My Health Reform Provision

Yesterday, Ezra Klein offered his prediction for health care reform:

In 2006, it would have been a great deal. But as the legislation winds its way through the Senate, there will be unpleasant compromises, and unconscionable omissions, and the constant knowledge that though this is progress, it is not sufficient, and the people who stand in the way of a better bill are frequently incoherent or disingenuous. And that will be terribly frustrating for supports of the effort. The result will probably be a historic win when compared to the status quo, but I doubt it’s going to feel like that for supporters of the initiative.

This is a pretty good generic description of how congress works, but I think it may be wrong. I think the dynamics of the health care issue—particularly the financial dynamics—lend themselves to a strongly bivalent outcome. That’s because to the extent you crack down on private sector interests (progressive!) you free up money that can be used for subsidies and Medicaid expansion and the like, which is also progressive. And if it looks like a comprehensive health reform is likely to pass, I think two or three or six Republicans will want to hop on board, since there’s no use getting on the wrong side of history. At the same time, if you lose the momentum I think the coalition for reform could very quickly start rolling downhill. If Republicans think there’s any chance of blocking anything from passing, then their interest in a compromise will dry up instantly. If you have a weak-or-nonexistent public plan, then you can’t afford to provide much in the way of new benefits to people. And if you have a plan that doesn’t provide dramatic new benefits, but does piss off union leaders and Democrats from high-cost states (this is the Dianne Feinstein issue), then suddenly it’s not clear who the constituency for your bill is. The piranas will circle, and the whole thing can collapse.

Consequently, my take is that we’ll either get a very strong progressive bill or we’ll get a real legislative train wreck. Ezra’s analogy was to the stimulus bill, but my analogy would be to comprehensive immigration reform—tons of moving pieces mean you can lurch from dramatic change to hopeless coalition breakdown and back again very rapidly.