It is increasingly looking like any health care reform that passes at this point is largely going to be based on the Senate version of the bill. While there was an initial strong back lash against this, the progressive movement has largely broken into two camps:
- Support the bill as a step in the right direction and something to build on
- Fight the bill pushing Congress to come back with something better through reconciliation
This split exists for a variety of reasons, but I think a key element that's largely been left ignored is simply this: trust.
The bill that the Senate has crafted is complex. It has a lot of different regulations with limitations and requirements on the insurance industry that all interact with each other. As the bill moved through the Senate pieces were added, removed, and tweaked to give us the final result. So is that final result going to make for meaningful reform? It depends on who you ask.
I can site you a long list of health care policy experts who will claim that this bill does a lot of good things. I can site you an equally long list of health care policy experts who will claim the exact opposite. The reason for this is that the bill is so deeply complex that nobody can really predict the outcomes of it. Every expert has to make assumptions about the behaviors of insurers, the insured, hospitals, and pharmaceutical companies. Depending on how they construct their assumptions, they wind up with different results.
Faction 1: Kill the Bill
The Kill the Bill faction largely assumes that insurance companies are bad actors who will exploit every loop hole they can find. That while we create rules that explicitly forbid some of their worst practices, they will find ways to weasel around these rules. This belief is not unfounded because the insurers have demonstrated a penchant for doing this in the past. Their profit motive encourages this behavior and so it will be difficult for any regulatory regime to keep them under control.
Faction 2: A Good Start
The "good start" faction largely assumes that the construction of the regulations in the proposal will have the desired effect. That the new proposal has made it sufficiently difficult for insurers to find loop holes. That various measures will help expand access and contain cost through how they interact.
The Battleground
Given those two sides, the fight about the policy has largely evolved into a back and forth over specific clauses of the bill. The problem with this is that all the parts of the bill are linked together. Any one element can be pulled out and looked at independently of the rest and seem like a bad idea on it's own. So we have this debate about things like an excise tax, or a requirement on insurers of where to spend their money, but in the end as a whole, nobody really knows if this is a good bill or not.
Largely where your position falls in this debate is a matter of how much you trust Congress. Since this bill is entirely based on a complex series of regulatory changes, we can't really know what the outcome is going to be. If you tend towards trusting Congress, then you'll tend to fall in the "Good Start" faction, and if you tends towards not trusting them you'll fall into the "Kill the Bill" faction.
Keep it Simple Stupid
Of course, as progressives, we fought for a simpler solution: the public option. Of course some of us fought for single payer and we may still end up there in the long run. But all of our solutions called for the government to provide an alternative to private health insurance. In that, we did not have to trust the private insurers to do the right thing or for the framework of regulation to work perfectly. Instead we would have an out if the regulatory reforms didn't do their jobs.
Lacking the public option we are left with what is a matter of faith really. Even those who have the acumen to understand every nuance of this bill are unable to predict it's ultimate outcome. Our history is replete with legislation that has had all manner of unintended consequences. So this bill may actually be a really good thing or a really bad thing and no expert can really say which one it is with any certainty.
The Politics
At this point though it seems our fate is written. The politics dictate that some form of health care reform happen and so they will push out whatever bill they can get the votes for. There is still some haggling over the details but in the end we largely know what the bill will look like. What we don't know is whether this bill will work and we probably won't know that until 5-10 years from now. So we are left to trust our legislators and hope that if they did screw this up we can get this right the next time.