More health care agonizing

In response to my earlier post on health care, Ezra cautions:

First, insurers are one of many relevant interest groups, and nowhere near the most powerful. That title goes to business, whose level of activation, mobilization, and support, will be the singular variable that decides whether health reform succeeds or fails....

The legislative construction here is exceedingly delicate and, contrary to Brian, I don't think much can be said about it without pretty detailed study. Indeed, I don't even think detailed study gets you very far, as much is unpredictable, and personal. I wouldn't have thought Utah's Bob Bennett would be a possible fulcrum for a viable compromise, but I was wrong. This, incidentally, is why I give so much attention to the Wyden-Bennett process. At the moment, it's the only viable legislative coalition being built, and watching what they actually do and who they actually attract and what is actually being demanded of them is the best early information we're going to get. But much that I assumed going into this process is not, as time goes on, looking all that accurate. And one thing I'd caution liberals of is letting the insurers loom too large in our minds. They are one of many impediments to reform, but for various reasons, we tend to think of them as the primary obstacle. They're not. For reasons I'll say more about later, the Republican Party is, and the only force able to overcome their political opposition is probably business.

Obviously I didn't mean to imply that health care will be a huge debacle no matter what if Democrats try to go universal. But the possibility is absolutely there, and the mandate fight only makes it more likely. Insurance companies may not have as much overall sway in the fight as, say, the Chamber of Commerce does, but they certainly have enough to, under the correct set of circumstances, influence the one or two holdout senators standing between a viable plan and a collapsed one. At the end of the day, the insurance companies are the entities that will face the brunt of new regulations. They're not going to like that, and they're going to want, in some sense, to be bought off. My only point is that the promise of a mandate only strengthens their hand in that fight. It puts a lot, politically, at stake. Other business interests, they'll say, are getting an in-kind kick back from this regulation... so what do you have for us? The answer to that question may prove to be trivial. Or it may rob the next president of political capital in his or her next fight. Or it may force millions of currently uninsured people into the patronage of an industry and a service they very much dislike.

The point is not that there's no complexity beyond what I've laid out here. It's that making a promise as absolute as universal health care is--by setting the bar as high as possible--a great way to make failure obvious. Add in the fact that we're talking about constructing a system that will greatly change a large, private, for-profit industry and you end up with a bunch of twisted incentives on both sides.