New in the mail, the paperback copy of Paul Starr’s Remedy and Reaction: The Peculiar American Struggle Over Health Care Reform. I flipped it open to Page 95 and learned something:
Clinton’s original decision to embrace managed competition was an effort to skirt the political problesm of pay-or-play, especially a steep payroll tax, and he continued to be determined that his health plan avoid any general tax increase, though it did include a 75-cent-a-pack hike in cigarette taxes. Yet for political as much as policy reasons he was also determined that health-care reform reduce the deficit over the long term. It would be no easy feat to achieve universal coverage while reducing the deficit without any general tax increase. The president’s various decisions about the health plan stemmed from an effort to achieve all three of these seemingly contrary political objectives and from a recognition that he would have to adjust the balance among them as he moved from building public support to getting legislation through Congress.
Those of us who followed the 2009-10 effort closely will recall some similar issues. It’s really unfortunate that so many public programs have this kind of Rube Goldberg quality, but that’s what you get when you have politicians who don’t believe they can ask voters to pay higher taxes. If you ask me, paying more in taxes in order to pay less in insurance premiums would be a great trade if it also built a simpler, more efficient overall system. But the shift to a true national insurance program would really have to feature some kind of broad-based tax increase.