Wayne O’Leary

Slouching Towards Romneyville

Fifty years from now, people will wonder what all the fuss was about when euphoric Democrats finally passed health-care reform. The controversial legislation is not half as oppressive and interventionist as hysterical Republicans claim (it’s certainly not socialism), nor is it nearly as historic and transformative as triumphalist Democrats assert. What Congress has done is to reinforce the existing health system and tweak it; fewer than 20% of potential health-care recipients will even be affected.

President Obama is right when he says the legislation is not “radical” reform. Truly fundamental, thoroughgoing reform would have meant enacting a single-payer, Medicare-for-all plan or (at the very least) one with a “robust” public option. What Obama has signed is neither of those; it is a federalized version of the Massachusetts plan Mitt Romney produced as Bay State governor during his prior incarnation as a moderate Republican, plus some added insurance-rule changes.

The Romney dispensation, with its individual mandate, health exchange, and exclusively private insurance options, bears no resemblance to what Democrats said they wanted over the years. As congressional passage neared, claims were made that the majority party was consummating the cherished dreams of FDR, Truman and JFK, but nothing could be further from the truth. Those Democratic forefathers visualized a universal, tax-financed, government-run system, a social-insurance entitlement like Social Security.

No can do, said the smart guys in Congress and at the White House. The president himself characterized single-payer advocates as leftist extremists, the counterpoint to the right-wingers who wanted no change at all in the system. The market-oriented approach Democrats ultimately chose was selected because it was the only route to reform and increased coverage that did not entail taking on the health-care establishment, especially the insurance industry, by threatening its existence or prerogatives.

It had the added advantage of not being anything liable to be labeled “liberal.” Democrats were traumatized by the Reagan-Gingrich years; they had the bejesus scared out of them, and they’ve never recovered. Federalized Romneycare allowed them to “do something” that did not overtly suggest a big-government solution. Predictably, Republicans accused them of that anyway, so in the end it made no political difference that they really enacted a center-right program more conservative than what Dick Nixon, of all people, proposed in the early 1970s.

Perhaps, in 21st-century America, this is all we can expect. Perhaps large, path-breaking public reforms free of corporate control and influence are no longer possible in the post-Reagan environment, with its cynical small-mindedness and anti-government biases. If so, it’s a sad commentary on where we are as a country. “Don’t let the perfect be the enemy of the good” was the constant administration mantra during the run-up to the final vote on the health-care bill. Don’t worry about that. On a scale of 10, with 10 being “perfect” and 7 or 8 being “good,” the legislation that passed comes in at about a 3 or a 4. It’s better than nothing, as many have said, but it’s really beneath us in concept, scope, and imagination — and in the end, it probably won’t do the job.

The so-called reform now on the books preserves the complicated, unwieldy rattletrap of a system we already have, the employer-based, insurer-dominated, profit-driven structure that has become the premier example of how not to organize medical care. There are undeniably worthwhile insurance-market reforms now in place aimed at preventing arbitrary denial of coverage or cancellation of policies, but as Dr. Howard Dean has said, these guarantee that the Government will likely spend years in court fighting the insurance companies over coverage loopholes, reimbursement levels, medical definitions, and legal terminology — in short, the meaning of the small print in the new health-care law. The grasping insurers could have been eliminated from the process, but they were given a new lease on life, along with millions of involuntary new customers to exploit.

Of course, large numbers of previously uninsured Americans will now be insured (partly, perhaps largely, at their own expense), but unlike every other developed country, we will not have universality. No more than 32 million of the estimated 47 million uninsured (roughly two-thirds) will be covered. The president acknowledged that only a single-payer system could cover everyone, and that was a non-starter. In retrospect, it appears that the much-heralded public option, too, was really off the table from the start. Democrats, the president included, gave it lip service to placate their base, but once the pending legislation reached the reconciliation stage and serious negotiations began, it disappeared without a trace.

The tragedy of the public option’s demise is that it was the main device for cutting consumer health-care costs (i.e. premiums) through competitive pricing. In an oligopolistic cartel system, premiums can be restrained in only one other way — through government price controls, which the enacted plan also does not have. Even had the public option survived in its final form, however, it would have been available only to uninsured and self-insured individuals entering the exchanges — a fraction of the total market. Except for new Medicaid eligibles and those who can now avail themselves of the long-overdue insurance-market reforms to prevent discriminatory industry practices, this will be the only portion of the population impacted by health reform. For the rest, nothing much changes, including those annual premium increases. Administration claims that everyone’s costs will go down are essentially faith-based; there’s nothing in the law to make that happen.

The scheme we’ve adopted is unlikely to improve things for the great mass of people. Respected health-care analyst Trudy Lieberman, writing recently in the Columbia Journalism Review, reported that the Massachusetts plan, the model for the national reform legislation, has not uniformly reduced insurance costs. Quite the contrary, it has actually raised coverage rates for small businesses and for older state residents not yet on Medicare, while simultaneously precipitating a serious doctor shortage and long waits for treatment.

Maybe Obamacare will work out better and allay my fears. Then again, probably not. The market is what it is, and this is a market-based reform. In the words of the Randy Newman song, I could be wrong, but I don’t think so.

Wayne O’Leary is a writer in Orono, Maine.

From The Progressive Populist, May 15, 2010