my mind is how he could possibly have any faith in the ability of the health industry to regulate itself after seeing what happened when the financial industry was left to its own devices.  What possible reason would anyone have to believe that the industry that has always had the opportunity to make the kinds of changes that are needed, and hasn't, would ever do so now?  

    Obama is, in fact, leading on this issue, but he is doing it in the most cowardly way possible.  This is not new; he still believes he can address the nation with platitudes and slogans and worn-out campaign rhetoric and we won't notice what is happening behind the scenes.  There's a Wizard of Oz analogy in here somewhere, I think (I've been desperately searching for the ruby slippers, but I think we are stuck in Oz for the duration).

    This is not an aberration: it IS Obama, and I think we can expect more of it on the issues yet to be dealt with.

    And I will go out on a limb and suggest that we are not likely to be any happier how these other issues are resolved than we are with the way health care is shaping up.


    So Clintonian/New Democrats are against Importing (none / 0) (#3)
    by Dan the Man on Thu Dec 17, 2009 at 09:41:07 AM EST
    drugs from Canada?  Guess I learn something new every day.

    Not sure (5.00 / 2) (#6)
    by Big Tent Democrat on Thu Dec 17, 2009 at 09:43:49 AM EST
    if that is part of the program.

    Doubt it is. I assume that is just enforcing the Obama PhRma deal. More like a pork thing.


    Seems to me that they have (none / 0) (#4)
    by MO Blue on Thu Dec 17, 2009 at 09:42:27 AM EST
    eliminated or watered down many regulatory reforms to the point that we are left with neither a regulatory reform model or a public sector model.

    But the skeleton of it is still there (5.00 / 1) (#7)
    by Big Tent Democrat on Thu Dec 17, 2009 at 09:44:17 AM EST
    the public insurance model is long gone.

    Maybe a toe or a leg bone (none / 0) (#9)
    by MO Blue on Thu Dec 17, 2009 at 09:47:53 AM EST
    with large holes in them.

    Honestly (none / 0) (#13)
    by Big Tent Democrat on Thu Dec 17, 2009 at 09:52:30 AM EST
    Since I am not a believer in the regulatory reform framework, I have not really given it much thought.

    The public insurance model may be gone from this (none / 0) (#14)
    by steviez314 on Thu Dec 17, 2009 at 09:56:44 AM EST
    bill, but it is not long gone.  After all, Medicare still exists.

    So, at any time, saying "extend Medicare to ages xx-yy" has clear meaning to the public and can be debated.

    I guess I'm of the viewpoint that the expansion of Medicare can happen outside of this year's effort and will happen sooner than we think.


    the problem with that (5.00 / 2) (#25)
    by CST on Thu Dec 17, 2009 at 10:12:11 AM EST
    as I see it is that the politicians will pass this bill, call it a "win" and move on.

    I don't see them wanting to revisit this anytime soon considering the amount of fighting that's gone on this time around.

    And after 2010, it might be too late to even use reconcilliation.


    Best argument (none / 0) (#15)
    by Big Tent Democrat on Thu Dec 17, 2009 at 10:01:14 AM EST
    yet on this.

    If I was a regulatory reform proponent, instead of insulting public insurance proponents, that is the type of argument I would be making.


    Yup (none / 0) (#17)
    by andgarden on Thu Dec 17, 2009 at 10:02:47 AM EST
    What's sad for the rest of us is that if we had tried doing that this year, we might have been able to make it happen. And if not now, when? Medicare is not new.

    What disturbs me (5.00 / 1) (#19)
    by lilburro on Thu Dec 17, 2009 at 10:05:26 AM EST
    is the regulatory reform people who now bring up reconciliation as something we could possibly do later, even though they have claimed all along it would wreck the entire process blah blah blah.  They just want to go first.

    My question is, is expanding Medicare or developing a PO going to be more or less difficult since it was publicly defeated in this bill?  I'm not actually seeing that it will get easier to do those things in the next 10 years.


    I'm an optimist. I think expanding Medicare (none / 0) (#26)
    by steviez314 on Thu Dec 17, 2009 at 10:13:58 AM EST
    will be easier after this effort.

    This bill just had too many moving parts.  Some needed 60 votes, so an early decision was made to not split up the bill into 2 parts.

    A single bill, say next year or the year after, just designed to lower the Medicare age, is a one-sentence (small exaggeration) bill that needs 51 votes.  No death panels, no Stupak.

    Look at all the bills that pass on the 51-vote track.  How simple they are:  Go to war or not.  Cut tax rates from x to y or not.

    And I think, as a single issue, divorced from the regualtory issues in this bill, it's politically a winner too.


    Insults are not most persuasive (none / 0) (#31)
    by Coral on Thu Dec 17, 2009 at 11:03:35 AM EST
    argument to win reluctant skeptics back to your side.

    I really fail to understand why Obama's spokespeople are so eager to slam someone like Dean, who has wide support among some of their most active base. At the same time they are full of soothing words for obstructionists like Lieberman, Nelson, Lincoln, et al.


    I posted this earlier (none / 0) (#32)
    by jbindc on Thu Dec 17, 2009 at 11:32:38 AM EST
    And despite what you might think of Politico, I think this piece makes a good point:

    Sen. Joe Lieberman (I-Conn.) is taking a thrashing from his former Democratic colleagues and liberal activists for forcing a Medicare expansion out of the health bill.

    But in the end, Lieberman may have done President Barack Obama one of the biggest favors in the health care debate.

    That's because any bill with the Medicare buy-in would have drawn fierce opposition from doctors and hospitals, two groups Obama has worked hard to keep on board.

    In effect, Lieberman spared Obama from having to make a difficult choice down the road - between liberal supporters who wanted the Medicare expansion and two big constituencies whose opposition could have scuttled a bill.

    "They can't lose the hospitals or the docs," one health care lobbyist told POLITICO.

    Both groups hold big sway on Capitol Hill and, more importantly, in local communities where they can quickly mobilize grassroots opposition.

    Their muscle helped kill President Bill Clinton's reform effort more than a decade ago and it was on display again this past week when word spread that Senate negotiators were considering expanding Medicare to younger seniors, ages 55 to 64.

    In less than a week, the groups mobilized and succeeded in beating back the plan. The episode illustrates why Obama has sought to keep the two influential health care stakeholders as allies, not adversaries.

    And as the Senate writes the fine print in the bill, the quick demise of the buy-in shows how quickly the two constituencies were able to shift the ground in Washington to block something they didn't like.

    Not all were surprised...... (none / 0) (#30)
    by vicndabx on Thu Dec 17, 2009 at 10:50:23 AM EST
    Somewhat surprisingly, the regulatory reform proponents were surprised by the strong reaction.

    I think many of the "regulatory reform proponents" were well aware of the fact that the public option/gov't proponents would be upset.  Lieberman for all his faults crystallized this understanding when he stated, in so many words, that the long-term end result of the buy-in was gov't run insurance. The reason why many with experience in health insurance know simply expanding gov't insurance won't work is the model on which many pro-gov't folks base their assumptions is flawed w/r/t coverage, reimbursement, and people's expectations. What works for Medicare works because it is limited.  Why do you think providers of care helped get the Medicare buy-in killed?

    Medicare works only because the payout is so low. Increase that, and it's "value" get's diluted substantially. Let more folks in on the fact that their out of pocket expenses will increase causes even further erosion in the value prospect. I'm not saying Medicare isn't effective in terms of covering folks, what I'm saying is it's value in terms of dollars spent exists only because of it's use in a limited population. Take that away and it becomes no different from any other insurer - and less effective at that since it does not concern it self w/quality & effectiveness of care.