Enough Tinkering

Kudos to Jonathan Cohn for his important new book. One of the reasons we are talking about what’s the right approach — or the most politically feasible approach — to insuring all Americans is that millions of Americans are telling pollsters and politicians that the health care system is in crisis. The public has put this issue on the table for the political system — not the policy wonks.

Individuals, like those profiled in “Sick,” experience the health care crisis in many ways. But is there a explanatory diagnosis for why the health care system is not serving them?

Perhaps some people think the problem is not enough careful tinkering with the system we have. But increasingly, the diagnosis that makes the most sense will focus on the structural failures of the private health insurance industry.

If insurance companies make their profits by denying care, refusing to cover people who are expensive, spending more money on advertising than they do on wellness, and just passing along increased health costs, then the public may decide that tinkering with the private health insurance system (and subsidizing and regulating them to do what their business plan doesn’t allow them to do) is not the way to go.

So I’m betting that the public, making the diagnosis that the private insurance industry is a key part of the problem, is unlikely to be impressed by tinkering.

And many experts and commentators (who do think in their heart of hearts that single payer is the way to go) may be surprised that the public won’t see “regional buying pools” and individual mandates as giving them the kinds of guaranteed coverage the system doesn’t currently offer.

This promises to be an exciting discussion. Many of us who think single-payer is the right direction have thought long and hard about step-by-step ways to get there.

Jacob Hacker’s plan, recently published by EPI, is structured to allow lots of choice — including ways to let Harry and Louise keep the private health plans they now have if they like them.

But the big question is the one Jonathan asks here: will tinkering, even at an ambitious scale, get us a health care system that covers everyone, affordably, and with the kinds of structural arrangements that can begin the reorganization of the health care system to control the spiraling health care costs our economy is now facing?