It was a compelling enough argument to help elect a lot of Democrats to Congress. So much so, that even The Escalater has decided he needs to get in on the action. His solution, by most reports, is unsurprising: more fiddling with the tax code. The plan he is expected to outline tomorrow night would set a limit on the deductibility of employer-based health care, capping it at $7,500 for individuals and $15,000 for families. According to the administration, 80 percent of workers who have employer-based insurace would get a tax cut. The other 20 percent, who had more expensive benefits, would have a tax increase.
And the 47 million without insurance at all? The administration has another plan that would take some of the federal money received by hospitals and other facilities and give it to states to provide more coverage to the uninsured. It's hard to see how that kind of shifting of funds would have much of an impact--while states might be able to cover some of their uninsured population, how do the health facilities that have lost funding make up the gap?
Ezra sees some good in this plan, incremental as it might be.
The full deductibility of employer-based benefits has had nothing but pernicious consequences for the health system, creating and strengthening a structure that traps Americans in jobs, giving employers absurd control over their workforce's health security, and penalizing the entrepreneurial and unemployed alike. And every taxpayer, whether they have insurance or not, is forced to subsidize this unjust, inefficient structure. It's crazy. Progressives should indeed support efforts to sever the Gordian knot tying insurance to employment and, now, with Democrats in control of Congress, should see this proposal as a starting point atop which a yet-more progressive tax change can be constructed.
In the sense that the Bush plan is opening up debate on whether employer-based insurance is a start. But if we're going to be talking about incrementalism (assuming the final goal is a single-payer system) why not take a serious look at the Wyden plan? Which, actually, Ezra has, here, here, and here. In that second post, Ezra makes a critical point that those whose primary goal is providing universal access--making sure that the 47 million uninsured people in this country get coverage, and soon--need to take to heart.
Can anybody truly see Congress passing a piece of legislation and a president signing a bill that, in one stroke of the pen, dissolves Aetna, UnitedHealthGroup, Kaiser Permanente, Blue Cross, and all the rest? We're talking about the full dissolution of multibillion dollar corporations that employ thousands and thousands of people, contribute heavily to a wide swath of politicians and provide massive tax revenues to a large collection of states, and have been the sole providers of health coverage for nearly a century now. Forget whether you, or I, think their demolition would be a good idea: Do you see it as a possibility?
The Wyden plan, kludgey though it may be, does a couple of key things: provides a minimum level of coverage (an actually quite generous level--equivalent to the Federal Health Services Benefits plan--the same one Member of Congress get), that is universal. No one can be denied coverage for any reason. It leaves the insurance companies in business, but it also puts them in the business of actually covering people, rather than their current business of figuring out who to deny.
Full disclosure here, I used to work for Senator Wyden, and have a great deal of respect and good will toward him. But he and I have always had our policy differences, so when we had a phone conversation a few weeks ago about his plan, I had some tough questions for him. Most of which he had answers for. I still see two sticking points, however. One echoed today by Atrios, is having an individual mandate--requiring individuals to buy in. There are tough administrative problems in getting everyone to choose and enroll in a plan. The other concern I have is shared by Ezra, and that's cost containment, both in service provision and in administrative costs.
Competing, of course, with the Wyden plan is the Kennedy Medicare for All plan which would expand the program to a true single-payer plan, covering all Americans. The primary difficulties for this plan is overcoming the health insurance industry by legislating it out of existence, and the fact that Medicare is in pretty shaky condition at the moment, and would require an intensive and expensive overhaul to be expandable.
There will be innumerable plans offered by innumerable presidential contenders in the next year, one of them already brought up by Hillary Clinton, which would start by expanding access to cover all children. It's a start.
Some of these plans will be too little, some of these plans might be too much. It seems to me that we as activists need to put aside for now preconceived notions of good and evil in this debate. We need to be open to possibilities beyond single-payer and keep our eyes on the goal of universal coverage. The last major attempt at comprehensive national health insurance reform was a total debacle. We can't let another 15 years go by without a serious effort to reform the system.
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