Creating a new foundation to build on

CREATING A NEW FOUNDATION TO BUILD ON…. Dr. Marcia Angell had a provocative piece following Saturday’s House vote on health care reform, and given her expertise and credibility, it’s getting a fair amount of attention. The pitch is pretty straightforward — the Democratic plan isn’t nearly ambitious enough; single-payer is the way to go; and it’s better to kill the existing plan. Angell would prefer to see reform fall apart for now, and then “trying again later” for a stronger reform effort.

As a matter of policy, I’m sympathetic to Angell’s approach. As a matter of strategy, her advice is the wrong way to go. Ezra Klein had a good piece on this today.

Failure does not breed success. Obama’s defeat will not mean that more ambitious reforms have “a better chance of trying again.” It will mean that less ambitious reformers have a better chance of trying next time.

Conversely, success does breed success. Medicare and Medicaid began as fairly limited programs. Medicaid was pretty much limited to extremely poor children and their caregivers. Medicare didn’t cover prescription drugs, or individuals with disabilities, or home health services.

But once the programs were passed into law, they were slowly and continually improved. They became more expansive, with Medicaid growing to cover not only poor families but also poor adults, and the federal government giving states the option, and matching dollars, to include more people under the program’s umbrella. Medicare was charged with covering people with long-term disabilities, and it was eventually strengthened with a drug benefit, more preventive coverage, the option of supplementary plans and much more.

As we talked about yesterday, the same is true with Social Security — one of the greatest progressive policy achievements of the 20th century, which was, at best, weak and incomplete when it was created.

The key, in each instance, is creating the new foundation. Once the system is in place, and Americans have a baseline of coverage and protections, improvements can be made. Exchanges can be expanded. Public options can be strengthened (or, if things go poorly over the next couple of months, created).

If reform dies — or, more accurately, if it’s killed — the alternative is not single-payer, it’s 20 years of inaction and adverse political consequences for those who tried.

Conversely, if reform survives, it means coverage for the uninsured, and new protections for those who are already covered. It means Americans who would have died because they lacked insurance will get care, and Americans who would have gone into bankruptcy will keep their heads above water.

As Jon Cohn noted, “The House bill wouldn’t stop such hardship altogether. But it would reduce it significantly — arguably, by as much as any single piece of domestic legislation since the Great Society. Surely that qualifies as something more than ‘a few improvements around the edges.'”