No Public Option
Hm... The NYT says:
[S]enators said the tentative agreement would sideline but not kill the “public option” championed by President Obama and liberal Democrats in Congress ( Read more... )
[S]enators said the tentative agreement would sideline but not kill the “public option” championed by President Obama and liberal Democrats in Congress ( Read more... )
In principle, I would like to believe this, but I actually secretly believe that when you have to corral Blanche Lincoln and Joe Lieberman (not to mention the 58 other people) in order to pass your bills, you have to give them a lot of leeway. By not pushing on reforms that would substantially negatively impact industry (or, at least, their profits), he has kept industry from launching massive public relations campaigns against reform (which would probably have scuttled it).
And it has been successful, in the sense that we are pretty close to passing an actual bill. It seems likely to me that this is the best we could have expected from any president, in practice, given the makeup of Congress. As they say, politics is the art of the possible.
Fundamentally, I think people expect too much of him. That jibes with what I said when he got elected.
I mostly agree with the rest of your analysis. The public plan, even in its strongest form, was not going to do enough to combat costs or provide real competition for the insurers.
There is an amendment afoot to make sure that the administrative overhead of anyone participating in this new option is limited to 10%. That's actually the same overhead limit that Switzerland uses for their insurers, so it would be nice if that passed. I doubt it will, though - fundamentally, it is extremely difficult to pass any sort of rationing (and an administrative overhead cap is just another form of rationing).
Given this, a public option based on nationalized private insurance might be a better idea than any of the public plans discussed so far, especially if the government can negotiate rates with the private insurance companies. The private companies participating in it might have *more* ability to lower their costs, since they will all be getting premiums from healthy people, as well. We'll see, I suppose, when we know what the proposal actually looks like.
There is a great deal else we could do to make insurance cheaper. We're also not making it so that insurers can compete in different states, putting caps on torts (although that wouldn't help, in practice), or doing anything about the fact that doctors order unnecessary procedures because of insurance billing schemes. The list goes on.
It is interesting that they are talking about allowing those 55 and up to opt into Medicare. LBJ's original plan for Medicare was to have the eligibility age drop over time (to 0, ultimately); this is as close as we have ever gotten to that. It would be interesting to see if they let people get this instead of their employer-provided insurance.
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If Reid, Biden, and Obama were willing to really take a stand, they could go to reconciliaton -- and if the current Senate Parliamentarian didn't want to approve the use of reconciliation for the healthcare bill, they can fire him and get a new one. There's precedent for that, too: In 2001, the Republicans fired the Parliamentarian for refusing to consider reconciliation for the big tax cut bill, and got a new one willing to accept the ludicrous notion that the tax cut would not adversely affect the deficit.
I also have to say, I'm a bit worried about anything that lets the private insurers go interstate, because that could destroy the power of states to regulate insurance. Currently, the office of the CA Insurance Commissioner is actually pretty powerful -- John Garamendi used it very effectively to crack down on rescission. (I have a friend who credits Garamendi with saving his life -- his employer-provided insurance, which was notorious for rescissions, was kicked out of the state, and he got a new, better policy, just a few months before he was diagnosed with brain cancer.) It's quite possible that if insurers in right-wing states can sell into California through a national system, the national regulations will be considerably weaker than those we might otherwise impose ourselves. I will not be satisfied with such a scheme unless states are still explicitly allowed to set a higher floor than the national rules.
The unnecessary procedures / tests things I absolutely agree with, and as far as I can tell, the only bit in the bill dealing with that is bad -- pandering to the idiots who are decrying the new mammogram guidelines.
I do agree that expanding Medicare eligibility is an interesting way to go -- it'd be nice if they could build in some kind of one-way ratchet where an executive official would be free to continue expanding eligibility. (e.g. Give the HHS Secretary the power to expand the eligibility age by one year, in any year that CBO and OMB agree that Medicare will be able to offer unsubsidized coverage to new enrollees at a lower cost than the median private individual market plan for the new age being added.
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Right. In some respects, the whole argument has been a red herring.
If Reid, Biden, and Obama were willing to really take a stand, they could go to reconciliaton
That would be extremely difficult to pull off. They would have to go through the bill point by point and argue about its effect on the deficit.
If they fired the parliamentarian, the Republicans would ride that all the way through 2010.
If it came down to a majority vote, it might be possible that some of the support would evaporate anyway. The squeaker of a victory in the house was largely due to the assumption on the part of several representatives that the Senate would water down the bill. Special interests would start leaning hard on many of the Senators in a way that they don't have to right now.
I also have to say, I'm a bit worried about anything that lets the private insurers go interstate, because that could destroy the power of states to regulate insurance.
It doesn't have to work that way. There are examples of federal intervention where states are still allowed to set their own standards. CARB is one (although "California" isn't the same thing as "states"). NCLB is another (sort of).
Okay, I didn't say they were great examples. I'm sure there are better ones, but my brain doesn't seem to want to come out with any now.
The fact that many of the poorer states basically have insurance monopolies is enough to make me think that we need something to foster competition in the private sector (if we are to continue to have a private sector). Especially as the insurance companies are also exempt from antitrust legislation. I don't like the idea that the only competition might come from a single public option that wouldn't even be available to everyone.
I like your idea about giving the HHS secretary the power to expand the eligibility age, but it would either never happen, or she would get the power, but it would be so contingent on various preconditions that in practice she would never be able to use it. And the unsubsidized Medicare numbers I'm hearing from this deal are not very attractive as yearly insurance rates (ISTR reading $7600? That seems insane!)
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Or it would be a story for a week or two, after which most Americans would shrug it off as another weird, incomprehensible issue of Senate rules. It's not like the GOP took any heat at all over doing exactly what I'm discussing. Granted, that's partly because the Dems don't appear to have the ability to even make a clear argument about fairness, when they're getting trampled on in this kind of dispute, let alone actually present it, in a unified manner, to the media and the electorate. It really seems like most of them don't understand how to campaign, which is sort of astonishing, considering that they did get elected.
In any case, the GOP is going to whip its base into a frothing rage no matter what -- in fact, they'll use the argument that the Democratic supermajority is running rampant and acting unfairly even if we treat them with the utmost respect, try to bend to their interpretations of the rules, etc. That's exactly what's happening right now.
BTW, the squeaker in the House was also, at least in part, due to defections by some liberal House members who refused to support the already-watered-down bill. I expect a bill that was fairly similar, but with a slightly stronger public option, would pick up as many votes on the left as it lost on the right.
The situation with CA and environmental regulations is special because the exemption was written into law. CA had an EPA before the federal gov't created one, and they decided to let states that wanted adopt the CA standards rather than the weaker federal standards. Federal insurance regs could allow every state with a pre-existing stronger regime to keep it, but probably wouldn't, especially not if the law creating the regulatory regime has to get 60 votes.
Competition between Arkansas Blue Shield and Ohio Blue Shield isn't competition -- they're branches of the same entity. There are a handful of very large companies that function as an oligopoly nationally, with near monopolies in many submarkets. Dissolving the separation between the markets just means we have a single national oligopoly, very likely with either a) a federal regulatory regime weaker than what we now have in CA, or b) the ability to seek out the weakest regime from what the states currently offer. Neither is all that appealing.
On the price, if you're an older individual -- say, 55, the youngest that will get to buy into Medicare under the proposed expansion -- you could easily see low five figures in the current private market. The full cost of my insurance plan at Motorola (which I saw when I was on COBRA) was around $5,000 per year (and that's just medical, not including vision and dental). So, $7600 sounds high to me, but not absurd, especially if we're only talking about a market of people over 55, who have considerably higher medical expenses than the average across all working-age people.
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