Is a flawed health-care bill better than no bill at all?

Marcia Angell, a single-payer supporter and former editor of the New England Journal of Medicine, doesn't believe the House bill is better than nothing. She thinks, instead, that it "throws more money into a dysfunctional and unsustainable system, with only a few improvements at the edges, and it augments the central role of the investor-owned insurance industry." The fact that we need to do something does not mean we need to do this. "I would rather see us do nothing now," Angell concludes, "and have a better chance of trying again later and then doing it right. "

This is, I think, a misreading of not only the politics of this issue going forward, and also the history of health-care reform going backward. Failure does not bring with it a better chance for future success. It brings a trimming of future ambitions.

Truman sought single payer. His failure led to Kennedy and Johnson, who confined their ambitions to poor families and the elderly. Then came Nixon, whose reform plan was entirely based around private insurers and government regulation. He was followed by Carter, who favored an incremental, and private, approach, and Clinton, who again sought to reform the system by putting private insurers into a market that would be structured and regulated by the government. His failure birthed Obama's much less ambitious proposal, which attempts to reform not the health-care system, but the small group and nongroup portions of the health-care system by putting a small minority of private insurance plans into a market that's structured and regulated by the government, and closed off to most Americans.

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.

It is not hard to imagine health-care reform following a similar path. The exchanges can be opened to all employers and all individuals, creating a competitive insurance market virtually overnight. The public plan could be strengthened, or the government could begin to set payment rates for insurers who participate in the exchange (as is common in other countries). Subsidies could expand, and new funds could be used to encourage the development of integrated care organizations rather than simple insurance companies. The public option could be strengthened and the employer tax exclusion converted, as Ron Wyden has long advocated, into a standard deduction, which would strike at the heart of the employer-based market.

But all that is predicated on the creation of this new, flawed, insufficient system. As any scientist will tell you, it's much easier to encourage something to evolve in a certain direction than it is to create it anew. The idea that a high-profile failure in a moment where a liberal Democrat occupies the White House and Democrats hold 60 seats in the Senate for the first time since the 1970s will encourage a more ambitious success later does not track with the history of this issue, nor with the political incentives that future actors are likely to face. If even Obama's modest effort proves too ambitious for the political system, the result is likely to be a retreat towards even more modest efforts in the future, as has happened in the past.

For more, see Jon Cohn.

Photo credit: By Alex Brandon/Associated Press

