IT IS predictable that disappointed factions on the Democratic left would need some way to vent anger at their leaders for pragmatically abandoning many features of health-insurance reform that the left wanted (and that, in many cases, would have made reform cheaper and more effective). It's not so predictable, and seems self-destructive, that Howard Dean and netroots organisations like FiredogLake would go so far as to oppose the bill, and rally their members to lobby their representatives to vote against it. But it seems simply bizarre that pro-reform liberals like Markos Moulitsas and Keith Olbermann have decided they oppose a mandate to require every individual to purchase health insurance.

You cannot have universal health insurance without a mandate. Every country in the world that has a universal health-insurance system either requires its citizens to buy health insurance, or includes its citizens in a default insurance programme automatically and taxes them for it (which is effectively the same thing). The reasons for this are simple, and have been covered hundreds of times since the current debate over universal health insurance began during the Democratic presidential primaries in late 2007. If you don't oblige everyone to buy health insurance, then many young and healthy people will bet on not needing insurance, and will decline to buy it. That shrinks the remaining pool such that it is made up of older, sicker people with higher medical costs, and thus premiums will rise. That in turn will cause more healthy people to leave the system. This is the phenomenon of "adverse selection". Ultimately you're left only with rich old sick people, and nobody else can afford insurance. This is known as an insurance death spiral. If you want affordable, universal health insurance, then everyone has to buy in.

One would think that at this late date in the health-reform narrative, everyone would have grasped this point. One way to read the strange new opposition to the mandate is as a reminder that a substantial segment of the new, energised leftist segment of the Democratic Party began the decade as centrists or libertarians, and were pushed left (in some cases far left) during the Bush administration. Mr Dean, Mr Moulitsas and Mr Olbermann all fit that bill, and you can hear a slight libertarian echo in Mr Moulitsas's current rhetoric. Though, to be fair, the main thrust of Mr Moulitsas's anti-mandate argument is that granting private insurers a monopoly and pouring more money into the system will raise prices unless it is accompanied by European-style provider-cost regulations, which are not currently on the table.

But another way to look at it is this: Americans are still not used to the way universal health-insurance systems work. Mr Olbermann, for example, is angry that working-class Americans will be obliged to buy health insurance that could cost up to 17% of their incomes. Mr Olbermann is right; that figure is too high. But there is plenty of time before 2013 to ensure that no one ends up paying such extortionate premiums, and it's a good bet that, if reform passes, no one will. What happens in systems where people are obliged to buy health insurance is that, if such insurance is unaffordable, governments are forced to find a way for people to afford it, or governments are voted out of office. In the Netherlands and Switzerland, the private-based universal health-insurance models to which America's current reform aspires, governments employ a mixture of provider-cost controls, premium regulations, and subsidies to make sure nobody has to pay 17% of their income for health insurance. If people were forced to pay that much for health insurance, governments would fall—and they have.

I remember what it felt like to move to the Netherlands and be told that I would have to buy health insurance, or I'd be kicked out of the country. For an American, it certainly felt...different. Then I encountered the other difference: I signed up for a plan, and found my premium cost me a quarter what I'd been paying in America. That was the result of decades of constituent pressure on politicians to get health-insurance costs down. Mr Olbermann and Mr Moulitsas are still thinking like free-market consumers of health insurance: they don't like it, so they want out. Of Albert Hirschman's trio of options for consumers in failing organisations, "Exit, Voice, and Loyalty", they're choosing "exit". When you move to universal health insurance, you have to get used to choosing "voice": if you don't like it, you fix it. And if they want their side to continue winning any elections, they should probably get used to "loyalty", too.

(Photo credit: AFP)