Who won? It's the exact same question people asked in 2008, after each of the presidential debates. I didn't like it then and I don't like it now. What's "winning"--scoring more debate points, making fewer gaffes, or simply appealing to more voters? And aren't all those judgments pretty subjective anyway?
But if Thursday's event didn't produce a winner, it was clarifying.
Health care reform, as I've said many times now, is really about achieving three basic goals: Making sure everybody has insurance, making sure coverage is good, and making sure that, over time, medical care will cost less. Thursday's discussion revealed the stark differences between the two parties--not just over how to pursue these goals but also over whether they are even worth pursuing.
Making sure everybody has insurance is primarily a matter of providing access to policies, regardless of medical status, and then guaranteeing that people can pay for them, no matter what their income. The former requires re-engineering the insurance market--in particular, organizing the non-group market into insurance exchanges, through which insurers will sell regular policies at regular prices even to people with pre-existing conditions. The latter requires providing subsidies, based on people's incomes, which in turn requires raising some money.
The Republicans made clear on Thursday they rejected both ideas. Re-engineering the insurance market requires too much government, they said, and providing subsidies requires too much money. The best they could offer were "high-risk pools," which would provide thinner coverage--at higher prices--to people who couldn't get insurance on their own. This means expanding coverage to only 3 million people, rather than 30 million, but the Republicans hardly seem to care. When Obama asked Wyoming Senator John Barrasso to speak to the problems of the uninsured, Barrasso responded by saying he wanted to talk about ... the already insured.
Not that Democrats mind talking about the already insured. Reform's second goal--making sure everybody's coverage is good--is primarily for the benefit of people who have insurance today. Many of these people have coverage that won't meet their needs, although they may not know it yet. Only when they get sick will they discover that their plans have loopholes, allow for exorbitant out-of-pocket costs, and leave them with little recourse if there are disputes over what's covered. The Democrats propose to fix this by establishing a minimum set of benefits that all plans must cover, limiting the amount of out-of-pocket expenses insurers can pass along, and creating appeals mechanisms for consumers upset about denials.
This approach, too, is one the Republicans rejected on Thursday. Over and over again, Republican representatives and senators said the problem wasn't insufficient regulation. It was too much regulation. They called for allowing people to purchase insurance across state lines--and allowing small businesses to form associations that would be exempt from existing state regulations. The effect of such changes, as the Congressional Budget Office has noted, would be to erode benefits--to weaken, not strengthen, the protection from medical expenses insurance now provides. Senator Tom Coburn praised this transformation, suggesting the great exposure would turn people into smarter consumers. Well, it might do that. Or it might simply mean people with medical problems face even more onerous financial burdens.
And what about making medical care less expensive? The Democrats' approach is to try a combination of approaches: Eliminating waste, redirecting Medicare payments so that they reward efficiency, altering the tax treatment of insurance, and so on. They admit it will take time and that they are not sure which approaches will work best. But these efforts get at the root causes of rising medical costs--not just profit or administrative inefficiency, but also the tendency towards unnecessary over-treatment.
Republicans in theory should support many of these ideas, but, as usual, they had nothing good to say about them. Instead, they continued to pound the Democrats for cutting Medicare, even though the Democratic reductions are calibrated to make the program more responsive--and even though the Democratic reductions are far smaller than the ones Republicans have championed over the last 15 years (not to mention the ones Representative Paul Ryan still supports).
Instead, the Republicans' great hope for reducing cost lay in de-regulation--which, again, succeeds only by shifting medical expenses back onto the people with medical problems--and malpractice reform--another idea that Democrats support but that, according to CBO, doesn't actually account for that much spending.
The Republicans have their justifications--and, to be fair, if they are convinced government spending and regulation will do more harm than good, then they are right to hold these many views. But it is not as if their alternatives even come close to solving the problems Democrats would. Instead, Republicans seem to believe these problems are fundamentally unsolvable, at least in any manner they would find acceptable.
And this explains the message Republicans delivered over and over again on Thursday: Rip up the bill and start over. That's not a plea for compromise. That's a demand for capituation. And it frames the choice for Democrats pretty clearly. Either they will act alone, or they will not act at all.