Thursday, November 12, 2009

Politics: Campaign Finance First

TORONTO, ONTARIO - While we STILL don't know the full contents of what health care reform bill will (or will not) pass Congress this year, some elements seem to be showing up in most "viable" proposals. Unfortunately, some of these provisions are, as Newt Gingrich would say, "singularly bizarre."

Take the idea for enforcement of the concept that all United States residents will be required to purchase health insurance. It appears that all "viable" proposals have this being done through the income tax system--if a person doesn't buy insurance, he or she is "fined" (exactly how that is distinct from a "tax" on an income tax form is unclear) based on income, and can go to jail for not paying just like for any amount owed to the Internal Revenue Service. To a Canadian, this is absolutely absurd. We have lines on our provincial income tax returns that, in the case of Ontario, are a very simple tax based on one's income that goes to pay for the health care system. The United States is going to great lengths to make health insurance not look like a tax, when the net effect is little different.

Of course, the United States is not heading toward a single-payer system like the one in Canada. Yet, if the most dire predictions of Republicans are correct, it might as well be. If the Federal government has to approve all these health plans--an element of the "viable" plans--then they argue that it will de facto define what a national health plan will be, inhibiting competition in the marketplace. At some level, this is a rather strange argument--isn't the whole problem that too many people don't have adequate health care plans, or there would only be talk about cost control, not about how many people are uninsured? A Canadian would say that that's rather amusing--a single-payer system could solve both those problems by covering everyone and mandating cost levels.

So why isn't a single-payer system even on the table in the United States? Or, better yet, a managed competition system resembling the Swiss system or the Enthoven proposal in 1993, which would still be market-based but not hold all the questions and strange aspects that seem to be infecting the "viable" proposals? It seems pretty simple--health insurance lobbyists want to ensure the viability of their industry, which would disappear entirely under single-payer and would have its profits effectively limited under a Swiss or Enthoven-type regulated model.

If the health care system is still a mess when this is all over, people will be looking for when the mistake was made. I go back to the argument I first heard from David Brooks that I've written about before--Barack Obama needed to do campaign finance reform first before any major initiative like health care reform. Brooks' predicted result of Obama favoring "legislative pragmatism" over "policy pragmatism" seems to be reflected in the "viable" proposals being quite sub-optimal from a policy perspective. It didn't have to be this way. The mistake was not doing campaign finance reform first.

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