What's the takeaway? Because we lack the political will for the better system (cuz, you know, socialism), what we got is about what we had to get.
Start with the proposition that we don’t want our fellow citizens denied coverage because of preexisting conditions — which is a very popular position, so much so that even conservatives generally share it, or at least pretend to.
So why not just impose community rating — no discrimination based on medical history?
Well, the answer, backed up by lots of real-world experience, is that this leads to an adverse-selection death spiral: healthy people choose to go uninsured until they get sick, leading to a poor risk pool, leading to high premiums, leading even more healthy people dropping out.
So you have to back community rating up with an individual mandate: people must be required to purchase insurance even if they don’t currently think they need it.
But what if they can’t afford insurance? Well, you have to have subsidies that cover part of premiums for lower-income Americans.
In short, you end up with the health care bill that’s about to get enacted. There’s hardly anything arbitrary about the structure: once the decision was made to rely on private insurers rather than a single-payer system — and look, single-payer wasn’t going to happen — it had to be more or less what we’re getting. It wasn’t about ideology, or greediness, it was about making the thing work.
Hopefully, what we're getting will be a step in the right direction. After all, the single most successful subsystem of American health care is Medicare, which has its faults but that everybody seems to agree works pretty good, which is a single payer system.
But thanks to politics, echo chambers, and the seeming disconnect between the stakes of the game and the game itself in some circles, we can't just move to the smarter, more efficient, more humane system right away.
Okay. Guess we'll just have to take a deep breath, steel ourselves for the long slog up the hill, keep up the pressure on our duly elected representatives, and keep winning the war of evidence and ideas.
I think these words of Churchill's, though used in a different context, might prove instructive:
The United States invariably does the right thing, after having exhausted every other alternative.