The healthcare social contract

Rereading my column on healthcare from yesterday, I was unfair to one strand of progressive opposition to the Senate healthcare bill. The left has two main arguments. The first is that private insurance companies are such scoundrels that anything which puts business their way must be bad. On this view, the public option is the indispensable wedge that will eventually get private enterprise out of the business altogether. The second argument, to which progressives' attention has turned lately, concentrates on the mandate. This creates an obligation on government, they say, to ensure that good-quality affordable insurance is available. They say the Senate bill fails on this score. Again, the public option is the remedy, but the larger point is that the mandate is immoral if it forces people to buy "junk" insurance.

I think the first argument, which opposes private health insurance on principle, is wrong. Yes, healthcare faces special problems: unregulated private enterprise won't do. But if competition in pursuit of profit is fundamentally wrong, as many progressives seem to think, you should not stop at healthcare. (Well, to be fair, many progressives don't stop there.) This platform is stupid politics as well. Deluded as they may be, Americans believe in competition and profits. Private health insurance is popular with the people who have it, as Obama recognised when he promised at the outset that nothing would change for those who were content with their existing arrangements. Progressives should come to terms with properly regulated private health insurance.It works fine in other countries.

The second argument, though, is right. The mandate does have to be part of a social contract that makes insurance available and affordable. The Senate bill should certainly be criticised if it fails to pay sufficiently generous subsidies, or regulates the product carelessly (allowing companies to force bad policies on to their new captive market). That is a necessary debate about the right subject.

Does the Senate bill meet the obligation to provide adequate, affordable insurance? I think it does. I give its subsidies and regulations pretty good marks. (See Jonathan Cohn at TNR.) Of course I can understand why progressives aren't satisfied--but I cannot understand how so many of them can see this bill as worse than nothing. That remains a mystery. No doubt the bill can be further improved. Any new system, once in place, will be continually tweaked in any case. Looking ahead, the mandate is good politics. It does create an obligation, and governments will not be able to shirk it.