The Dutch Option
Jon Cohn has an excellent article on the Netherlands that makes a rather obvious point that seems to elude some leftie activist: it’s possible to have a health care system that does everything any leftie wants — accessible quality care to everyone without a government run health care option. Now, this is a bit complicated because we already have a bunch of “public options” of varying degrees — Medicare, VA, federal employees and so on — but the basic point that a public option, especially any public option could have ever passed through the Senate, is not the be all end all of health care reform needs to be repeated over and over.
The big difference between the Netherlands and the US, even if we pass the Baucus bill, is how they treat insurance companies:
Still, there’s a catch. A big catch. Private insurance in the Netherlands works because it operates more or less like a public utility. The Dutch government regulates industry practices tightly–more tightly than the reforms now moving through Congress propose to do in the United States. The public insurance option was supposed to make up for that deficiency, at least in part, by setting a standard for service and affordability that the private industry would have to meet–and by offering a fail-safe option in case the private plans simply couldn’t keep up. If Congress ends up gutting the public plan, in part or in whole, then it needs to work even harder on making private insurance work. And it’s an open question whether that will happen.
I’m a bit more sanguine than many liberals on how much a possible bill could do on this front. Any bill that passes will have some basic, necessary regulations like community rating, some kind of mandate and guaranteed issue which will the foundation of any health care system that rests on treating private insurers as public utilities. I think that once we have some sort of system in place, there will be pressure to make the system better as more people are directly invested in it through higher taxes and the mandate. Of course, there’s a fear that all the mandate+subsidize system will do is lead to insurers competing not on quality, but on the skimpiness of benefits and through better marketing and advertising.
Another general point to consider when dreaming up health care systems is path dependence. Atul Gawande has made the point that just about every system we lefties admire wasn’t built up from scratch in a day. Instead, countries faced dilemmas of coverage and equity and built on what systems they had. There are both good political and pragmatic reasons to approach health care reform this way, which means that we should probably be focusing all of our efforts on making the insurance regulations and the exchanges as good as possible.
