Dear Jon,

Thanks for the shout out (for my Atlantic piece) on your blog, which I just read. Given that it was so positive in tone about my article overall, I hate to complain. But given that you focused disproportionately on one small statement, which you called “bizarre,” I did want to explain myself.

I don't pretend to know the ins and outs of this bill as well as you, Jonathan Cohn and Paul Starr, all of whose opinions I rely on. In fact, even before seeing your post, I had an exchange with Starr that made me think twice about my wording in the Atlantic piece. So I do believe it will be more significant than Kennedy-Kassebaum, and you all have persuaded me that in my Atlantic piece I understate what the bill (if it’s passed) will achieve.

Here’s what I was thinking. First, that was a small piece of my article, and while I’m responsible for what I wrote, I didn’t imagine so much would be made of it.

Second, I wrote the piece at a time when the bill was being systematically eviscerated as it proceeded toward passage. Under those conditions, I was feeling pretty negatively disposed toward the tatters that remained. Now, although I’m still disappointed with some of the compromises made, I’m feeling more positive about the bill—and will feel more upset if it doesn’t pass. (This may be an argument for online journalism over old-style print journalism with long publication lead times.)

Third, there’s been relatively little attention paid to the ways that those of us who are insured will continue to suffer at the hands of impenetrable policies, insurance company employees who deny and delay reimbursements, red tape, and other crazy aspects of our system. As noted by David Leonhardt of the Times, another commentator I respect and trust a lot, the plan “would not improve most people’s health care anytime soon.” His piece of August 26 is well worth reading. So in the end I don't think we'll look back on this bill as having been "transformational," in the way that Medicare was. Too much will stay the same.

Finally, you took “Obama vs. Clinton” as your framework. I used Clinton in my piece not to stack up the two presidencies to see whose was better (not a game I find useful, and too early for it in any case) but to give a historical sense that even a presidency filled with compromises and disappointments can still be one that, in the end, does a hell of a lot of good. Few would describe Clinton’s presidency as “transformational,” but Obama would be a success if he achieved as much. That’s all I meant.

In sum, I do think you’re right that the Obama bill, should it pass, won’t be “closer” in scope or impact to Kennedy-Kassebaum than to Medicare. But I remain skeptical that it will be a “sweeping historical accomplishment,” as you predict, and still think it will fall somewhere between those two other bills in how much it really changes health care for most people.

I hope you’re right and I’m wrong.

That’ll teach you to praise something I wrote!

Best,

David


My reply:

Since my original post ignored most of your essay and focused on the small area of disagreement, I might as well do the same with your letter. Our disagreement centers around how big this health care bill will be vis a vis Medicare. You write:

As noted by David Leonhardt of the Times, another commentator I respect and trust a lot, the plan “would not improve most people’s health care anytime soon.” His piece of August 26 is well worth reading. So in the end I don't think we'll look back on this bill as having been "transformational," in the way that Medicare was. Too much will stay the same.

First, Medicare also left health care as it was for most Americans. It only effected the elderly. Granted, it covers about 30% more people than the Senate bill does. But (moving on to point #2) the Senate bill also introduces myriad delivery reforms that have the potential to slow the runaway growth of health care, which is arguably as large a social problem as the uninsured.

While I think the Senate bill would be a bigger accomplishment than Medicare, you can argue both sides of that question. I also hope I'm right.