Compromising Position

If the House and Senate conferees assembling this week to negotiate a prescription drug benefit and Medicare reform bill do in fact come up with a final product, the only thing certain is that they will have built a house divided against itself.

The bills that the House and Senate have sent to the conference committee would legislate two irreconcilable visions of health insurance and the roles of the state and the market. House Republicans, who passed their bill on almost a straight party-line vote, authorized tax subsidies to seniors who choose to opt out of Medicare to join HMOs. Those seniors whom the HMOs don't want -- the sicker ones, with chronic conditions -- will be left behind in Medicare, which will perforce become a more rickety, less sustainable program unable to compete with the private insurers.

The Democrats, by contrast, want to expand Medicare's reach by having it pay for seniors' prescription drugs. In the Senate, led by liberal warhorse Edward Kennedy, most of them voted for a bipartisan bill that did create that benefit, but in a fashion so spotty that it would cover only a quarter of seniors' drug expenses.

Two equal but opposite wagers have been made. Kennedy, noting that every universal benefit the government has created has gradually been expanded to meet the public's demands, is betting that the fragmentary coverage offered by the current bill would grow in time to a comprehensive universal program. His right-wing counterparts, meanwhile, believe that by subsidizing HMOs to pick apart the senior market, they can forestall Medicare's expansion and weaken government's role in health insurance.

Historically, major social legislation in America hasn't emerged from the melding of fundamental differences. Social Security and Medicare were enacted by Democrats who believed in those programs; the Civil Rights Act wasn't written by segregationists. Today, however, the public demand for prescription drug coverage has peaked when Congress is controlled by Republicans opposed to public insurance.

Any bill emerging from conference that includes elements of both visions, then, will not resemble our landmark social legislation. If anything, it will look like the Missouri Compromise -- the 1820 act in which the free states of the North and the slave states of the South tried to work out a formula for expanding their rival societies into the territories west of the Mississippi River.

But the Compromise proved to be more an irritant than a solution. It both delayed and heightened the conflict between the regions. Just as a Medicare compromise today would do nothing to resolve the growing conflict between the champions of the market and the champions of the state.

The market apostles are driven chiefly by their own ideological passion.

There is no public clamor to privatize Social Security or Medicare. For that matter, there's little clamor from private enterprise to get a piece of the public action. No private health insurer has expressed eagerness to enter the senior market even with the subsidies that Republicans would provide.

Healthy old folks are still old folks, and for HMOs, no ideology will ever carry the weight of an actuarial table.

The advocates of increased governmental responsibility for health coverage, by contrast, are heeding a public outcry more than the siren call of ideology. Socialism has never loomed very large in the psyche of the American legislator. What does loom large is the increasing number of seniors for whom prescription drugs are obtainable only by virtue of cutting back on some other necessity. A fearful asymmetry, then, structures current American politics.

Republican ideologues have the zeal and power to push policies that have little public backing; Democratic pragmatists will defend popular programs and push to expand them only when the public demands it in no uncertain terms. The problem with the Democrats' ideological timidity is that it lets the right-wing Republicans define the terms of debate and lets too many foreseeable crises build to a boil. In particular, with U.S. employers cutting back on adequate and affordable health coverage, decent retirement plans and on-the-job education, either the role of the state must be beefed up or America will revert to its pre-New Deal, fend-for-yourself economy. When the market abdicates a necessary role, the nation needs a Democratic Party that's unafraid to argue for governmental responsibility.

But pragmatic Democrats and ideological Republicans have structured the current legislation, and if the conference committee manages to emerge with a compromise of sorts, it will have codified the fundamental conflict in American politics. An achievement of a sort, I suppose, but a far cry from enacting a solution for Americans who can't afford their medicine.

Harold Meyerson is editor-at-large of the Prospect.

This column originally appeared in yesterday's Washington Post.

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