Do you mean a post on Reich’s own blog? I’ll check that out.

The only other question I have now is whether the Wyden bill would really move us as far from employer insurance as you think. But it’s probably not a very salient question given the bill’s prospects.

Here, I think the Klein post I link to above implicitly makes the argument that employer-based health care is the biggest cause of our system’s failures since he writes: “It has arguably been among the most costly and perverse mistakes in the history of American public policy.” I know there are other sources that probably make this point more explicitly, I just can’t remember where to find them.

As for a generic public option with no strings attached, my main objection is just on cost (not a small objection given the current deficit problems); I don’t think it will do a ton of harm otherwise, but I’m also skeptical that it will have nearly the benefit that is hoped for.

Of and by itself, with no strings attached, I don’t think the public option would do much, if anything, to reinforce the employer-based system – I just don’t think it would weaken that system, either. Then again, if you take the Obama Campaign/Administration at its word (and I don’t think many wonks do), strengthening employer-based health care is the entire point of the public option.

So, if decoupling is off the table entirely, my objections are that a public option isn’t going to accomplish much good but will still cost a lot of money that we don’t have, and that the employer mandates (which are unnecessary to a public option if there is decoupling but are at least arguably necessary if there is not) double down on the central problem with the US health care system.

Beyond that, the compromises that have been made to get the leading legislation this far have both added significantly to the costs of the plan and simultaneously undermined much of the (already limited, in my view) good that the plan could have done, making those compromises a double whammy. (For more on this, see Robert Reich’s July 19 post).

Which raises the question of what the state of play for health reform would be with John McCain in the White House and Democrats in control of Congress. I’ll say right now, I wouldn’t put Democrats above holding back on health reform just in order to deny a member of a party that has headed off reform for years and years a historic, Nixon-goes-to-China-style victory. But even if Democrats behaved perfectly according to principle, taking the best deal they could get from President McCain, it’s worth thinking for a moment about what pressures John McCain might be under from his own party. Is there any particular reason to believe that he would not be pressured to follow the party’s traditional approach to the issue, which is that when it comes up for consideration to make it quietly go away? From a rational-actor perspective, I’m not sure that in the scenario you raise incentives would be aligned in a way to bring about reform.

But I think a slightly subtle misunderstanding comes through here with your last response. As you say, many if not most people who look at this (liberals like myself and Ezra Klein included) think the employer-based system should be scrapped. We don’t disagree that that is something that should be done. But the argument that it is a desirable reform is not the extent of the claim you have made, nor the part of it I’m asking for a defense of. The claim I’m asking you to defend is that “the coupling of insurance and employment in our system is the root cause of those two problems. In essence, employer-based health care ==> high costs ==> poor access.”[emphasis added] (I’d add that I wouldn’t necessarily admit a one-to-one correlation on the second arrow there either, as there were many uninsured before costs started their upward spiral over the last fifteen years. But for now I’m just asking about your argument for the exclusivity or at least primacy of the first arrow.) That’s a much sharper claim.

To me it looks above as though you are providing good arguments from experts for decoupling as a general proposition (on which you are absolutely correct there is near-consensus among experts, and this non-expert), but not that decoupling is the singular cause of cost growth to the extent that if it cannot be accomplished because of politics, any other reform would be inferior to the status quo.

The only other thing I’d say is that we are still basically on your turf. My initial question was whether you had advanced an argument for why the bill being discussed is likely to do more harm than good apart from the fact that it fails to decouple coverage from employment. But we’re still talking about decoupling, partly because I took you up when you stuck with that part of the discussion. I think the one thing you have mentioned that would fill the bill is that far from decoupling, the bill has an employer mandate to couple them more tightly. That’s a fair response, even if it still revolves around the decoupling question. Other than that, I understand you are opposed to the public plan, but because the discussion has been so much about decoupling, I’m not clear exactly why. I don’t see how the public plan enforces the employer-based system, and I’m not sure you’re saying it does.

So I have two questions if you’re still interested in discussing it in this thread: 1) How does the public plan contribute to the harm the bill will do? and 2) Taking decoupling off the table, and for the moment granting that to expand access without decoupling virtually compels expansion of employer-purchased coverage, is there anything still else that tips the bill into more-harm-than-good territory? I just want to be sure I understand the reasons for your opposition as fully as I can.

Btw, did you watch the president’s presser last night? The reception was terrible left, right, and center. I didn’t think it was so terribly bad (though man can that guy go on), but then he was defending a policy I’m at least partially behind. But failing to alter the debate significantly with a voluntary prime-time press conference seems like a prima facie failure to me.

Anyways, a public option, of and by itself, doesn’t necessarily throw the baby out with the bathwater – I don’t think it will do very much good, to be sure, and I think it will not justify the cost, but it’s not a dealbreaker for me – I’d be okay with it if it came with a decoupling of employment and insurance.

You are correct that the double-down in my formulation is the employer mandate. The bottom line for me is that the public option as constituted in HR 3200: 1. Is extremely expensive at a time when the national deficit is getting dangeroulsy high to begin with; 2. Reinforces the existing employer-based system, which is why our system is so messed up in the first place; and 3. Will only marginally increase access to care while ensuring that systemic costs (which are themselves one of the two central problems that result from the current system) continue to rise.

Similarly, on the opposite side of the political spectrum, the Arnold Kling piece E.D. linked to on the sidebar this morning includes the statement “We will help the President convert the tax deductibility of health benefits to a refundable tax credit, as supported by economists of all political persuasions. ”

So between Klein, Cutler (from his pre-Obama campaign days, at least), and Kling, you’ve got a pretty diverse group claiming that just about all economists agree that the employer-based aspect of our system must be addressed for any reform to be meaningful in the long run.

While I don’t have any good hard data readily available to me, the problems with an employer-based system are fairly intuitive, I think. Separating the consumer and the customer creates a perverse incentive for the denial of treatment, which means that treatment has to be paid for out of pocket on top of the premiums that are already being paid. Additionally, tying insurance to employment exacerbates the preexisting condition problem since someone who changes jobs is going to lose their coverage for that condition; whatever problems may exist in an individual-based market, at the very least someone who develops a condition will be able to maintain their coverage as long as they want without regard to their employment situation. Finally, our employer-based system also divorces patients from directly feeling the pinch of their insurance costs, which has the effect of artificially increasing demand for health care (this last claim may be less agreed-upon, though, I’ll admit).