Who Will Do The Fighting?

by digby

Atrios has this right about the mandate argument:

I feel like those more supportive of this bill are attacking anti-mandate strawmen. The reason for thinking that without a public option or similar mandates are going to be a disaster is that without competition or sufficient affordability (due to not quite generous enough subsidies), you’re forcing people to buy shitty insurance that they can’t afford. Mandates aren’t bad in and of themselves, but they’re bad if they aren’t part of a comprehensive plan which is… good!

That’s right. A mandate as part of comprehensive reform that includes real competition, generous subsidies and a strong regulatory structure is not inherently bad. I could have made the argument if people had a choice in the exchange to pay into Medicare or into a public plan over which they had some control as a citizen rather than an expendable consumer. But without that or much more generous subsidies and/or strong mechanisms to control costs and keep the medical industry from gaming the system, it is very hard to see how most people will see this as a “benefit they’re getting” in the end, although some surely will. And in the current political environment, it is very, very hard to see how that improves any time soon.

When this bill is passed, Republicans will still be Republicans and the media will still be the media. So what’s more likely to happen is that everyone who has a problem with their insurance company is going to blame the Democrats for failing to “fix” things. There will be stories of people who refuse to buy insurance and they’ll be derided as free riders or extolled as freedom fighters depending on your point of view. The Medicaid expansion will be characterized as welfare (for illegal aliens!) The subsidies will be called budget busters, even if they aren’t. Old people will believe that they are sick because Democrats are killing them. And the deficit vultures are circling ominously waiting for a chance to take a bite out of this 900 billion “deficit neutral” program and apply it to the debt instead.

Perhaps all that was inevitable. But sadly, because of the perverse insistence on denying liberals any political stake in the reforms, even much of the base of the Democratic party now see the bill as little more than a capitulation to the medical industry which allowed this current heartless health care system to spin out of control in the first place. The congress may pass it, but there’s no constituency except some policy wonks and medical industry shareholders who will be cheering its passage and defending it from the inevitable assaults. That’s very weak politics in my book.

Maybe there’s a chance that Dean’s call to kill the Senate bill will propel some further progressive changes around the edges before they pass it. And 20 years from now it’s possible that we will have “bent the cost curve” in health care by making more people join the pool and allowing some of them to avoid high cost emergency medicine through more primary care. Let’s hope so. But I find it hard to believe that Americans are going to feel that they have secure cradle to grave health care as those in other industrialized countries do until the government is willing to take the responsibility for adequately regulating the medical industry and creating a strong mechanism for ensuring that all people are covered through something other than “the market.” Single payer is the rational, efficient way to do this, but they could have gotten there other ways. Unfortunately our political system is so sick from living on a diet of toxic lobbyist money that I think we probably have to cure that before any of that can happen.

I still think there will probably be a bill, but it will take everything Obama, Pelosi and Reid have to pass it with a razor thin margin, which doesn’t convey a lot of confidence. Hopefully, the fallout won’t be too bad and the improvements will hold long enough to foreclose repealing the good things in the bill. But if anyone thinks that the obstructionism isn’t going to continue as the Democrats come back to “fix” things, they aren’t looking at the political dynamics clearly. The Republicans understand very well that they have to do everything they can to keep any improvements in the safety net from becoming entrenched. And the medical industry isn’t going to stand for any “fixes” that don’t benefit them.

This will be a pitched battle for some time to come. It probably would have been helpful to Democrats to have some liberals on their side fighting for it. But the liberals were too shrill and had to be put in their place. Expecting them to get in the trenches and battle the opposition on this issue after kicking them repetedly and then telling them they have to like it is arrogant and short-sighted. Democrats respect the military. But they don’t respect their own troops. And it’s hurt unit cohesion and morale.

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