The irony is that some of the health reform proposals on the table this
year are a bit of back to the future. The health insurance exchanges
that Obama envisions — regulated markets that the government would set
up where insurers would compete for business — are the successors to
the managed competition that Clinton sought. The regulations on insurer
behavior and the out-of-pocket caps are direct descendants of the
There are important ways, however, in which the bills currently
working their way through Congress do not go as far as Clinton’s plan
did 15 years ago. In attempting to ensure that Americans can keep the
coverage they like, they do not always ensure that people can leave
insurers they do not like. The insurance exchanges, in particular, are
limited to the self-employed, the uninsured and small businesses.
Someone who works for a larger employer would not have any more choice
under these proposals. Indeed, the problem with trying to make sure
that everyone can keep what they have is that you can’t change very
much. This makes it hard for advocates to explain exactly how
health-care reform will improve conditions for the insured, at least in
the short term.
I get, I mean, ideally, that you want to help the most screwed people, the totally uninsured or uninsurable, first. But part of the problem with our current health care system is that even the winners are losers. Even if you’re on the best insurance plan imaginable and you have a job you love and would never leave, you can still get whomped for more money than you could ever afford to pay because something happened you couldn’t anticipate. If we’re going to completely reform health care in this country we’re going to have to deal with the fact that the best-case scenario in the world really, really, really sucks.