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Why Don't Conservatives Understand Health Care Policy?

In my article about the health care bill I noted:

the [Republican] party desperately lacks for genuine health care expertise. Being a member of a party long committed to defending American health care naturally makes one disinclined to study the horrifying reality of the system; likewise, a thorough understanding of the health care system makes one disinclined to support the party that has spent decades blocking its reform.

Steve Bell's column at David Frum's FrumForum today offers some depressing confirmation of this view. Bell, a former Staff Director of the Senate Budget Committee and visiting scholar at the Bipartisan Policy Center, inadvertently demonstrates how few people on the right understand this issue at any level of detail.

First, Bell thinks Reid would be smart to use reconciliation:

I have been mystified for months now, watching the Senate stagger through “regular order,” making the kinds of political deals that enrage voters.  Why doesn’t Reid use reconciliation?

If you believe that the duty of the Majority Leader of any party is to aggressively address the party legislative agenda and the interests of the President, if he is of the same party, then it seems almost mandatory that the Majority Leader use every parliamentary tool at his or her disposal.

Some in the mainstream media have pooh-poohed the idea of using reconciliation from Day One.  The argument, generally goes like this:  if Reid uses reconciliation, then it will forever ruin relationships with Senate Republicans.

I think that’s silly.  Relationships cannot get much worse between Senate Democrats and Senate Republicans than they are now.  And, who cares?

I agree that "angering Republicans" is a silly argument. The better argument against reconciliation is that reconciliation only allows measures related to revenue and outlays. That means you can't set up insurance exchanges, can't regulate the insurance industry, can't do a lot of important things. Now, I think the reconciliation route would certainly be better than nothing. But passing a bill through regular order is far superior. There may be some better argument for reconciliation, but Bell seems totally unaware of the most important limitations.

Bell proceeds to argue that, if Reid forgoes reconciliation, he should try a compromise:

Indeed, this would give Reid a chance to really talk with the Grassleys and Enzis of the Republican Senate about “what is possible.”  What a refreshing notion—the art of the possible.

As a start, Democrats could concede on tort reform to some extent, Republicans could concede on across-state-line insurance competition, both sides could forge an agreement on portability, a pool for those who don’t have insurance, broadened ability of “related groups” to get group health insurance, and on a prohibition on insurance denial due to pre-existing condition.

I believe that such a deal — outlined in very rough form here — would probably get 70-80 votes in the Senate.  The 15 “theological” senators from the Progressive Caucus and the 15 on the obdurate right of the Republican caucus would scream.  That would confirm that such a deal is in the interests of most senators and most citizens.

This plan won't work. If you forbid insurance companies from discriminating against people with preexisting conditions, then people will go without insurance until they're sick. This would a death spiral of rising rates, more healthy people dropping their insurance, and a collapse of the system. That's why if you want to prevent insurance companies from discriminating, you need to require everybody to buy into the system. And if you do that, you need to subsidize coverage for people who can't afford it, which means (if you're not using the George W. Bush method of public financing) that you need to come up with spending cuts and more revenue.

I wonder how much of the GOP opposition is rooted in a lack of understanding of the issue. Large chunks of the right seem to genuinely think Democrats are imposing this individual mandate, cutting Medicare and raising taxes out of some insatiable thirst for power and government control. The truth is, that's the most moderate, insurance industry-friendly way to eliminate the worst, cruelest abuses of the health care system. That's why Mitt Romney settled on the same approach in Massachusetts.

Now Democrats are trying to recreate Romneycare plus a whole bunch of delivery system reforms designed to slow long term cost growth. And the Republicans are screaming socialism. How can Democrats deal with Republicans when even the moderate budget staffer/think tank scholar types have only the vaguest idea how the policy works?

[Note: in an original, hastily-unpublished version of this item, I attributed the column to David Frum. That it was actually authored by somebody with Bell's wonk credentials strengthens my argument.]