Are you an Incrementalist….or a Maximalist?

In discussing John Edwards health plan, Andrea’s post gets right to the heart of the matter. Are you an incrementalist…or a maximalist?

If you are an Incrementalist, you favor a policy of making changes by degrees; or gradualism. If you are a Maximalist, then you favor a direct and immediate approach to achieve a goal in its entirety. Of course, as a realist would argue, the political feasibility of a policy may influence which approach you support.
Andrea favors a maximalist approach, while Adam accepts that incremental gains are more realistic over the short-term.  Even though I’ve worked in primary care for the past 20 years, I am still on the fence as to which approach has the greater likelihood of success.  My heart tells me we ought to pursue a single payer system now.  The need is immediate, and the political climate is more favorable now than it has been in 12 years.  My head tells me that our trillion dollar healthcare system, which consumes 16% of GDP, has too many people, making too much money, with too many political connections to allow radical changes.  

Having said that, if a plan makes significant progress in any of the following three areas, I am likely to support it.

1) Immediately covers some of the 47 million uninsured. This is a crisis, now, and the longer we wait the more people will get sick, die, or go bankrupt This is not a place for purity regarding policy. We have an ethical obligation to cover as many as possible as quickly as possible. The role here of advocacy groups is critical, and we need to help them keep the pressure on our lawmakers.

2) Regulate or eliminate private, for-profit health insurance. Their profit is generated by insuring healthy people and denying coverage for sick people. It really is that simple. They are an unnecessary drain on the limited amount of healthcare dollars. Specifically, they do nothing to improve access to healthcare, improve health outcomes, or contain costs. Until they go, even incremental improvements are unlikely.

3) Minimize, or eliminate, employer-based health care. It’s bad for the employee, the employer, and the consumers who purchase their product. Scrap it now.

And just for the record, President Bush’s healthcare proposal in his State of the Union address did little to address these problems.  His modest offering was mostly a niche option for people who can afford to treat their healthcare purchasing dollars as another investment vehicle.

John Edwards proposal makes progress in all three areas. It is not the clean sweep that many of us would prefer, but as healthcare proposals go it is reasonably ambitious. Importantly, it sets the standard that the other candidates will need to meet or exceed. There’s value in that.

Now…if Obama can top that…well, I’m listening.

(If you want a fascinating, but at times mind-numbing, discussion on health care reform; go here )


  1. Nick D

    February 7, 2007 at 2:59 pm

    Looking from the down the road, possiblist perspective, you have to go with gradual increases. And then when things are turing marginally around, bring about a whole new system.

    Health care reform is something that will not survive either measure in my opinion. But rather a mixture of the two, and a dose of sacifice from people wanting private and public coverage.

    Rome wasn’t built in a day, as my grandmother tells me. but atleast the party is started.

  2. asearing

    February 7, 2007 at 5:29 pm

    Actually, if we could just expand Medicare to cover every adult who isn’t insured right now – and expand state kid’s health insurance programs to cover every child without insurance I’d be all for that.

    I’m becoming more of a maximalist after spending 10 years advocating for incremental change and seeing not that much progress.

  3. Healthcare-Now

    February 8, 2007 at 10:02 am

    I support H.R. 676 The United States National Health Insurance Act. Let’s not wait till the so called “system” completely implodes because of inability of insurers to collect increased premium dollars business.

  4. Healthcare-Now

    February 8, 2007 at 10:05 am

    how would you explain the “gradualist” approach to a laid off worker whose 18 months of COBRA had run out and is unable to get individual policy because of a “pre-existing condition?

  5. sturner

    February 8, 2007 at 12:25 pm

    I see patients on a daily basis with similar stories. It is a miserable and dangerous spot for them to be in. I, too, support HR 676. However, if Rep. Conyers bill passed tomorrow, what is the earliest date by which it could provide the intended benefits? My guess is that you are looking at January 2009 and a Democratic president. So, for the next two years a “gradualist” approach is all that worker may have (see Adam’s comment regarding extending Medicare to uninsured adults). Furthermore, there is no reason that incremental gains in covering the uninsured should not complement the efforts of “maximalist” groups (like Healthcare-Now) to achieve their common goal of universal health coverage.

  6. Nick D

    February 8, 2007 at 3:05 pm

    Hit the nail on the head sturner.

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