A Historic Bittersweet Victory

Last night health care reform, HR 3962, passed the House of Representatives by a vote of 220 to 215. It was a truly historic moment and the bill will help millions of Americans. Yet as a progressive the passage of the bill is at best bittersweet.

The bill is not single payer. It does not have a public option tied to Medicare. The bill funnels billions to private insurance companies and foolishly eliminates the SCHIP program. It would prevent life-saving biosimilars from reaching the market in a timely manner. The new exchange is not well designed and lacks the robust risk adjustment mechanism needed to encourage competition based on quality. The annual out-of-pocket limit is far too high, and for many middle-class American families the tax credits are going to be insufficient. The bill did not take some of the huge steps really needed to rein in costs, like creating a single payment setting mechanism. It will not start in earnest for several years. And as a final insult, the Stupak anti-abortion amendment was added at the last minute.

It is important to acknowledge what good this bill will do. The most overlooked but important part of this bill is the expansion of Medicaid to everyone below 150% of the federal poverty level. No longer will there be a confusing patchwork of qualifications and waiting periods between the states. This expansion means that every American in poverty will have health insurance they can afford. Medicaid is not perfect, but it will expand coverage to 15 million Americans who would not have otherwise had health insurance. That is millions of Americans this bill unequivocally help.

The bill also contains many important consumer protections that are long overdue. Some of the most horrendous practices like rescission and not covering pre-existing conditions will be gone. Most importantly, the bill will set an important precedent. As a nation we will have made the commitment to help every American get health insurance if they want it. That is critical. Once a nation makes that commitment, they almost never back slide.

The bill does have a public option that would be available everywhere on “day one.” It is weaker and more restricted than it should be, but I strongly believe in the long term it will succeed. People will like it and it will grow steadily into a real force which will improve our health care system. At the very least, it would make sure right away that there was one decent insurance plan on the exchange not trying to rip off people. That is a huge accomplishment in itself.

What is most important is not how this bill will work, but what foundation it will lay. This will not be the end of health care reform. The system this bill creates is so imperfect that there is no way it will not be heavily modified, and possibly completely overhauled, over the coming years.

This bill will lay other useful foundations. It will make it so that any American who really needs/wants health insurance can get it. No longer will the Americans be denied insurance all together. By setting narrow rating bands the bill promotes the idea of equality in health insurance for all Americans regardless of sex, race, health, or pre-existing condition.  (Unfortunately, on the same token the Stupak amendment lays a strong ant-choice foundation in health care reform; if it remains in the final bill, the damage done by the Stupak amendment will probably never be reversed.)

The most important foundation the bill will create is a public health insurance alternative to hold the private insurance companies honest. The public option will be something the progressive movement can build on. If our new health care system only funneled billions of government subsidies to for-profit insurance plans that all Americans are forced to buy, that would be a foundation for long term disaster. Without the public option, the reform bill will be built solely on a base of greed, profit, and corporate welfare. That will simply not be sustainable and its failure could discredit the whole universal health care movement.

This bill that passed the House is disappointingly weak for progressives; but I’m not fighting to win the whole war with this battle, I’m fighting to lay the proper ground work needed for the next health care reform battle. This bill will at least provide progressives the tools they can use build with. This is why it is important to fight for the critical components like the public option, risk adjusters, and strong community ratings. (It is also why it is important to fight to remove components that will not easly be undone, like the Stupak amendment) It is not about what public option will be right away, it is what progressive can turn it into in the future.