Community Rating

| Tue Jul. 28, 2009 8:35 PM EDT

Scott Lemieux isn't happy with the compromise healthcare bill being put together in the Senate:

The normal justification for passing a compromise bill is that once a new system is entrenched it can be tweaked later. But I don't think it applies in this case. The public option is the core of the reform; a Blue Dog bill isn't so much half a loaf as a few meaningless crumbs. And far from making a public option more viable in the future, if anything, passing something that could be called health-care reform will reduce the impetus to pass actual reform. And, worse, a bill with no public option will further entrench the insurance industry and make it easier for them to block actual reform in the future.

Ezra Klein disagrees.  Partly this is because a public option would cover only a small fraction of the currently uninsured ("That's not a gamechanger, it's a tweak"), but mostly because he thinks what really matters isn't how they're covered, but merely that they're covered:

What has kept health-care reform at the forefront of liberal politics for decades is moral outrage that 47 million of our friends and neighbors are uninsured. That medical costs are one of the leading causes of bankruptcy in the United States. That an unemployed machinist gets screwed by fly-by-night insurance schemes while a comfortably employed banker need never worry. That the working class ends up in emergency rooms with crushing chest pains because they didn't have health insurance and didn't get prescribed cheap blood pressure medications five years before.

One of these days I need to think this through more rigorously, but I have a slightly more idiosyncratic view that's closer to Ezra's than Scott's.  Both coverage and a public option are important, but I think what's more important than either one is a simple change that — to my surprise — hasn't attracted any real opposition: community rating on a national scale.  Basically, this means that insurance companies have to take all comers at the same price.  They're allowed to adjust premiums for things like age and gender, but they can't refuse you due to preexisting conditions.  If your blood pressure is high or you have a family history of breast cancer, they still have to accept your business.

This hardly solves every problem.  In particular, it doesn't do much to rein in costs.  But if you combine (a) Medicare, (b) our current employer-based insurance regime, and (c) community rating along with subsidies for low-income families, you've essentially institutionalized universal healthcare insurance.  Not everyone will take advantage of it — there will always be a few people who go without coverage even if it's affordable — and you still a need a few other things like out-of-pocket caps.  Still, it's basically a statement that everyone in the country can and should be covered.  And once that becomes a cultural norm, it will never go away.

It will also, I suspect, eventually turn the private healthcare insurance industry on its head.  But maybe not.  That's the part I haven't thought through completely.  But if there's any single thing that's critical, it's moving public opinion in the direction of viewing healthcare as a universal prerogative.  Community rating plus low-income subsidies doesn't get us 100% there, but it gets us pretty far along.

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