The Fight Between Carnival and Lent by Pieter Bruegel the Elder.

Last night, the US House of Representatives passed a controversial healthcare reform bill. This is the final, decisive part of a process that has been rumbling away ever since the election of Barack Obama, over a year ago, and has been the focus of one of the bitterest and most devisive political fights in recent history.

The background to this is that America is, according to the Institute of Medicine of the United States National Academies, the “only wealthy, industrialized nation that does not ensure that all citizens have [healthcare] coverage” – in other words, unlike most other wealthy contries, America provides no medical care to its citizens, forcing them instead to procure expensive health insurance to ensure that they are able to pay for any treatment they may need. Most middle-class workers get healthcare as a perk from their employers, and the very poorest citizens are covered via. a government programme called Medicaid, but there remain many who fall between those two stools – particularly the self-employed – who have been historically uncovered, as well as many who commercial insurers rejected on the basis that they had pre-existing medical conditions. In 2007, that corpus included 15.3% of the population, or 45.7 million people. Meanwhile, even for the rest, American healthcare was disproportionately expensive and somewhat substandard when compared to that of Britain, France, Germany, Japan and Scandinavia.

The bill that was passed last night actually fixes very little of that. It will make healthcare in the US somewhat cheaper – The Congressional Budget Office’s estimate is that the bill will decrease the federal deficit by $138 billion over the 2010–2019 period, generating more savings further out. It does this by taxing the commercial health insurance providers, and specifically high-value “Cadillac” health plans – in other words, taxing the rich. Medicaid has been extended up the property ladder, meaning that those somewhat above the poverty line are also automatically covered. Another programme subsidises healthcare for those somewhat wealthier – those earning up to 400% of the poverty line can now get insurance at a reduced rate.

The bill also makes it harder for health insurers to reject applicants with pre-existing conditions, as well as criminalising employers with more than 50 staff who do not provide health insurance to their workers. What it does not do, however, is provide a mechanism by which the state can offer healthcare; this does not establish an American NHS or anything like it. Finally, abortion is explicitly excluded from any public spending; subsidised plans may not be used to pay for such procedures.

Dryly, it seems uncontroversial. It costs less than the status quo ante, extends coverage and doesn’t kick any sacred cows. Instead it has inspired vitriol, and not all of the arguments have been entirely insane.

Conservative objections
The Republican Party, institutionally, has a nuanced position on healthcare despite the shrill tenor of the Conservative debate. They do not oppose the concept of universal healthcare reform, it just opposes the current Bill’s methods. The problem with healthcare in America, they say, is not a lack of government regulation; it’s the lack of a free and open market. Both sides agree that the main reason why healthcare is the US is so expensive is because most of it is procured via. insurance, which is expensive and invites waste. To the Republicans, this means that a system of tax credits should be set up and patients should be enouraged to shop around before spending their tax dollars, providing an incentive to consumers and providers to demand better-quality and lower-cost protection. The bill that passed last night is the opposite to that; by ensuring that money is transferred, directly and impersonally, from an insurance company (or government body) to a healthcare provider, it actually reinforces the perverse incentives that drive costs up and quality down. This is the argument that has been obscured by allegations of “socialism;” a Republican looks at institutions like Britains NHS, and sees that while it may be cheaper and better than what is offered in the US, it can be made cheaper and better still by removing government intervention.

They further object on the grounds that the excise tax on high-end insurance premiums reduces the amount of money available to invest in developing new medical discoveries – new vaccines, better machinery, and scientific research. There is some evidence to suggest that this may be justified.

Slightly less justifiable is the complaint, from some Conservatives, that a nationally funded healthcare programme is obligated to fund coverage “self-inflicted” ailments – the effects of drink and drug abuse, diet-related conditions, so on – which is arguably not in the public interest.

Finally, there’s the usual raft of demented and religiously-inspired objections – death panels, abortion funding, anything said by Glenn Beck etc.

Liberal objections
Liberal opposition has mostly coalesced around the opinion that the current proposals don’t go far enough. And, in truth, they don’t. The money saved by the programme is too little over too long – $100b over a decade may seem like a lot, but over the same period the programme will actually cost ten times that, and it can be substantially cheaper. The lack of a public option means that some will still miss out, and the Conservative complaint that the bill continues to prop up the insurance companies that have parasitically leeched off of the healthcare industry ring true.

So between those two poles – the orgiastic carnival of the ruling Democrats’ wishes that the bitter restraint of the Republican objections – was strung a bill that, really, no-one wanted. The process of passing it was ugly, but eventually the electorial arithmatic demanded that it be pushed through. For the Democrats, not least amongst them the President, the magnitude of the process demanded an outcome to avert electorial disaster. And in truth, while it’s not a great bill, passing it was the right thing to do. It’s statute now; it can be improved, its provisions can be extended, the backroom deals and inefficient compromises can be weeded out.

The big loser in all this is Congress; not necessarily Congressional Republicans, but the Congress as a whole. Otton von Bismark said that laws are like sausages; you don’t want to see how either are made, and in this case Congress has been the sausage factory. In some ways the whole business has demonstrated Congress at its worst, its most corrupt, disfunctional and venal, and while the President’s ratings may have slipped during the passage of the Bill, the Congressional leaderships of both parties have tumbled to sickening lows. But in another sense this is unfair. Heathcare wasn’t easy to pass because no consensus existed for it. Congress simply reflected the will of the people who elected it.

But the role of the politician is to lead as well as to follow, and the debate was ineptly framed by both sides. The Democrats must carry much of the blame for that – theirs was the duty to push for their policy; they had all the advantages, but squandered their goodwill on dead-end compromises and ephemeral policies that were doomed to fail, leaving their most evangelical advocates disillusioned and unenthused. The Republicans had fewer responsibilities but their conduct was deeply dishonourable. Instead of making a reasoned case for a free market intervention, and thus allowing a proper debate about the healthcare choices that America was presented with, they dragged the discussion into the mud, and suffered heavily for it.

Further reading:
The Economist’s Democracy in America
Matt Yglesias
Outside the Beltway
Fivethirtyeight