After reading a number of posts and emails misinterpreting this piece of mine, it's obvious that I need to elaborate. There's an awful lot of literalism on all sides going around these days, so it's important to be precise with my hyperbole.
To clarify, when I wrote "most people are already "free" to buy insurance" it was in direct response to the language being used to sell the bill: "We are giving health care to 30 million people" and "this is the greatest progressive achievement since Social Security." I was making an argument about the politics not the substance of the bill. However, it's not inaccurate to say that policies are available to many of the 30 million -- even some of those with pre-existing conditions, by joining the high risk pools that exist in 31 states. The problem, obviously, is that they just can't afford them or have made the assessment that they would rather take the risk than spend the money. I certainly never said that fact made the reforms completely meaningless. (Indeed, I said the opposite.)
But that wasn't the point of my post. In my view these mandates make this bill something quite different from "entitlements" as people know them. And it's a psychological/philosophical difference as much as a practical one which I believe it makes these reforms much more vulnerable to repeal.
I'll let Robert Kuttner make the point much more artfully, as he did on Bill Moyers last night:
ROBERT KUTTNER: Think about it, the difference between social insurance and an individual mandate is this. Social insurance everybody pays for it through their taxes, so you don't think of Social Security as a compulsory individual mandate. You think of it as a benefit, as a protection that your government provides. But an individual mandate is an order to you to go out and buy some product from some private profit-making company, that in the case of a lot of moderate income people, you can't afford to buy. And the shell game here is that the affordable policies are either very high deductibles and co-pays, so you can afford the monthly premiums but then when you get sick, you have to pay a small fortune out of pocket before the coverage kicks in. Or if the coverage is decent, the premiums are unaffordable. And so here's the government doing the bidding of the private industry coercing people to buy profit-making products that maybe they can't afford and they call it health reform.
You should watch the whole thing if you missed it. Shrill bloggers aren't the only ones who have this point of view.
One thing the old political hands may not realize is that in this era of 24/7 cable and the internet this is the first time most people have watched a big piece of legislation enacted in such close-up detail. And what they are seeing is shocking and disturbing --- the obvious corruption of the process by wealthy corporate interests. There's a lot of populist resentment out here and it's coming down on the heads of the Democrats who are now ironically seen to be funneling taxpayer dollars to rapacious corporations which have been making people's lives miserable, insurance companies being among the worst of them. This health care debate has reinforced that perception. (And sadly, that perception isn't exactly wrong.) It makes health care reform a very different animal than our other social welfare programs.
On the practical political level, I think that rather than being thrilled they are "getting health care" many uninsured people are going to be very disappointed to find that the "benefit" is that they are going to be required to buy something --- especially from companies they don't like or trust. And even if they get subsidies, it's still going to be expensive by the standards of people who make between 30 and 60k a year. Suddenly requiring healthy people to come up with a few hundred dollars a month to pay Aetna isn't really mitigated by the argument that it would have been more before the reforms. I realize that's how mandates work but I don't think people are being adequately prepared for that reality.
In addition, there are others in the individual market who don't qualify for subsidies and Medicaid who currently have expensive private insurance. Many of them are expecting to financially benefit from this reform but may instead see no change. Their coverage will eventually improve and be more secure but they are not likely to feel that improvement is an advance on par with the New Deal or the Great Society, the biggest achievements of which were straightforward government programs that benefited everyone equally. This reform does not feature the same psychology of the social compact, which FDR and Johnson both understood to be requirements to keeping such a structure in place.
The Medicaid provision is obviously a good expansion of the safety net. But with Ben Nelson already arguing for scaling that back and the inevitable convergence of deficit fever, immigration and tiresome old "welfare" arguments to attack it, I think it's awfully vulnerable as well. (The Medicaid constituency could probably use some ACORN organizing to vote on the issue, but the congress decided to throw them under the bus on the basis of a doctored gonzo video and some shrieking from FOX news.)
There has been no public education about responsibility to buy insurance in all this or any strategy to manage expectations of what people will get with Health Care Reform. And because of that the right is going to have a field day telling everyone that the nanny state liberals are forcing them to give to money to insurance companies and then spending their tax money on poor (brown/black) people. So, again, running around saying "Mission Accomplished" is bad politics.
As for the promise to fix all the problems once the bill is in place, I think people are vastly underestimating the forces that are going to be brought to bear to prevent that from happening. Republicans aren't so disorganized that they forgot that they must stop Democrats from giving people reason to believe in government. In addition to deploying their formidable communications apparatus to present health care reform as a massive failure to the majority who are currently covered by employers and will only see the effects from afar, they are going to strangle improvements in the cradle by any means necessary including leveraging their most valuable new voting demographic in the age of Obama --- the elderly. On top of that, we are entering an era of deficit fetishism and have an industry that has shown it will do everything in its power to protect its interests. It's not impossible, but watching the Democrats operate at the zenith of their institutional power over the past year does not give me any confidence that they want to, much less can, battle all that back.
I never said to kill the bill. I don't actually think it's possible to do it at the hands of liberals. (It's health care.) I was hopeful that it would be better. Now the Democrats are going to have to sell it to the public, fight off the deficit scolds and the industry and keep the teabaggers from immolating themselves on the steps of congress just to prove that death panels exist. I think it's going to be a hard sell and the political risks of this particular bill at this time are tremendous.
As for the internecine politics, there were numerous graceful concessions from the left from the beginning on health care that were not exactly easy to make, from single payer to the abortion language to immigrants. But it was the late dangling of a swap on the long held dream of a medicare buy-in, getting liberals to sign on and then allowing the loathed Lieberman, of all people, to capriciously snatch it away that was the real gut punch. And admonishing them to "get with the program" within minutes of that outrage while Lieberman preened that the president thanked him was gratuitous. Lucy and the football is an overused metaphor, but this was a classic. You'd have to be soulless not to be angry about that.
However this discussion has actually gone a long way to assuage my personal anger and give me some hope that the netroots are much more powerful than I realized if people are so worried that our utterances can affect turnout and public opinion. And that means that the era of lazy Democratic politicians reflexively using the left as a punching bag in order to prove their Real American bonafides may finally be coming to an end. Of course, the likes of Joe Lieberman and Ben Nelson are still the deciders so the establishment should relax, secure in the knowledge that liberals' actual effect on policy is still properly marginal.
I don't know how this bill will play out politically. It's not what I thought health care reform would be, but perhaps it is better than nothing. Your mileage may vary. I think it definitely is better for the working poor if we can hang on to the funding, which I think is dicey. As for the rest, we'll see.
But the first thing Democrats need to do is dial down the end-zone dance and start talking about this bill for what it is. Indeed, if I were them, I'd work hard to lower expectations. I do not believe this legislation will be exempt from repeal or serious whittling away as time goes on nor do I think that the political system will allow the quick fixes that will be necessary to keep people on board while they get the reforms in place, regardless of whether the Republicans come back into power during the implementation period, which they very well could. This just isn't a big New Deal style social insurance program and selling it in those terms is setting the stage for a backlash.