Some of the usual suspects are out this morning with criticism of Tom Carper's compromise proposal to insert a robust public option into the Democrats' health care bill, but allow states to opt out of it by legislative or popular action. I'm not going to call these people out by name because I consider some of them friends and they're doing good, important, productive work. But this compromise is leaps and bounds better than most of the others that have been floated, such as Chuck Schumer's proposal to have a public insurance option that would be forced to negotiate at private market rates. Here's why:
1) If the public option is indeed popular -- and the preponderance of public polling suggests that it is -- we should expect the solid majority of states to elect to retain it. Perhaps some Republican governors or legislatures would seek to override the popular will in their states -- but they would do so at their own peril (and at Democrats' gain).
2) Behavioral economics further suggests that default preferences are extremely powerful. Making the public option the default would probably lead to much greater adaptation than requiring states to "opt in".
3) If the public option indeed reduces the costs of insurance -- and most of the evidence suggests that it will -- than the states that opt out of it will have a pretty compelling reason to opt back in. Say that Kansas opts out of the public option and Missouri keeps it. If a Kansan realizes that his friend across the border is buying the same quality health insurance for $300 less per month, he's going to vote restore the public plan in a referendum or demand that his legislator does the same in Topeka.
4) Even in states that do opt out of the public option, the fact that voters could presumably elect later to restore it creates an extremely credible threat to the private insurance industry that will itself help to create price competition.
5) The ability to negotiate at Medicare or Medicare-plus-X-percent rates really is what makes the public option so powerful. It's not just having "another option". Although creating an additional competitor would certainly be valuable, as health insurance is a virtual monopoly or duopoly commodity in some regions, you could achieve that goal through a variety of other means such as co-ops or exchanges, some of which are already in the health care bill. Rather, it's the ability of the government to potentially provide more efficient (i.e. cheaper) delivery of health insurance than private industry because of its advantages of scale that distinguishes the public option from something like co-ops. As a general rule, then, compromises that allow the government to take advantage of its size and negotiate at Medicare-type rates should be preferred strongly to those that would neuter it.
6) If the policy wonks are wrong about the public option reducing health care costs -- I don't think they will be, but they could be -- this creates a relatively pain-free way to remove it.
...
Now, if you could have a Jay Rockefeller-style, Medicare-for-Anyone type public option with no strings attached, would that be a superior alternative? Of course. But that amendment was rejected 8-15 by the Finance Committee and has very little chance of becoming law. Some sort of compromise is almost certainly going to be necessary. This is almost certainly the best compromise that has been floated so far. I don't really see what the problem is.
211 comments
Would states that opt out of the public option under this compromise have to pay taxes to support a system from which they are not benefiting?
I agree, especially about the public option purism part. I also thought that the trigger could have been a good idea, because it could have gotten more concessions from the insurance companies than a mandatory weak public option - simply because of the political obstacles to a public option.
A state-based public option program is a good idea, and in fact, probably the best solution to the partisan divide. Those that don't want it, shouldn't have it and an opt-out system, rather than an opt-in system, will force politicians to take a stand.
Any idea what premiums would be for a Public Option "Medicare" plan? Because Medicare isn't exactly "Cheap" especially if you're using the benchmark of people who haven't paid into the system for 10 years. I believe premiums are about $6000-$7000 per year, per individual.
The other issue, is Medicare's reimbursement rates are increasingly not covering the costs of some procedures... And as a result, doctors are turning people down, rather than take a loss on a procedure.
How would the Senate and House democrats reconcile a House bill with a strong mandatory public option and a Senate bill with the "opt out" public option?
Ah, and another point, this will keep the liberal activists active. The 2010 cycle will be troublesome for the Dems if they aren't enthusiastic enough, but if they really want a public option, they'll need to take the state houses and senates.
KCDC makes a very good point. States that "opt-out", as Nate notes, would still benefit from the existence of a public option in other states, and the threat it would pose to the insurance industry in "opted-out" states. Of course, this could be attacked as unfair taxation, but the fact is that I live in Chicago and pay for FEMA, which rarely if ever has provided any help to Chicago (the only flood we ever had was underground, but that's a story for another time).
Nonetheless, having worked in dot-coms, I can tell you that the "automatic opt-in" is indeed powerful, as long as you don't abuse it. People react strongly if you spam them, for example, and will go to the trouble to remove themselves. When I worked for a well-known subscription-based site, there was great debate as to whether we should email subscribers in an attempt to increase traffic. "Sleeping dogs" who had forgotten that they were paying the (auto-billed) monthly subscription fee were unlikely to unsubscribe unless you reminded them about the fee they were paying for an unused service.
My point is that if the funding were, like Social Security, a national payroll tax, even for those people in states who've opted out, most people wouldn't even notice money that was removed before they receive their check.
Those self-employed people who don't pay withholding are actually the ones who would be most in favor of a public option, so there would even be some momentum toward opting back in as results from other states come back.
My guess is that the most populous states would not opt out, with the possible exception of Texas, so the advantages of economies of scale would be preserved for such a nationwide plan. Perhaps the opted-out states could be taxed at a proportionally-lower rate to represent the benefit which accrues to non-participating states, or perhaps their portion of funds allocated could be put into a trust fund which those states could use for specific health-related goals.
This would penalize states for absolute inaction (leaving people uncovered) but allow them to experiment with alternatives that might produce some benefits.
@Max: presumably the same way they reconcile any other bill with House/Senate differences. My guess is that the House will go along with whatever the Senate is able to pass b/c it's better than nothing...but they might kick and scream the whole way so that the liberal members don't lose credibility w/ their constituencies.
Totally agree with Nate on the necessity of compromise. I still think the trigger option would be preferable from the liberals' perspective, but allowing states to opt out might also get some moderate dems from red/purple states to get on board.
Is there any lobbying and financial clout for the public option? Wouldn't national private health insurers simply pick off states one-by-one and flood them with opt-out money, especially if opting out could be achieved by legislation rather than by public referendum?
Kansasan? Come on.
As a political strategy, i can't disagree with you. But how do you turn your backs on the states in the south? What I mean is that the south is dominated by Blue Dogs and Republicans and it is the south who have the highest percentages of uninsured.
Look at Texas, my state. One in four people are not insured in Texas. What do you think Texas is going to do? Opt out of course. Do you think that will bring political change? No. the very people it will benefit are opposed to it. They have bought, hook line and sinker, all the rhetoric their conservative leaders have fed them.
I worry that with state participation in a public plan optional, red states trending blue in the long term will employ opting out as a means to maintain or even strengthen what would otherwise be a fading hold on the reins of government by "incentivizing migration" of the poor, especially blacks, and the enlightened who simply become disgusted.
Per Nate's analysis earlier today, the dems/progressives will become even more concentrated in places where they politically don't need to be.
Precisely. We can have Texas and
Confederacy holding the rest of the country hostage on this.
@A Temporary Name,
I have to say, as much as it is important to me that the south and Kansas/Oklahoma/etc get covered by the public option, I feel that if the people so badly don't want to have a public option in their state, so be it. Democracy sometimes works that way, and that's just the way it is. If they don't want the public option forced on them, even if it benefits them most of all, that's unfortunate, but it's their democratic choice, and I'm inclined to allow it.
I think this opt-out compromise is THE solution, and I count myself among those who are of enthusiastic support.
I think, for those of you who think a public plan is a good idea, this "State opt out" idea is a grand deception.
One can imagine about half the states instantly accepting it. Then there will be pressure on the other states to accept it over time...just like what happened with the 21 year old drinking age.
In other principles though, I'm still opposed to a "Public" option. Look at Massachusetts for example...they have a public option, and prices have gone up for health care...faster than the rest of the nation.
Alex has got the point. A state-by-state public option will have the same effect on liberal voters that "family values" battles have had on conservative voters--it's something that will get them fired up at a local level. Politically, this is an absolutely brilliant move for the Democrats. Plus, it calls the Republican bluff on the evil federal government. I'm sure they'll have an argument against it, but a state-by-state public option is a good idea.
@A Temporary Name,
Then that's really their own fault then isn't it? Besides in a few years after seeing how other states have cheaper insurance they can always opt in.
And I'm with Nate on this - I saw Ed Schultz(sp?) bitching about this last night, but I think it's a pretty spiffy deal, and only a handful of states would likely end up opting out. (my state safely being not one of them).
Certainly leagues better than no PO or a really weak watered down PO.
Massachusetts doesn't offer a public option
KCDC writes:
Would states that opt out of the public option under this compromise have to pay taxes to support a system from which they are not benefiting?
The public option is self-financing; it is required by law to charge premiums that cover the costs of the plan. So nobody will be paying taxes to "support" the system.
What you are probably thinking of is the subsidies that will be paid to low-income people to allow them to buy insurance. But the people in "opt out" states will still receive those subsidies; they'll just have to use them to buy insurance from private insurers.
I agree 100% with Nate on this; the "opt out" model is an all around winner. If this is the figleaf the Blue Dogs and Olympia Snowe need to support a genuinely robust Public Option, it's well worth it.
The problem that I have with Opt out is how people who are "out of network" get medical coverage. In the private insurance world, your plan (say Blue Cross/Blue Shield) has certain coverage for medical services rendered by approved medical facilities, and different for medical services rendered outside -- including outside the region.
How will Opt-out work? If I am living in Wisconsin, which would likely opt in, what happens if find myself in Iowa when I need to see a doctor or go to a emergency room and Iowa is a opt out state?
This is a seemingly small detail that will, however, affect the viability of this local option plan.
In the best case scenario, this opt-out will happen by government referendum, which means that uninsured people in red states who want the public option won't be able to get it because of Tyranny of the Majority. In the worst case, the Republican Governor will veto the PO regardless of what his citizens want.
Either way, some people get screwed out of health care they both want and need. But if the public option is not opt-out, who loses? No one needs to take it if they don't want it.
I know there are a lot of registered Democrats here, but try to resist that Dem urge to throw in the towel in the first minute of Round 2. The SFC vote was just the first stage, and Baucus and his blue dog partners lose control of the process when the bill leaves his committee.
Democrats should still be fighting for a the strongest option at this point.
I agree with Juris.
A large part of the appeal of the public option is that it is 100% portable, nationwide.
That can be part of what makes hunting for jobs difficult, because you can't relocate without losing your current insurance.
The trickiness of "in network" vs. "out network" would just compound that issue.
However, if they worked it out so that coverage was guaranteed to residents of "opt in" states whilst traveling in "opt out" states, then I'd probably be more comfortable with this compromise plan.
Also, I would expect to see a lot of people in opt-out states finding ways to establish legal residence in opt-in states, for purposes of being able to get the cheap coverage... Could create an interesting dynamic.
@Pat
Raising the drinking age to 21 (if memory serves me correctly) was a carrot and stick option for states. The Fed would withhold highway funding from states that opted out. So they were effectively held hostage since what state doesn't like pork?
[To my knowledge, the only state that didn't comply was Louisiana since they made a great deal of revenue on alcohol sales; particularly around Mardi Gras. It also explains why the highways in Louisiana were crap until they finally acquiesced]
But your suspicion regarding opting out of a public option is probably true. I think it will become readily apparent that the public option will be a better decision and force states to finally adopt. And that's why it makes sense because the whole point of health insurance reform is make things better.
@Pat:
Massachusetts doesn't have a public option.
Surprise, surprise: an opponent of the public option is uninformed on the topic.
@Juris,
Urgent/emergent care is covered by any plan I've run across, regardless of network affiliation or location.
From personal experience, the decision point is when the patient stabilizes and needs additional/rehab/psych care. But that's no different than when you fall ill while on vacation. You may voluntarily choose to travel home prior to selecting the next care-giver.
Now, if I live in an opt-out state, and travel to an opt-in.. I'm not going to be covered just by stepping across the border. This isn't universal coverage, by any stretch.. it is a public plan that can be bought into, with subsidies for the poor, but is never going to cover 100% of the citizens in any opt-in state. A visitor from an opt-out state would either have their own plan, or be self-pay. Same as now.
Pat,
Massachusetts does not have a public option:
http://nearing.newsvine.com/_news/2009/07/27/3077152-wsj-editor-attacks-the-non-existent-public-option-in-massachusetts-video
Nate,
Isn't Schumer opposed to a public option that can negotiate medicare-plus rates for its members?
@yoink
Your point about self-financing is well-taken, but as I read it opting out of a public option does NOT opt people out of mandated coverage. In other words, everyone would still be charged some sort of premium (or a non-coverage "penalty" tax), and if there is no public option, those funds would be used to subsidize care via a private provider.
I don't think that the "opt-out" is allowing anyone to opt out of insurance, it's just allowing states to opt-out of having a public option. Frankly, I would have no problem with this, as long as the opt-out is somehow voted upon and not by the fiat of the governor.
If "opt-out" means "opt-out" of paying, then I think there would be too much incentive to stay with the status quo, i.e., leave uninsured people without health care.
@ juris
Most private insurance is done by state or (often only local) provider network anyway, and often requires pre-approval of out-of-network care. The only substantive differences between a public option and private would be that public coverage is cheaper, has a broader network, and the insurance company is the department of health and human services. If you bought the public option and got sick in a non-PO state (in an emergency), HHS could still pay for or reimburse your care if that was allowed by the final plan. It's just that a person living in the non-PO state could not buy such a plan.
While a robust option nationwide would be best, this plan would not be that bad if it works.
@Athena
Schumer supports a more robust public option. He was trying unsuccessfully to float an idea that he believed could pass.
Couple of items I haven't seen discussed.
How will employers react to all this? If there is a public option, will they be inclined to keep medical coverage for their employees?
If I get the public option and get a job at a place that has employee coverage I'm not going to be inclined to change to that coverage (based upon past negative experience with employee insurance). Or will the company force me to get on their insurance?
If states can opt out of the public option, what effect will that have on businesses decisions on where to locate? For example: a lot of RV manufacturers are located in Oregon because of the lack of sales tax.
And finally what is my paycheck going to look like when all this goes down? Will there be a new deduction underneath the Medicare deduction line?
@Juris
My understanding is that an opt-in state would cover its own residents, rather than offer insurance to anyone who received care in-state.
Therefore, if Wis. is an opt-in state, even if you go to Iowa (an opt-out) for care, your insurance would work out a payment arrangement with the provider in Iowa. Likewise, an Iowa resident, if treated in Wisconsin, would not be eligible for the public option accepted in Wis., because the Iowan is not a participant in the plan. The Iowan would have to rely on whatever insurance is available in Iowa.
The other great thing about opt out rather than opt in is that the governor could not do it alone--state legislatures and their govs (and in some cases the people via referendum) would all have to agree to opt out
Great article. A few thoughts (I didn't read the preceding comments so I apologize if I repeat something thats already been said):
1) It seems like the only states that would opt out of the public option would be the super-conservative/libertarian ones. If people insist on voting against their best interests, I would rather they didn't but there's only so much patience I have before I'm willing to let them have it their way.
2)My guess is if a public option passes in ANY form, it would become so popular that a stronger option would probably be passed in the future (both because it would change public opinion and because more democrats would be elected).
BTW
The 21 drinking age did have the desired effect of cutting down on alcohol related crimes. There was, of course, a rise in underage drinking issues. Raising the drinking age proved to be a good idea, unlike the mandatory 55mph speed limit.
I agree with Nate here. Look at the stimulus as an example of the kind of politicking that would happen. Republicans made their full-throated protests heard, but when push comes to shove they are taking the money. This same kind of pressure would come to bear on the "opt out" approach. Republicans will express their moral indignation, but there will be heavy pressure from voters to include the public plan to reduce costs. Let them have their cake and try to eat it. Even if their constituents don't punish them for their hypocrisy (and it seems they never do), so be it. We still get effective reform. Pretty brilliant.
KCDC said…
“Would states that opt out of the public option under this compromise have to pay taxes to support a system from which they are not benefiting?”
If they were it would be no more unfair than the federal taxes Kansas pays that support the US Coast Guard. Not much ocean frontage in Kansas last I checked.
KCDC:
Would states that opt out of the public option under this compromise have to pay taxes to support a system from which they are not benefiting?[sic]
Well, I would suspect that most of the states which would opt out of it are in the south and the plains/northern rockies, and most of them already receive back quite a bit more in federal tax dollars than they pay in (http://www.taxfoundation.org/files/fedspend_per_taxesbystate-20071009.xls) even if you were right all it would do is pay states that opted in for all the money they are sending to the 'beggar states' anyway.
I might add, I live in Arizona, and I'm certain that given our legislature's current tilt to the far right they would immediately opt out, but I still think this is a compromise worth considering precisely for the reasons Nate lays out. Health insurance premiums have spiraled upwards at an alarming rate here as well as everyplace else, and a credible threat that can't be blocked just by lobbying to bend some rule in Washington is still a good one.
Beyond the most important goal of insuring as many people as possible at the lowest cost the longer term political impacts of this I think are great. You would see people moving from states without to states with the public plan... states without would see falling tax revenue, falling population (and house seats) and you'd see no decrease in costs in those states. It could have long term affects as people would have a "control" to compare the effects on cost/care that the public plan would bring. This could crush the GOP long term.
Nate, in #2 above you mention "adaptation" where I'm pretty sure you meant "adoption." Very different.
Nate: One thing I'd caution to be careful about when writing on this subject. There are two proposals floating around with Carper's name vaguely attached to them that sound similar but are very substantively different. One is an "opt-in" proposal, and is the one Carper himself seems to personally want. The other is the "opt-out" proposal all the liberal blogs are all interested in all of a sudden. The "opt-out" proposal has all the nice features you outline.
The "opt-in" proposal, on the other hand, is a nightmare, and does something radically different-- rather than just being the opposite of opt-out, the "opt-in" proposal kills the national public option entirely and instead creates multiple regional public options as well as a collection of tiny co-ops and similar entities. This other Carper proposal would basically give each state a certain amount of seed money sufficient to start a local insurer, and tells that state "do whatever you want with this". I think it is important to keep the two Carper-related proposals separate.
Letting states decide is an interesting idea. I wonder if any conservitives who are always talking about states rights will be persuaded. I think creating some kind of tort reform, and allowing states to opt in or out to that as well would be a resonable compromise.
I do have one small bone to pick.
"The ability to negotiate at Medicare or Medicare-plus-X-percent rates really is what makes the public option so powerful."
ummmm ... how do the strong plans negotiate for medicare rates? My understanding is that the rates are set by law. If the government could, because its size, negotiate better rates I am all for that. I am however hesitant about setting prices by law.
I think describing the strong plan as "negotiating" is at best misleading.
Sorry .. it is one of those things that really bugs me.
(First: Thanks, Wayward Son.)
Here's another angle for you, Nate: inter-state competition for labor; other indirect consequences of being an "In" or "Opt-Out" state.
I could envision a state that is now losing population (e.g., in the upper Midwest such as Michigan) using the fact that it has a public option as a way to sell the state to prospective businesses and employees. Depending on how the public option is structured, and how it is paid for, it could help to draw and to retain skilled population.
If a Kansasian[?] with a public health option steps into Canada and immediately breaks his foot, is he covered?
@ Davy;
As per the last time I bothered reading (more like "skimmed")the proposed bills;
Employers are required to offer insurance to their employees in some form. They can't just drop you to fend for yourself. Keyword OFFER: You don't have to accept it.
If states opt out of it, then it will be up to each business to decide what that means to them. *shrug* If a business thinks they can save money relocating to another state, they'll do so regardless of reason. (One more reason for states to opt-in if it starts swinging that way)
Your paycheck won't be effected any more than it already is for other employer provided care: you still need to enroll in and pay premiums for the public option. It is not funded by taxes.
Again, that's just on my previous skimming of the proposed bills. I don't exactly follow too closely...
The impact of this amendment cannot be examined in a vacuum. The rest of the bill needs to be filled in. Let's start with the Baucus Bill CBO estimate.
Revenues:
$404 billion cut from Medicare.
$201 billion in taxes on health care insurance.
$224 billion in taxes on health care providers.
Spending:
$461 billion in subsidies to buy insurance.
$345 billion to expand Medicaid, which would have to be matched by the states.
It is safe to assume that the Public Option will cost some additional undetermined amount in startup costs and overhead to be paid for with some unspecified taxes.
***
The states themselves are going to take an enormous hit in Medicaid matching funds that they simply do not have a budget to pay.
The citizens of the states are going to get socked for paying for the Public Option whether or not the states opt out of the program.
If the states decline to opt out of the public option, they can heard Medicaid beneficiaries into the public option to reduce the matching fund hit on their budgets.
Therefore, every state will be economically compelled to accept thepublic option their citizens are already paying for whether or not they think it is wise public policy. Some choice.
[To my knowledge, the only state that didn't comply was Louisiana since they made a great deal of revenue on alcohol sales; particularly around Mardi Gras. It also explains why the highways in Louisiana were crap until they finally acquiesced]
You are correct, sir. In fact, Louisiana's initial compromise was to raise it to 19, but the federal government said "nuh-uh" to that, and they were essentially forced into making it 21.
The funny thing is that this all happened in the early to mid 1990s, if memory serves, so it wasn't that long ago.
I also think alot of the people complaining that "The South and Texas will never be insured!" don't actually live in the South. Southern Republicans love thumbing their nose at the rest of the country, but not when it comes to providing things for their citizens other states already have.
How many of them turned down those stimulus checks? Republicans, especially in the South, are generally only promoters of limited government when it's politically useful. The genius of opt-out is that it makes it politically poison, as long as the public option actually does what everyone thinks it does (i.e. reduces costs and provides competition)
It's all well and good to say that Democrats in a state which kills the PO will benefit. It's all well and good to say that if people really want something, they'll get it changed.
In the meantime, PEOPLE WILL DIE from lack of healthcare, plain and simple. Are we really prepared to accept that? We have the votes, we have the power (use reconciliation, for Christ' sake) to get the non-compromise bill we want, that we DEMAND.
If Obama is unable to pressure Congress to get the right bill passed, not this watered-down BS, I'm not voting for him in 2012, I'm not giving him another dime. Democrats will reap the rewards either way.
You're making an excellent point with this post. Good work.
Nate, for me the problem is not political. It is ethical. Politically, this sounds like a successful strategy. In the long term, I think it would be a successful strategy. In general, I believe in looking to the long term over the short term...
BUT, I simply cannot bring myself to support any compromise that would allow state governments to disallow a public option when the people in their states are already among those who suffer most from lack of affordable health insurance. Even if those people were only denied a public option for a few years, a few years is too long. It is not acceptable to me at an ethical level, and that is why I and so many other people cannot put our support behind this opt-out compromise: We can't leave behind those people who are most in need, even if it's only temporary.
"Are you really sure you can't see the Trojan Horse in this "opt out" proposal?"
Are you really sure you can't see any difference between the civil rights movement and public healthcare?
There is no inherent cultural stigma against the state providing healthcare in this manner. You aren't going to have the KKK going around lynching people who are on the public option.
And as others have stated, there's economic incentive to accept the public option, as long as it works. If other states have better and cheaper healthcare because of accepting the public option, then the states that opt-out will eventually acquiesce simply to keep their economies going.
There is no equivalent pressure with the civil rights movement, and there was huge cultural stigmas against it.
Apples and oranges.
" It is not acceptable to me at an ethical level, and that is why I and so many other people cannot put our support behind this opt-out compromise: We can't leave behind those people who are most in need, even if it's only temporary."
Meanwhile people will die in the states that would accept the public option, because you refuse to compromise your ethics and the public option dies completely.
Sorry Nate, but I'm not prepared to accept any compromise on the public option. Don't you get it? Progressives have already compromised by giving up single-payer. The public option is the compromise.
And I have to say, I'm really sick and tired of hearing that we progressives have to compromise on the public option because "the votes for it aren't there." Well, the Democrats have solid control of the House and 60 seats in the Senate. If the votes for a strong, robust public option aren't there, the only reason is that Democrats won't vote for it.
So, no. No more bullshit "compromises" where progressives are the only ones who give up anything. If the Democrats won't pass a real public option (which, again, already represents a significant compromise on the part of progressives), then all that is is proof that the Democratic party is worthless and progressives need to start throwing their time, energy, and money into building a real progressive party in this country. End of story.
>>KCDC said...
>>
>> Would states that opt out of
>>the public option under this
>>compromise have to pay taxes to
>>support a system from which they
>>are not benefiting?
I think there is a fundamental misunderstanding of what we are talking about here. In none of the plans being talked about are taxes being used to pay for the public option. The public options are all designed to be self supporting through the premiums charged to cover costs. The premiums of the public option would be much lower because of the the economies of scale and the absense of expensive costs of things like profit, bloated executive compensation and marketing budgets.
Any money transferred to this plan or brought in from taxes would be used to subsidize the payment of premiums by the poor to purchase insurance in state based exchanges. The only difference in an opt-out state is that the public option would not be available on their exchange, forcing people to choose private options with a higher price or lower service level.
Also important: in most of the plans floating around, these exchanges are only available to those who are not covered by employer-based insurance.
"Meanwhile people will die in the states that would accept the public option, because you refuse to compromise your ethics and the public option dies completely."
Pyromanfo, I don't think this is a black and white issue. The choices are not currently (A) the opt-out public option or (B) no public option for anyone. If it ever gets to that point, let's talk again, but I am optimistic that we can actually achieve some sort of public option.
@Caroline
How is it not an ethical decision to say "There is not enough support to pass the best plan, but there is enough support to pass a good plan. Therefore, let's pass a good plan so that will reduce pain and suffering of some people rather than just leave all the people out in the cold"?
When you choose "the best plan or nothing", you are making a choice that either EVERYONE will win or EVERYONE will lose. When that is as long a shot as it is now, you're specifically deciding that it's worth it to not have any reform for that slim chance you'll get the exact reform you need.
Pan,
See my comment right above yours. I am not choosing "the best plan or nothing." It's just that I haven't seen enough evidence to believe that a public option for all Americans is dead yet. Obviously, a public option for some is better than a public option for no one, but do you really think the debate has reached that point?
Folks, there's already an "opt-out" compromise on the table: the original Public Option. No-one is forced to buy into the public option, they can use whatever insurance they want to buy. The original plan has the added value of leaving it up to the individual (or the individual's employer) whether or not to "opt-out," instead of leaving it up to the "bureaucrats" in the [state] capital.
No, what this is is Democrats in blue states telling Democrats in red states that they'll have to fend for themselves. Screw it - next time I'm voting for Saxby Chambliss and Paul Broun.
I absolutely LOVE this compromise. Like Nate says, it's not as good as what Jay Rockefeller proposed which in turn isn't as good as single payer [what I want].
However, this is awesome in terms of being way better than the stupid single state co-ops that might spring into existence under a trigger.
I say way to go!
The opt-out does seem to be a good idea, especially the "10th-Amendment argument" against against the public option (which I find to be really specious, considering the interstate-commerce clause would override the 10th Amendment when it comes to health care), but it then causes its own Constitutional questions to arise, especially with respect to equal protection. For example, the Kansas/Coast Guard analogy above. Ignoring the fact that the Coast Guard is a branch of the US Military (as is, btw, the Navy), Kansas does derive benefit from the Coast Guard in terms of national security. What gets unloaded at a dock in Houston or Philadelphia could have far-reaching ramifications, especially if a hitchhiking disease or an NBC (nuclear/biological/chemical) weapon is on board. Those things don't just stay at the docks. But the opt-out is different. If Kansas chooses to opt out of the PO, then in effect it may be chipping in for others to have the PO instead. Of course, the PO is going to be set up to be self-sustaining, but the seed money has to come from somewhere.
Second, you have the issue of a person who works in an opt-in state whose job has been transferred to an opt-out state. If this person and his family are using the public option, do they get to keep it? Or will they be forced to give it up, per the laws of their new home state?
If this is the way things go... electing Creigh Deeds in Virginia just got a lot more important. I do not want Bob McDonnell deciding Virginia doesn't need the Public Option!
@Smidge204
Thanks.
I hope this flies. I'm pretty sure my state will go for it.
Also, I think we ought to ease off the 'people will die unless we get this done' theme. I know there is truth to this and it is why the President is promoting reform but I think we run the risk of looking like our conservative counterparts yelling DEATH PANELS!
As a middle aged guy with no insurance, I want this as badly as anyone.
Leroy Sunset writes:
In the meantime, PEOPLE WILL DIE from lack of healthcare, plain and simple. Are we really prepared to accept that? We have the votes, we have the power (use reconciliation, for Christ' sake) to get the non-compromise bill we want, that we DEMAND.
Sigh. Why is it that there are so many people (well-intentioned people, too) on the left who just will not make the least effort to inform themselves about the actual contents of the proposed legislation?
If a state "opts out" of the public option that does not mean that it's citizens are somehow denied healthcare. In fact, all the citizens in those states will be required by law, just like those in the "opt in" states, to purchase health insurance. The indigent in the "opt out" states will, just like those in the "opt in" states, receive subsidies to help them purchase that insurance. There will still be the "insurance exchange" in place that will ensure real competition between the insurance companies. Further, insurance companies will have to keep an eye on premiums in the "opt in" states and make sure they don't go too far above them, so the public option will still be exerting downward pressure on insurance premiums even in "opt out" states.
In other words, the total effect on the citizens of the "opt out" states would be almost nil.
If Obama is unable to pressure Congress to get the right bill passed, not this watered-down BS, I'm not voting for him in 2012, I'm not giving him another dime. Democrats will reap the rewards either way.
Ah yes, the good old "all he needs to do is grit his teeth harder" argument. Just what weapon, exactly, is Obama meant to use to "pressure" Congress to force them to vote for the healthcare bill of your dreams? In politics you play the cards you're dealt. So far, Obama has been playing them brilliantly. He's close to making meaningful health reform a reality; a goal that has eluded all his predecessors for more than 60 years. And for this I'm meant to be angry at him?
@A Temporary Name:
As a political strategy, i can't disagree with you. But how do you turn your backs on the states in the south?
We didn't. If their elected officials pass legislation opting out, they turned their backs on us. After all, they elected them.
What do you think Texas is going to do? Opt out of course.
I'm seeing a lot of this: folks assuming that every state with a GOP legislature will instantly opt-out. I just can't imagine that's going to happen. The national GOP is tooth-an-nail against this because it's part of the obstruction they need to win political points for 2010. At the state level it's completely different...just what political gain is a state legislator really going to get from taking the option away? There's simply no upside, and there's a ton of risk. I'd offer even odds on not a single state opting out, or ten-to-one on less than 4.
As Andrew said above, the robust Public *Opt*ion already lets those who don't want to participate retain their current insurance (or lack thereof). So the Opt-out plan, rather than giving us more options, actually puts one more hurdle in front of potential insurees: you will have to make sure your state does not opt out, and then as an individual you will have to opt in. This is a recipe for lower participation rates and ultimately fewer economies of scale. It also sets the stage for massive confusion as 50 state legislatures start debating the healthcare issue all over again
A national public option, either opt-in or opt-out for individuals, is probably a better step towards effective reform. On the other hand, it might be worth giving this up for the probable pressure it puts on red state politicians.
@shma:
In the worst case, the Republican Governor will veto the PO regardless of what his citizens want.
No, you're confusing opt-out with opt-in. The governor can't "veto the PO" because the legislature doesn't have to pass a bill to get it. He could veto the legislature's decision to opt-out...and I'd say that's a great feature.
This is of course the reason it's imperative that this be opt-out rather than opt-in. It pays lip-service to letting the states choose...but it extracts a very high electoral price from anyone who chooses wrong.
Josh - It's funny that you bring up Creigh Deeds. He's a perfect example of what's wrong with the Democratic party today. He's a milquetoast, center-right politician who made trying to appeal to conservatives (especially in the western part of the state) a centerpiece of his campaign. Well, guess what? Those voters are sticking with McDonnell. And since a milquetoast, center-right politician isn't going to inspire anyone else, Deeds is going to lose, and lose big.
The lesson for Democrats here is obvious, of course, if they choose to see it: Stop trying to kiss up to conservatives. If people want to vote for conservatives, they'll vote for Republicans. You can either offer them a compelling alternative, or you can lose. It's really that simple.
Look at Texas, my state. One in four people are not insured in Texas. What do you think Texas is going to do? Opt out of course. Do you think that will bring political change? No. the very people it will benefit are opposed to it. They have bought, hook line and sinker, all the rhetoric their conservative leaders have fed them.
Just we saw with the stimus bill there'd be squealing and posturing. They might even opt out initially. But in the end they'll cave, save for some token they'd extract.
That's the key really. Making sure there is a way for them to claim their dignity and principles (even though any rational person looking at it realizes they caved).
This is actually roughly how it works in Canada. The federal government transfers money to the individual provinces for them to implement their own health care system, with the provision that they must follow a set of guidelines with certain principles obeyed. Even the hardest core "DAT THERE IS COMMUNIST!!!" province (Alberta, has been one party rule by the Conservative party for over 3 decades, and before that a fire-and-brimestone radio preacher for about 4 decades) bunkles under and implements a health plan because they'd get slaughtered on election day if they opted out.
Yoink - Sorry, but the old "Obama has no control over what Congress does" argument isn't going to fly. Not after what happened back in June with the war supplemental. Back then, when progressive Congressmen were threatening to vote against more money for war, Obama and Rahm Emmanuel browbeat and threatened them until they did what the White House wanted. But now, all of a sudden, we're supposed to believe that the White House can't do the same to the Blue Dogs? Please.
Obama has shown that he is willing to threaten progressive Democrats to get them to support his right-wing agenda. The fact that he won't (and it is definitely won't, not can't) do the same to conservative Democrats to get them to support progressive agenda items tells us all we need to know about his priorities.
Nate, there's a great big hole in your logic.
Lets say we have this satellite we'd like to put into orbit around the Earth. To do this, the rocket carrying the satellite has to reach a certain distance from the launch site. However, fuel costs being what they are, you decide you can only afford to get the rocket halfway there. But hey, that's better than nothing, right?
Errr.. no, actually, its worse than nothing. The rocket isn't going to just hover there and wait for more fuel later on, its going to come crashing right back down to the Earth unless it has enough gas.
You're a statistician, and I'm sure you know what Adverse Selection is. Please explain how it is that you think you can overcome Adverse Selection-how Healthcare Reform is to achieve orbit-without universal coverage.
I don't see how that's possible. Unless the risk is distributed evenly across a large enough a number of participants, the risk per participant will be so high that the average cost per participant will be astronomical. The ONLY way to drive down costs is to achieve a large enough number of participants without severe health problems in the pool to balance those that do have severe health risks, distributing the risk evenly across both groups and therefore reducing its effect per participant.
So no, compromise is not an option. You have to achieve a certain level of coverage before the cost-cutting effect of the Public Option takes hold. Else, it all comes crashing back down to Earth.
Universal Single Payer is the only viable Public Option.
Two words: reverse psychology.
Hunter: I'm going by what's in the HuffPo article linked in the post:
'But theoretically, the "opt-out" approach would start with everyone having access to a public plan. What kind of public plan isn't yet clear. States would then have the right to vote -- either by referendum, legislature, or simply a gubernatorial decree -- to make the option unavailable in their health care exchanges.'
I didn't mean 'veto' in the strict legislative sense.
(although my wording was certainly confusing. Sorry)
Rather, I meant that Governors may have the option of deciding, on their own, whether to accept the PO or not. If the governor has the power to opt-out of the PO by decree, even if the rest of the state supports it, it's a 'veto power' in the standard sense of the term.
But, once again, that's only the worst case scenario.
Here in Canada, we got to our universal public health insurance system through a long process which began with one province, Saskatchewan, and one determined provincial leader, Tommy Douglas.
Default opt-in seems like a good start to me.
What I'd like to see this site do now is a state-by-state breakdown of which states would be able to opt-out by virtue of the GOP and/or Blue Dogs controlling the state's gov and leg. It is a nice bone to throw Blanche Lincoln so she can vote for a bill and still get re-elected next yr, so I fully support the idea. Especially if, as I suspect such a chart will show, less than a dozen states will even try opting out and maybe only WY will succeed. But even if IA (my state) opted out (which is very unlikely, actually), I could always establish a residence across state lines in WI, MN or IL. As could everyone like me who really needs public health insurance. So, I reject the notion that people will die if their state does opt out. It'll reinforce red state/blue state division in America, though.
-Jeff
Burt wrote:
Yoink - Sorry, but the old "Obama has no control over what Congress does" argument isn't going to fly. Not after what happened back in June with the war supplemental. Back then, when progressive Congressmen were threatening to vote against more money for war, Obama and Rahm Emmanuel browbeat and threatened them until they did what the White House wanted. But now, all of a sudden, we're supposed to believe that the White House can't do the same to the Blue Dogs? Please.
Obama has shown that he is willing to threaten progressive Democrats to get them to support his right-wing agenda. The fact that he won't (and it is definitely won't, not can't) do the same to conservative Democrats to get them to support progressive agenda items tells us all we need to know about his priorities.
I notice that you don't mention what credible threat the White House can make against the Blue Dogs to force them to vote the way they'd like them to.
There's a reason the Blue Dogs are who they are. The Dems deliberately courted conservative-leaning candidates to win in conservative districts. These aren't (for the most part) people sitting in safe Democratic seats who just happened to go all squishy on the Democrat agenda. That makes it very hard to mount credible threats against them. If Obama says "I'll support a primary challenger against you" they can just laugh at him: A) his support won't do that challenger all that much good--these are districts that like to think that their voting for a Democrat who is willing to "stand up" to the party heirarchy, B) if the challenger is a more conventional Dem, s/he probably won't win in that district and C) for all the trouble the Blue Dogs cause, you'd much rather have them there than have them replaced with Republicans--and that's the most probable outcome of a successful primary challenge.
To speak of "Obama's right wing agenda" is, frankly, loopy. The man is on the verge of delivering on the promise of meaningful, substantial healthcare reform that will extend coverage to millions and prevent insurance companies from arbitrarily removing coverage from those who fall ill. It will be (if it comes) one of the greatest victories for the left in this country in decades. I know the left likes nothing better than playing "circular firing squad" but try to recognize when you're actually getting a victory and allow yourself to enjoy it a little.
Commonwealth Care in Massachusetts = a "public option"?
Mike Green writes:
Here in Canada, we got to our universal public health insurance system through a long process which began with one province, Saskatchewan, and one determined provincial leader, Tommy Douglas.
Default opt-in seems like a good start to me.
Yes. Presumably there are plenty of people in this thread who think that Tommy Douglas was a vicious Tory thug because he didn't refuse anything short of universal healthcare from the get go.
Statler N Waldorf writes:
Unless the risk is distributed evenly across a large enough a number of participants, the risk per participant will be so high that the average cost per participant will be astronomical.
But it is self-evidently the case that the vast majority of US citizens will be in "opt-in" states from the outset (all the blue states and most of the red). That's a huge risk pool. And those in "opt out" states are going to be part of the risk pool too; they are still mandated to purchase insurance on the "Insurance Exchange."
Bart DePalma said...
~~~~~~~~~~
One made a rather long spin er post re: health care w/out mentioning "Obamacare" once. May be time to take some time off as your winger agenda appears to be discombobulated, just sayin' ...
take care
There aren’t enough votes in either the House or the Senate to pass a universal single-payer overhaul of health insurance. So the options we are left with are—
1. Trying to get reform that falls short of universal single-payer.
2. Giving up and keeping things just the way they are.
I’m a fan of #1, and a public option with an “opt-out” provision sounds like a pretty good way to go to me.
Pat,
More information can be found here:
https://www.mahealthconnector.org/portal/site/connector/template.MAXIMIZE/menuitem.3ef8fb03b7fa1ae4a7ca7738e6468a0c/?javax.portlet.tpst=2fdfb140904d489c8781176033468a0c_ws_MX&javax.portlet.prp_2fdfb140904d489c8781176033468a0c_viewID=content&javax.portlet.prp_2fdfb140904d489c8781176033468a0c_docName=CommCareOverview&javax.portlet.prp_2fdfb140904d489c8781176033468a0c_folderPath=/About%20Us/CommonwealthCare/&javax.portlet.begCacheTok=com.vignette.cachetoken&javax.portlet.endCacheTok=com.vignette.cachetoken
It looks like a special plan just for people with low incomes, and it doesn't look like it's an insurance provider itself.
Yoink - Please. Democrats in tough/marginal districts need help from the national party more than anyone else does. Without assistance and $$$ from the national party, many of these Blue Dog Dems won't survive their next election. So that gives the White House more leverage over them than they have over the rest of the Congress.
As for your second point, there's no indication that we're about to get a bill that will be "one of the greatest victories for the left in this country in decades," or even anything other than a massive boondoggle for the private, for-profit insurance industry. The sad fact is that if we somehow get meaningful, substantive health care reform, it'll be in spite of Obama's efforts, not because of them. From the beginning, Obama (along with much of the Democratic leadership) made it clear that his number one priority in health care reform was to protect the profits of the bloated insurance industry that got us into this mess in the first place. He went out of his way to embrace and include the insurance industry, and exclude progressive voices, in those White House "panels" he did, and to praise and refuse to criticize those who were clearly opposed to real reform, on the right and in the health insurance industry. He took single payer off the table at the outset, even as an initial bargaining stance from which he could have negotiated down, and all along he has indicated that the public option is also negotiable. He cut deals with insurers and big pharma, and he has made sure to kiss the asses of conservatives every step of the way.
Whether Obama is a corporatist sellout, or just phenomenally inept, it's still not clear if we're going to get meaningful health care reform, and he's a big part of the reason why.
We already have a “public option” operating. It’s called “Medicare”, and it’s crammed full of the worst risks in the entire health-care system—the elderly and the disabled.
To try and drum up fear based on the assumption that a public option couldn’t possibly pay for itself is not engaging in honest debate.
@Caroline
Yes, I do really believe it has reached that point. The only way to be more sure is to see it completely fail to pass and have to start over. At that point, you've lost all your ability to compromise. A compromise only works if the opposition thinks it may not be able to defeat you. If they've shown they can defeat you, what's in it for them?
So you get a mandatory public option defeated, you get Obama blowing so much political capital he neither has the ability to get any kind of healthcare reform pushed through, much less many of his other goals. You get Republican with a huge win and rallying point going into the congressional elections. In other words, you are gambling with some incredibly high stakes.
Yoink,
The problem has nothing to do with locations, it has to do with even distribution across populations stratified not by location but by health status.
If everyone int he4 risk pool has a very high risk of health problems, the costs will be high, no matter how large N is. You have to get healthy people int he same pool as the sick, not a whole lot of sick people spread across state lines.
Man healthy people-say, a 20 year old with a fairly clean family history-that guy's not going to go out to sign up for the Public Option. Now, a 45 year old with a family history of diabetes, cancer or lupus is definitely going to seek out the Public Option. If everyone in the pool is a 45 year old with a family medical history that bad, what do you think the average risk per participant in the plan will be?
Cost is a function of risk. Unless you have a pool that includes healthy 20 year olds, the average risk per person-ergo, the average cost per person-is going to be large. And it does not matter if your high risk participants live in a Blue state or a Red one.
yoink: "I notice that you don't mention what credible threat the White House can make against the Blue Dogs to force them to vote the way they'd like them to."
Are you kidding? The only reason the house bluedogs win in tight races is because they have DNC and DCCC backing. If Obama wanted to hold their feet to the fire, he easily could by threatening to cut off their DNC money for 2010.
Anyways, the Blue Dogs look like they will fall in line regardless, so it is a moot point.
I'm personally all for opt-out. (Even though I'm so far left that I'd happily replace 3-6 Blue Dog/Lieberdem senators with Republicans, just to get the cancer out of the party).
But my one comment is, let's not have progressives at each other's throats about this. Say I think it's a worthwhile compromise, and you don't. I'm not being railroaded into this, I have my eyes open; and you're not hurting me any by pushing for more. We're really on the same side, and sure, we can have a reasoned argument to try to convince each other, but we should be sure to remember that in the next fight, we'll have each other's backs. (And, as you can see from my comment about Blue Dogs above, I'm not always a "just agree to disagree" person - it's case-by-case.)
Statler N Waldorf,
I am a reasonably healthy 25-year old, and I intend to go into the public plan if I am able.
Statler…
I disagree with your assumption that healthy people will automatically buy insurance from private companies. The benefits of a public option are these—
1. Vast reduction in overhead and waste, which leads to lower premiums, thus attracting buyers across the spectrum.
2. Elimination of the need to make a profit, which leads to lower premiums, thus attracting buyers across the spectrum.
3. No need for obscene executive salaries, which leads to lower premiums, thus attracting buyers across the spectrum.
4. Elimination of private insurer red tape which denies/delays/rejects medical treatment and leads to even worse medical situations.
All of these would appeal to every single person who would be buying insurance. To say that healthy people would flock to private insurers and shun the public option flies in the face of common sense. Everybody wants to save money and at the same time give themselves the best alternatives when it comes to medical care.
Opt-out is democracy. In the long run, it could very well end up saving lives - if a (large) state or states decide to opt out for a better state-run public option. Say, it's 2019, and President Beck has gutted the PO, and California opts out to go single payer...
So please. Of course you have a perfect right to support or not any politician you want. But on this particular aspect, please don't try to browbeat us with "[red state uninsured] PEOPLE WILL DIE". Those people have votes, a majority of those people have voted Republican, and could in the future vote for another party if it would save their lives. And if they don't, it's their choice.
Burt writes:
Yoink - Please. Democrats in tough/marginal districts need help from the national party more than anyone else does. Without assistance and $$$ from the national party, many of these Blue Dog Dems won't survive their next election. So that gives the White House more leverage over them than they have over the rest of the Congress.
I didn't say that they couldn't ensure that the Blue Dogs don't get reelected. I said that if they did so, the probable outcome is a Republican victory.
I also notice you're still not saying what threat you think Obama could use to whip the Blue Dogs into line. All this empty talk about him just "being tough" is nothing but talk. Tell me what, specifically, he would say to them to make them fall into line on, say, single-payer healthcare.
Which brings me to your truly bizarre point:
The sad fact is that if we somehow get meaningful, substantive health care reform, it'll be in spite of Obama's efforts, not because of them.
WTF? Seriously: What. The. Fudge? Democrats have been trying to bring about some sort of meaningful healthcare reform for decades and, with the exception of Medicare, their failures have been spectacular and repeated. There have been larger democratic majorities in both houses in the past, and still nothing could get done. Now it's looking all but certain that we'll get a plan that covers the vast majority of the uninsured, and makes the insurance carried by those who are currently covered much more secure: and you're suggesting that the President has played no part in making this happen? Oh well, I guess if he vetos the bill when it gets to his desk, you'll be proven right. Please feel free to hold your breath.
He took single payer off the table at the outset, even as an initial bargaining stance from which he could have negotiated down,
Oh, right. Because the country reacted so warmly and positively to the current proposals. Clearly what Congress needed to do was challenge them with a much, much more radical proposal.
We're you in a coma over summer, by any chance? If Obama had tried to propose a single-payer system, the deal would have been dead at the starting gate. No bills would ever have made it out of committee, let alone reached the floor.
Yes, Obama has tried to keep Pharma and the AMA and the insurance companies happy. Boy, what a craven sell-out he is, eh? After all, there's no way that Pharma, the AMA and the insurance companies could possibly band together to kill a health reform bill, is there? (Paging Bill and Hillary Clinton; would Bill or Hillary Clinton please pick up the white courtesy phone?)
Go read up on the various models of universal healthcare around the world. "Single payer" is one model among many; it has its advantages and its disadvantages, but it's by no means self-evidently the best. Look at Switzerland if you want to see a system similar to what the Democrats are working towards here. The WHO rates the Swiss model very, very highly (it is incomparably better than the current US system, and better than either the Canadian or the UK systems). There's no "single payer" and no "public option" either, come to that. Everyone is required to purchase insurance from private insurers, and subsidies are available for those who can't afford to. Crazy, I know.
Lets assume the Public Option ultimately does NOT work. More and more states could then opt-out...until the whole thing dies. Thus nixing the entire process if it proves to be so unwise (as many state). The last thing anyone should want, is a government program that blatantly does NOT work...yet is so embedded into the system it cannot be extracted.
On the flip side, if the Public Option is SOOOOO bad, shouldn't moderate Republicans embrace the opt-out clause? If a state's constituents want it gone in their backyard...POOF!! Gone.
This is a key compromise that both sides of the Democratic Caucus 'should' be able to live with. And, if it DOES ultimately drive down premiums...forces Senators and Representatives of opt-out states to listen to a DIFFERENT type of angry phone calls from their voters.
It even appeases the 'States Rights' crowd (to an extent). =^)
shma writes:
Are you kidding? The only reason the house bluedogs win in tight races is because they have DNC and DCCC backing. If Obama wanted to hold their feet to the fire, he easily could by threatening to cut off their DNC money for 2010.
And, once again, the point is not that the Dems couldn't get the Blue Dogs out, it's that they'd still rather have the Blue Dogs than have Republicans in those seats. Healthcare is an important issue; it isn't the only issue, however.
And yes, the Blue Dogs are coming around. Everyone seems to be coming around. Boy, that Obama has really screwed everything up, hasn't he?
@homunq
Perfectly well said.
The opt-out option sounds like a great compromise. It gets the damn thing passed, it gets the public option available for most people, it creates a big win (as opposed to a big loss) for the President and the Dems, and it creates a good platform on which to build.
It calls the Repub's bluff on so many levels. It energizes the left-wing grass roots for many election cycles to come. It's not only better than nothing, it's damn good.
If this is what it takes, then let's do this.
If we can get more, fine. But the perfect should not be the enemy of the good. Grab what we can get, give the country maybe 80% of what it needs here, and then come back and improve when and how we can.
It is brilliant.
Statler N Waldorf writes:
Man healthy people-say, a 20 year old with a fairly clean family history-that guy's not going to go out to sign up for the Public Option. Now, a 45 year old with a family history of diabetes, cancer or lupus is definitely going to seek out the Public Option. If everyone in the pool is a 45 year old with a family medical history that bad, what do you think the average risk per participant in the plan will be?
Why will only unhealthy people choose to go for the Public Option? I don't see how your first premise is supported. There has been no suggestion that the plans offered under the Public Option will be markedly more "bare bones" coverage than any other plans on the market. In fact, all the plans in the "Insurance Exchange" (including the Public Option) have to meet certain minimum coverage standards.
Not only that, but none of the insurance options in the "insurance exchange" are allowed to turn away any applicants. So if the private plans are all offering better coverage for competitive rates, nobody will choose the Public Option at all. The Public Option will have "worked," in that case, by scaring the private insurers into upping their game. On the other hand, if the public option is cheaper than the private options but a little more limited in coverage, then it is obviously going to be the first choice amongst the healthy--those who would choose to buy no insurance at all if it were not for the mandate.
In other words, there really is no possible scenario in which the situation you fear could reasonably be expected to eventuate.
Also, there’s some mythology floating around about using the reconciliation process to force a reform bill through the Senate.
The process can be used to pass a bill in the Senate, however in order for that bill to get to the floor for a vote it has to run the gantlet of those who will challenge every single aspect of it. These challenges cannot be rammed through using reconciliation—each and every one would be subject to the same old foot-dragging filibustering that the whole bill would be subjected to.
This was all eloquently explained by Jay Rockfeller on Charlie Rose about two weeks ago.
"And, once again, the point is not that the Dems couldn't get the Blue Dogs out, it's that they'd still rather have the Blue Dogs than have Republicans in those seats."
Actually that is the entire point. That's how Obama can pressure them to vote with him. He could lose half the Blue Dog caucus and still have a majority in the House. He doesn't need all of them.
"Boy, that Obama has really screwed everything up, hasn't he?"
What are you talking about? I never said Obama screwed everything up. I didn't even criticize him.
(Paging Bill and Hillary Clinton; would Bill or Hillary Clinton please pick up the white courtesy phone?)
HA! Good one.
Nice conversation today. Delightful lack of trolls.
Statler makes an interesting point. Wonder what the demographics of those 47 million uninsureds are and how that would affect the cost?
shma writes:
Actually that is the entire point. That's how Obama can pressure them to vote with him. He could lose half the Blue Dog caucus and still have a majority in the House. He doesn't need all of them.
Ah, brilliant strategy! Run people who sometimes don't vote with you out of the house and replace them with people who never vote with you. If only Obama was being advised by a shrewd political operator like you--we'd be living in a social-democratic paradise in no time.
Re: public option demographics
I could make predictions on who would pick which plans, but they are generally predicated on what I know now. Having used private insurance for a number of years, I've learned all sorts of things that aren't obvious up front.
A 24 year old is not going to be using the same thought process, so I hesitate to claim I know what they will pick. Who knows, maybe they'll all pick the private insurance plan with the $100 co-pay. And, even more shocking, maybe that's what they should choose.
yoink:
Are you just playing dumb here for effect? The point is to pressure them. When faced with voting with the administration or a guaranteed 2010 loss, you think they are going to nobly fall on their swords and give up their seats?
In one way, an opt-out plan will present hurdles for the GOOPers:
The GOOPers are constantly parroting the line that individuals need to be able to make a choice. If a public option is available, they already CAN make a choice - either take the public option, or choose from the other insurance plan (or plans) available.
If the state opts-out, though, the individual has a choice taken away from them - the choice of whether or not to buy a public option insurance plan.
As to whether a business does or does not support a public option plan, many businesses provide a health plan to employees, most paying from some to all the costs. If the company doesn't pay all the costs, they pay a certain % of the costs (25%, 50%, etc.). If they can get a cheaper plan, thus pay a lower total for the insurance (even though they still pay that same % as before), they should welcome another option, especially if that option shows promise of being cheaper. And, as current, no employee will be forced to buy into the company plan.
Many married couples work for two different employers. For some, it might be cheaper for each to buy the individual plan from the respective employer (especially if there are no children to be covered). For some, it might be cheaper to buy the family plan from one employer or the other, depending on which plan is cheaper and/or offers more of the benefits and services expected. For some, the married couple might buy individual plans, then convert to a family plan as they have children, then (when the children leave the home) convert back to individual plans, and finally convert to a family plan again at retirement (especially if the family plan is the only way to carry such health plans into retirement and to cover a survivor who otherwise wouldn't be eligible for that health insurance otherwise).
Mike in Maryland
@shma:
By George, you're right; the HuffPo article does countenance a Gubernatorial option. That's awfully weird...surely they wouldn't really write it that way, right? Seems like that would be really volatile, with states flipping back and forth a lot. Not to mention rather undemocratic.
Anyway, sorry for contradicting you when you were right in line with TFA. My bad.
Athena.
Be careful about the ecological fallacy. One individual does not represent the whole population.
Yoink,
The reason why many healthy people will not select the Public Option is the same reason why many healthy 20 year olds do not get insurance. If your risk of becoming ill is remote, and you do not face a high probability of occupational injury, and especially if you are economically disadvantaged (as many young people are), a simple cost-benefit analysis reveals that the money spent on health insurance would appear to be better spent elsewhere-say, on food or rent, especially if you live hand-to-mouth (as many minimum wage jobholders do).
As for the insurance exchange, the insurance companies most assuredly will not turn away healthy people who are at low-risk for hospitalization. To the insurer, such a person that seeks insurance is a gold mine- they pay steadily into the system without ever taking anything out of it.
However, this does not mean the insurers are offering better services/rates. If, say, your deductible is enormous, as are your copays, and the insurer fully intends to deny coverage of anything and everything - someone who buys such a plan looking for low premiums may think initially they are getting a great deal. However, the very minute they have need of that plan-say, they get hit by a car-they're fucked. The young budget-strapped person will not see that coming though, especially if the only thing they're paying attention to is the premium. This is often the case in situations where people are compelled to buy insurance, like at many Universities or in the Commonwealth of Massachusetts.
A Public Plan that required universal participation-say, something where every citizen is enrolled at birth or upon naturalization, and the only proof of insurance they need provide is proof of citizenship-this sort of plan brings such a large pool of health and unhealthy together that the average risk per person is nominal at best-and therefore, the costs needed to maintain the system are equally low. Therefore, the cost per citizen taken out in tax will be minimal compared to the premiums you would have to pay in a system where almost everyone in it is at high risk for illness or injury.
Listen, I realize there is stiff opposition to Universal Single Payer among conservatives. I also understand fully that President Obama wants to get something with at least the word 'reform' in the title, if nothing else to avoid looking like someone who can't get anything done, even with supermajorities in both houses. I have sympathy for him on that, and believe me, I do want him to succeed as a President.
However, I also want to make sure that what passes is more than just reform in name only. What I find particularly troubling is the possibility of the Reform bill that passes causing more harm than good in the long run. If this is so, whatever temporary political gains you make will evaporate once the program is shown to not work. If the Healthcare Reform Bill becomes law and then fails to contain costs, the conservatives will make hay out of it. They'll use it as the ultimate "see? we told you so".
Temporary gain in return for long term political agony is not worth it. Produce a bill that works, and you,ll be remembered for the next hundred years as the greatest President of the 21st Century. Produce something that falls apart within a few years, and you'll be a one-term nobody.
Davy writes:
Statler makes an interesting point. Wonder what the demographics of those 47 million uninsureds are and how that would affect the cost?
A large number of them are the young and healthy who figure they can risk going without insurance. If they all go for the Public Option they'll actually help drive Public Option premiums down rather than up.
Of course, a lot of them are also those who have been kicked off private insurance because the private insurers consider them too risky. But what Statler N Waldorf fails to consider is that the private insurers in the Insurance Exchange can't pick and choose their customers anymore. There's no reason for those people to flock to the Public Option; they have their pick of both Public Option and private insurers.
Indeed, if for some reason all the high-risk people went for the Public Option it would be required to raise its premiums commensurately--because it is required to cover its operating costs by its premiums. If it became the most expensive option no one would choose it (unless it was offering substantially better coverage for the money), so it would have essentially no effect on the market.
I think this is a smashing good idea -- it covers many people who need it, those that aren't covered can move, the states that don't want the public option are protected from having that choice. Perfect.
My question is: In the trillions of words that have been written about the health care debate over the last six months, why has it taken so long to get here? Such a succinct, simple, powerful idea -- what has taken so long?
wv: cohede -- what the Dems have to do!
shma writes:
Are you just playing dumb here for effect? The point is to pressure them. When faced with voting with the administration or a guaranteed 2010 loss, you think they are going to nobly fall on their swords and give up their seats?
For the last time: the reason that the Blue Dogs would laugh at any such threat is that they know it's B.S. Of course if they thought that the threat was real they would be motivated by it. But they would know perfectly well that come the election the Dems are not going cut their noses off to spite their faces. They aren't going to sacrifice unreliable votes for reliably hostile votes--and neither should they.
Yoink,
The last few sentences are exactly the problem. If the Public Option becomes a dustbin for everyone the insurance companies won,t cover because their risk profiles are too high, the PO will become hugely expensive. This will, as you say, have no effect on the market.
The whole point is to have an effect on the market. A Public Option which fails to do so is a disaster.
Statler,
You make a compelling point, but remember that the plan will have an individual mandate (young healthy people have to get insurance from somewhere), and that it would create a national standard for coverage. Additionally, most PO plans floated have different types of available plans, so there would be a more bare-bones option. Ultimately, some sort of public plan could end up being cheaper for those who seek minimal coverage. Not saying that will necessarily happen, but over time the public plans of all levels will probably become cheaper than bare-bones private plans.
@Hunter: Hey, no problem. I agree that it's very unlikely the governor will be given that power.
Statler N Waldorf: "If your risk of becoming ill is remote, and you do not face a high probability of occupational injury, and especially if you are economically disadvantaged, a simple cost-benefit analysis reveals that the money spent on health insurance would appear to be better spent elsewhere."
True, but other than single payer is there any option that these people would be satisfied with that still leaves them covered?
Statler N Waldorf: you haven't read a single word of the proposed legislation in any form, have you? Not a single one of the scenarios you describe is possible under the legislation as it currently stands--in any of the house or senate versions.
A) there's a mandate: that means healthy young people cannot choose not to buy insurance; they are required to do so by law and will pay a fine if they do not comply.
B) insurers can't offer the kind of bogus low-premium/low-coverage plans you describe. In order to participate in the Insurance Exchange all plans must meet certain minimum standards. Nor can insurers kick you off the plan after you get ill.
Please--just educate yourself a little about what is actually proposed here before you start pissing and moaning about what a disaster it is.
It's of course also necessary to bar private insureres from denying high risk enrollees. The mandate, the public option, and the elimination of enrollment denials only work if we get all of them.
shma,
I am, sadly, known for my prolix. It is not often I can post a one word response to a question, although here I can.
No.
Burt said...
Josh - It's funny that you bring up Creigh Deeds. He's a perfect example of what's wrong with the Democratic party today. He's a milquetoast, center-right politician who made trying to appeal to conservatives (especially in the western part of the state) a centerpiece of his campaign. Well, guess what? Those voters are sticking with McDonnell. And since a milquetoast, center-right politician isn't going to inspire anyone else, Deeds is going to lose, and lose big.
So, 'Burt', let's see if I have this correct:
A political party sees that the independents aren't going to vote for them, so they move a little bit away from the political center. They put out a lot of good-sounding PR, but don't actually practice that PR. They win for a few years (or even a few decades), but suddenly people start to see through all the PR for what the party actually is and does, and then realizes they've been hoodwinked.
Guess what? What you are advocating is EXACTLY what the GOOPers did during the 1960s through current - marginalize the most moderate, then when they stop voting for you, marginalize the next most moderate, then when they stop voting for you, marginalize the next most moderate, then when they stop voting for you, marginalize the next most moderate, then when they stop voting for you, marginalize the next most moderate, then when they stop voting for you, marginalize the next most moderate, then when they stop voting for you, marginalize the next most moderate, then when they stop voting for you, marginalize the next most moderate, then when they stop voting for you, marginalize the next most moderate . . . .
And in the end it is the people furthest from the political center (on 'your' end of the political spectrum) that are the only adherents to the party.
Want to destroy the Democratic Party by following the GOOPer example? To me, it sounds like that is what you are advocating.
Mike in Maryland
Yoink, you're starting to drift off into an ad hominem attack. Refocus on the topic, not me personally.
Now, to answer your statement.
The problem is where the young people will be pooled. If they are pooled in a private insurance plan rather than the Public Option, the risk distribution within the PO will not benefit from their presence in other plans. roughly, what you have suggested is the equivalent of saying,
"It does not matter if you donate to me or my political opponent, just so long as you donate to somebody".
Which is quite false. You surely would not benefit if I were to donate to your political opponent.
The risk per participant in the Public Option does not decrease when people of low risk sign up for non-Public Option plans.
Statler N Waldorf writes:
The last few sentences are exactly the problem. If the Public Option becomes a dustbin for everyone the insurance companies won,t cover because their risk profiles are too high, the PO will become hugely expensive. This will, as you say, have no effect on the market.
And, for the umpteenth time, it is NOT POSSIBLE for the private insurance companies to screen out the high risk patients. If they wish to participate in the Insurance Exchange they have to agree to accept all applicants. That's the whole point of the trade off on the universal mandate.
There is simply no mechanism by which the Public Option can become a "dumping ground" for high-risk people. If those people are buying their insurance through the Insurance Exchange then they will buy the best deal available to them. If the Public Option premiums are high, they will choose the private company plans.
Yoink,
again, watch your tone of voice. If the best you can do is insult your opponent, you have no argument worth debating.
Now, back to your statement. The insurance exchange is a segmented market. An individual segment-one of the insurance plans - would see a reduction of pooled risk within that particular risk pool. However, another segment external to that particular pool of risk sees no benefit from that whatever. Imagine we have a series of cups, each filling up with water. Now, if the goal is to prevent one-the Public Cup- from spilling over and making a mess, why would you drill a hole in one of the other cups? How would that benefit the Public Plan?
It wouldn't. Sure, the cup where the holes are dilled would benefit greatly-the risk of spilling over in one of those is decreased by having low-risk clients in it. but the Public Plan would not so benefit, nor would all the non-PO plans benefit-just the ones where the holes are drilled.
Now, if I want to attract young people to my plan, I will offer low-premiums-and an astoundingly high copay and deductible. The ONLY people who will sign on to such a plan have low risk profiles. it would be suicide for a high risk person to do so.
Therefore, the high risk people are left to go to the Public Option. It becomes de facto a dustbin for everyone the insurers want to dissuade through high deductibles and copays.
There's nothing in the HP article you link to saying that this would be the Medicare-rate negotiating form of the public option.
My bet is that this IS Schumer's "level playing field proposal" but further compromised to say that states can opt out.
Remember: the Senate HELP bill doesn't have a "robust" public option. It has Schumer's compromise.
I agree this is the best compromise approach compared to triggers, state-based plans and co-ops. But I doubt the Senate will pass any form of a Medicare-negotiating public option.
Statler N Waldorf writes:
The risk per participant in the Public Option does not decrease when people of low risk sign up for non-Public Option plans.
What you keep ignoring is the way the Insurance Exchange functions. Please explain to me why the young and healthy will preferentially opt for the private plans over the public plan? Remember, ALL the plans in the Insurance Exchange are required to meet certain minimum standards of coverage; so the private plans cannot offer "low premium/low coverage" options through the Insurance Exchange in order to skim off the young and healthy and provide them with de jure "coverage."
In fact, the most likely scenario is that the public plan will start off being slightly cheaper than the private plans (it's only covering operating costs, after all, and not trying to return a profit). If so, the young and healthy will naturally gravitate towards the Public plan--being most interested in keeping their premiums low rather than in the details of coverage. That, in turn, will allow the public plan to offer even more competitive rates, which will bring more people over to the public plan. That, of course, will force the private plans to become more competitive at the same time as it diversifies the risk pool in the public plan and raises costs (and premiums there). Eventually you move towards an equilibrium: and who knows what that would be.
What it can't be, however, is a case where every high-risk person is in the public plan and everyone else is in the private plans. That's simply not possible because of the way the Insurance Exchange and the public plan are structured.
Statler N Waldorf writes:
Now, if I want to attract young people to my plan, I will offer low-premiums-and an astoundingly high copay and deductible.
And, once again--just for luck--the rules of the Insurance Exchange DO NOT ALLOW THIS. All the plans have to meet certain minimum standards. The Exchange is not simply an open market.
Seriously, is this so difficult to comprehend? If I'm an insurer with the "cunning plan" of siphoning off all the young and healthy with essentially meaningless insurance I will not be granted access to the Insurance Exchange in order to sell that insurance.
I have to agree with yoink.
It is a mystery to me how the functioning of a public option can be so misunderstood. A public option will do everything private insurers do, under new rules which say no cancellations and no denial of coverage for pre-existing conditions, etc. But the public option will do this without the bloated costs associated with the private insurers, that come from bureaucratic waste, the profit motive and astronomical salaries for middle managers on up. This will all result in the public option costing less than private insurance. Period.
Now anyone can simply say over and over that the public option will be rejected by healthy young people, but without providing reasons why this would be so the assertion is just empty rhetoric.
The vast majority of people will buy that which delivers the goods (as spelled out by reforms mandated by upcoming law) for the least amount of money. A public option, even if run as sloppily as most private insurance companies, will still be the cheapest way to go.
I will gladly explain why a young healthy person would opt for a private insurance plan over the public option.
The cost of any of the plans in the exchange-all of them, really-are dictated by the pool of risk represented by each individual plan's membership. No insurer can contain costs with a pool that is exclusively high-risk. Therefore, the most profitable plans will attempt to attract people whose risk for hospitalization or medical services is low. We all know that young people, generally, are cash-strapped, especially those who have not attended college. hHowever, they bare unlikely to use services and therefore encounter copays or deductibles. So, you offer a plan with a low premiums and high copays and deductibles if you want to attract a young, healthy demographic.
That pools all the low risk cases into these private plans. The PO likely will attract those who are at high risk, as it will not offer high copays or deductibles. Guess what that does to the premium you have to charge if you want to sustain the program? It raises them, that's what. This effectively locks out people on low-incomes such as younger minimum wage earners who cannot afford the premium.
Now, instead of using loaded words like "why do you keep ignoring", why don,t you tackle the above argument and show me where the flaws in my logic are? If you're only going to attack me, then I will not continue to debate this matter (or any other) with you. Please refocus on the ARGUMENT.
Statler,
Bottom line is: There is no reason to believe that anyone--young, old, sick, healthy--will find a plan on the private market that is cheaper than the public plan so long as we have:
a)A public option
b)An individual mandate
c)A minimum standard for all insurance with no denial of coverage
And I want you to show me exactly where in the bill it says that copays and premiums are fixed to a specific number. I believe that you made this up, and I want to see if it is in fact true before I put my foot in my mouth by accusing you of lying before I know for sure.
I don't think that usual behavioral economics applies when you're talking about state officials who are also political candidates. There will be no opt-out inertia.
A simple fable.
Health reform legislation passes that includes a public option.
Joe is comfortably self-employed and is faced with buying insurance. He can buy from:
1. A private insurer
2. The public option
He thinks that the bare minimum plan is best for him, but the nice thing about reform is that in terms of minimum coverage he doesn’t have to shop around for features, only price.
He goes to private insurers and gets quotes of $700 to $1200 per month. He checks the cost of the public option—$350.
Now, if Joe is a moron, he will subscribe to a private plan. This means he pays more, and that he will be subjected to the meddling of insurance company bureaucrats every time his doctor orders some procedure that is considered necessary. Joe will eventually get his procedure done, but there will be delays involved and mountains of paperwork and he will be sent to a facility that nobody would go to otherwise.
But suppose that Joe is not a moron. He buys coverage through the public option, and if it operates like Medicare, when his doctor prescribes some medicine or procedure or even hospitalization there is no bureaucrat to interfere.
End of story.
Jacob, SnW, yoink: Statler is right about one thing. If young people decide they don't need insurance, then it makes more financial sense in their mind to pay the 950 dollar fine than it does to buy into any exchange plan, public or not. I don't agree that these people necessarily make up a huge fraction of the healthy uninsured (at least not without some evidence to back it up), but even so it's not ideal. I would have liked to give the PO to everyone, employed or unemployed. That way, this issue would be moot.
yoink:"For the last time: the reason that the Blue Dogs would laugh at any such threat is that they know it's B.S. Of course if they thought that the threat was real they would be motivated by it."
Actually, that's the first time you've admitted this, but whatever. If your worry is that Blue Dogs will start a game of chicken, all Obama has to do is follow through with a few of them. The losses would be inconsequential to the House and the rest of the Blue Dog Caucus would get the message. It would be a net gain, even, if the rest of the Blue Dogs fell in line. That's one of the advantage of a 40 seat majority. And there's no reason the Democrats can't move the DNC funds to other competitive races. They could come through on their threat and maybe still keep the same sized majority.
Pragmatus
Yes, that is overly simplistic and quite the fable.
Pragmatus:
As always, the devil is in the details. It all depends on what the minimums are. As with Statler, I want to see someone point to where in the bill it fixes the price of doctor visit, hospital visit, surgery and Rx copays. And not just that there will be a fixed price, but that the price will be fixed fairly low.
Because otherwise, there's a lot of difference between the applicant pool and pricing structure for a bare minimum plan with a $10 doctor visit copay and one with a $75 dollar one, or one with a $15 Rx copay and one with a $50 one.
Beginning of story.
Statler…
The cheapest, highest deductible, highest copay plans of private insurers now are very expensive, a minimum of $700 a month.
Please outline the logic whereby once these insurers are mandated to cover all comers, not cancel coverage, not restrict based on pre-existing conditions, that these premium rates are going to go down.
You are making assumptions based on impossibilities. Private health insurance will never be cheaper than any public option.
Another thing to consider about choosing insurance plans:
Cost is NOT the only factor. I'm very fortunate that, as a Federal government retiree, I have several plans that I can choose (on a yearly basis). I have chosen a plan that is not the cheapest (although it is near the cheapest) on the basis of being able to go to ophthalmologists at Johns Hopkins Hospital.
Every year, I review all the plans, and immediately rule out those plans that do not allow me to go to the doctors at JHH. I might be able to save $10 or $20 per month with a different plan, but that extra $10 or $20 per month is well worth it to me.
Why do I want to see the doctors at JHH? Because they can perform their services in some of the most advanced manner. Other hospitals might be able to perform the same services, but with technology, or following procedures that are 10 years (or more) out of date, especially surgical procedures that I might need.
And this same situation might develop with a public option - it might be cheaper for me to buy public option, but if I can't see the doctors I need or want to see at JHH, I might skip the public option, even if the public option saves me $20 or $30 per month.
Cost is an important factor to consider, but it is not the only factor.
Just like buying a house - let's say I could save $30,000 on a house 15 miles further from work, but how much more time will I spend commuting each day? How much more expense will I have commuting? HOW will I commute (Can I car pool? Does that mean the family needs to buy an additional vehicle? Can I use public transportation if needed or as a viable alternative? etc.) How much of my family and their growing up will I miss because of the longer commute, and is it worth it? How close are needed services, such as grocery store, drug store, medical services, police, fire department, entertainment options (and at what cost), etc.?
Some will choose to move further out for the immediate savings, without considering the other factors. Some will choose to move further out, as the other factors aren't important to them. Some will choose to pay a higher initial price, because the other factors are more important.
Mike in Maryland
shma,
Graphical depiction of US population by age in the United States, year 2000. Source: US census Bureau
Now, the above graphic is 9 years old, because that's when the last census was counted. You'll have to add 9 to each of the age brackets to see an estimate of the current picture, at least until the 2010 Census is completed.
As you can see, the largest current age group is about to retire. There is then a drop in the overall population (Generation X)and then the next largest bump occurs with Generation Y/The Millenials.
As the soon-to-be-retired are about to enter Medicare, the largest concentration of the US population by age other than they are persons who at the current age are either 1) minimum wage earners or 2) still paying off student loans.
Why is Chris Matthews on a personal mission to kill the public option? His spends all of his time worrying about possible political implications. He cares nothing about the policy implications. This guy is the ultimate insider with his DC blinders on.
Of all the so-called compromises on the issue of a public option(the public option is already a huge compromise for a single-payer system), this opt-out idea seems to be the best. It all depends on how it is set up and paid for. The posts raise a number of good questions that need to be answered. For me, the public option must be a federally operated insurance program, available nationally. As such, it should be funded by federal $$. I am not sure what the fairest way would be for states that opt-out.
Pan…
Most doctors favor a public option. Why? Because they are getting screwed by the rules and regulations and paperwork and contract reimbursement rates (not to mention unrelenting pressure to trim treatment costs) set by insurance companies.
Doctors fees in general, the fee-for-service question, and escalating overall costs are an entirely separate issue from whether or not there is a public option to compete with private insurers.
Let’s say that your car has a flat tire and also a big rip in the front seat. Saying “But what are you going to do about that huge rip in the front seat!?” is not a proper argument against getting the tire fixed.
Columbia…
Let’s see—Chris Matthews is opposed to the public option because he works for Fox News?
Pan,
Insurance companies themselves do not set the price of an office visit. Neither would the Public Option. What we are debating here are the things that insurers can control-copays, premiums and deductibles.
However, if we were to move to a purely socialized system like the British NHS, it would be possible to set costs on prescriptions, doctor's visits, etc. Personally, I would be quite happy with such a system, although I kind of prefer a hybrid where private providers could still operate alongside an NHS-like system, which is the model currently employed in France. The reason why i say this is simple. Philosophically I believe a government plan is better than any private plan you could ever come up with. However, the reality si that the dual system France employs works better than the British NHS. In terms of life expectancy, infant mortality, DALYs lost and disease prevalence, France is ranked number one in the world by the World Health Organization, whereas the British are #14.In comparison, the US currently sits at # 32, and Canada is at #6.
And its awfully hard for me to argue with statistics like that. The British NHS would be a vast improvement over where we are now-and Canada's even better-however, the leader of the pack is clearly the French, and I believe we should do what works over what I personally have romantic inclinations toward as far as models go.
So, if a dual system is better than a purely socialized model-as it appears to be-I'm willing to swallow my pride and concede to such a model on the basis that improving the quality of life for all Americans is better than promoting an ideology.
Statler…
I’m afraid you are incorrect. Any doctor who contracts through an HMO with an insurance company has his reimbursement detailed to the cent by the insurance company. It’s called capitation.
Only if your doctor is part of an HMO or a co-op. That leaves out private providers
SnW: Actually it looks like the largest current age group is in the 45-55 year range, still 10-20 years from retirement. And I'm not sure how many workers in the 20-30 age group are minimum wage workers.
All this census data really shows is that there are more 15-30 year olds than 30-45 year olds.
BUT, I have gone searching and found more information:
http://tinyurl.com/ygje95g
They represent about 30% of the total uninsured. So you are partially correct. On the other hand, 20% of the uninsured are minors who will be covered by their parents' plans and will grow up to form a healthy base of the PO insurance pool.
Pragmatus - wrong network. Matthews is with MSNBC. He has this show called Hardball.
Lawrence O'Donnell is another cynic who claims he knows how it will all play out because he was an aide to the finance committee 15 years ago.
shma,
Impressive bit of detective work there. The 25-55 year olds are about ten years away from retirement, at which time they will move over into Medicare. While that leaves us with a decade of them occupying the total pool of risk, they would contribute to the pooled risk of a universal single payer plan for only a decade or two, at which time the younger population will become the largest part of the risk pool.
Now, with the Insurance Exchange, so long as they are on their parents' plans they are obviously not on the Public option anddo not bring down the average risk per participant in that plan. Once they age out of that, they are likely to go hunting for the lowest premium they can get, at least until the student loans are paid off. That brings us back to their not being in the Public Option, which is where we would want them if we were to contain costs.
Statistically speaking, universal single payer is the only real way to handle Adverse Selection. However, thsi does not mean there would be no other insurers. Much as everyone contributes to the police force in their local area via taxes and yet is still free to hire a security guard or a bodyguard or whatever if they so choose, so too would individuals who want and can afford private insurance also be allowed to buy into such a plan while simultaneously participating in a universal single payer plan. The problem with opt-out is that it removes individuals entirely from the risk pool who choose to opt out-and the individuals with the greatest incentive to opt out are those with the lowest risk profiles. As stated before, this has the effect of increasing the overall risk for the remaining participants, and therefore, increasing their cost.
The only thing I can see of preventing that is simply not to have an opt-out. The central problem at hand is that costs are contained by the very fact of having a large pool containing more low-risk people than high-risk people. That, by definition, requires universal participation in a single pool.
Sorry, I'd meant to say '45-55' not '25-55'
I really should get a copy-editor sometime.
Columbia…
Wasn’t Matthews with Fox? I remember a blistering, in-your-face interview he did with Bill Clinton a few years back and was under the impression that Matthews worked for Fox. If not I stand corrected. At any rate, he has long been very conservative about a lot of things.
Statler…
Any doctor who is reimbursed by an insurance company is paid according to a contract amount, so the insurers do set the rates to the cent. If he works for an HMO, it’s via capitation, if not he is still paid a contract amount. He is never free to charge what he wants.
We all need copy editors.
Prag,
Bring it back to Adverse Selection, because unless you contain premiums, copays and deductibles, there isn't going to be a Public Option in another ten years. Many voices here (including Nate) are advocating for Opt-Out, many voices here champion the Exchange. Almost everyone save myself and maybe shma are looking at USP as an idea. And central to this whole argument is the matter of pooled risk. Its an idea borne out of statistics, a problem every insurer of any kind faces-and it is a kind we as a government will have to face if we are going to offer a public plan of any kind. I understand why some would want to avoid the issue; it makes me very uncomfortable to think about it, as I'm sure it does anyone who wants to see reform take place.
Nonetheless, we must not run away from it, no matter how uncomfortable it makes us. Like everything else in life, ignoring the biggest challenges does not make them go away-they just keep getting bigger and bigger, and harder to contend with.
Much as any gambler has to deal with the odds, we must deal with Adverse Selection. So I ask you to offer some explanation as to what you see as the best way to handle this thorny, nasty problem.
Statler…
Every time someone tried to peg you to proving that all the high-risk folks would end up in the public option, you skirt the issue and start talking about something else.
Let me ask this straightforwardly so you can answer it, quoting from an earlier post—
Let’s suppose health reform legislation passes that includes a public option.
Joe is comfortably self-employed and is faced with buying insurance. He can buy from:
1. A private insurer
2. The public option
He thinks that the bare minimum plan is best for him, but the nice thing about reform is that in terms of minimum coverage he doesn’t have to shop around for features, only price.
He goes to private insurers and gets quotes of $700 to $1200 per month. He checks the cost of the public option—$350.
Now Statler this is the question for you—why would healthy Joe, or sick Joe, or any Joe go to the private insurer when he can get the same bare-bones coverage for half the price?
You have dragged all sorts of arguments into this discussion that have no relevance to that simple question. All of your theorizing about Adverse Selection or escalating costs or insurers reimbursements to doctors have nothing to do with the question, and I will repeat it—why would healthy Joe, or sick Joe, or any Joe go to the private insurer when he can get the same bare-bones coverage for half the price?
If you can present any evidence that private insurance, with all the new mandates imposed on it through reform, will ever be less expensive than any public option, now is the time to put it forward.
Chris Matthews works for MSNBC.
Statler…
Private insurance premiums pay for—
♦ Costs of health care for its members
♦ Massive wasteful overhead, CBO says $300 billion yearly for the entire industry
♦ Profits to shareholders
♦ Exorbitant salaries to insurance company executives
Premiums paid to a public option would pay for—
♦ Costs of health care for its members
♦ A minimum of overhead, if we can extrapolate from Medicare
Thus, even if insurers pared down their waste dramatically, about as likely as me waking up on the Moon tomorrow, their premiums would still be higher than a public option’s because they would still have profits and those ridiculous salaries to pay out.
Your point seems to be that the public option would be unattractive because its premiums would cost more. In light of the above, you are claiming an absurdity.
"Look at Texas, my state. One in four people are not insured in Texas. What do you think Texas is going to do? Opt out of course. Do you think that will bring political change? No. the very people it will benefit are opposed to it. They have bought, hook line and sinker, all the rhetoric their conservative leaders have fed them."
Will the residents of a few states who would benefit from the public option be left out at the beginning? Yes. But as you say, many of them want to be left out. I'm not going to sit around feeling too much sympathy for them, and I'm certainly not going to let that small minority of irrational voters in a few southern states kill the possibility of reform for the rest of the country. And the states that opt out will soon be under significant political pressure to opt back in. This opt out compromise is a fantastic one IMO. Much better than the most likely alternative, which is to pass a watered down public option with no opt out.
Well Prag,
That's not true. I have stated explicitly why the PO would become a pool of high risk participants.
You have three variables to keep track of: premiums, copays, and deductibles. You have two strata of risk: high and low. The lowest risk persons tend to also be the youngest, and the young adults tend also to be the less economically well-off. However, theya re highly prized by insurance companies, because they pay into the system without taking anything out, so if they were mandated to have insurance, they will gravitate toward plans with low premiums and not concern themselves with copays or deductibles, as they have little reason to anticipate needing care.
High risk groups tend to pool where copays and deductibles are low as they do anticipate needing care. Insurers faced with a pool of high risk participants has to bring up the premiums in order to minimize their own loss, indeed, to even profit at all. This is called Adverse Selection.
The increase in premiums locks out the lowest income people, who also have the lowest risk, creating a negative feedback loop.
The PO will be most attractive to those with the highest risk, and therefore will likely evolve into the latter of the two plans described here.
Now, I have repeated this quite a few times, so you are quite wrong when you assert that I am not explaining why young people would avoid the public plan.
Prag,
Now let me add that in both this discussion and the recent GLBT civil rights discussion you have resorted to a series of ad hominem attacks against me and have steadfastly avoided the arguments I have made. If you cannot bring yourself to avoid this behavior, you are going to wind up on my trollList very quickly.
Obviously, the fine for not enrolling would have to exceed the cost of enrolling in the public option (for those who can afford to do so). But Prag's point remains that even with higher deductible plans (which would be more limited), the public option would STILL be cheaper from the beginning. HHS would almost certainly start the cost very low to attract a large enough pool to keep it low.
Statler, please explain why even a healthy young risk-taker would want to enroll in a MORE EXPENSIVE private plan rather than the public option.
Even if for some reason the lowest-tier public plan began at higher than market rates, most of the minimum-wage or loan-burdened people selecting it would be getting subsidies from the government. Couldn't HHS just offer higher subsidies to enroll in the PO?
Statler…
You’re a smart guy, but given to unhelpful impetuosity in your opinions. And once you get behind a notion that is indefensible, you still keep hacking away trying to prove it.
Now you retreat to the “troll” accusation.
Please do “include me out”. None of what I have said to you has gotten through; no sense both of us suffering from attempts to enlighten you.
:o) :o) :o)
Pragmatus:
First off, I'm for the public option. I just have that old fashioned belief that if you're going to argue for something you shouldn't pull important facts out of the air without actually backing them up with cites when someone asks for it.
You keep arguing based on the example of the private insurance costing $700 and the public option costing $350. Then you are baffled why no one "gets it." It's not that we don't agree that in that example the outcome would be that the person would mostly likely choose the $350 plan. The reason we don't "get it" is that we simply haven't been convinced this will be the typical situation.
First, we don't see where you've proven that there would be that big of a price discrepancy. You've simply assumed it to be true and then went on from there.
Second, you've never addressed what several of us have asked about here, which is how copays will be locked down. As such, you haven't proven that private insurers could offer a plan with a $100 office visit copay and a $50 Rx copay and price the plan at $250.
Now Pragmatus this is the question for you—why would healthy Joe go to the public option when he can get a crappy plan with high copays from a private insurer for $100 less?
Unless you can show somewhere in the bill that's going to prevent this, it's a fair question.
Statler:
Sorry, that was just a case of ambiguous language. It could have been re-written as "I want to see someone point to where in the bill it fixes the price of doctor visit copays, hospital visit copays, surgery copays and Rx copays."
Well, I just don't see what you're offering as enlightenment. I see it as cheap and manipulative, yes. You still haven't answered how you would handle Adverse Selection, and every time I bring it up you attack my person instead of the argument. What exactly is that going to enlighten me on, that you feel it unreasonable for someone to pose a question you don,t think you can answer?
Oh look, its the little man behind the curtain pretending he's the Wizard of Odds.
Still, I will honor your request. You ahve made the trollList.
I don't know if Chris Matthews is trying to kill the public option. I do know he is trying to convince his viewership that it's dead and can't pass the Senate. Maybe he honestly believes that. Maybe he is trying to set up straw men to frighten supporters to bring more pressure on lawmakers. Maybe he figures that, if it does fail, he'll be seen as insightful. Maybe he is a believer in incremental change - he was something, anything, to pass, and he figures we can come back later and improve it.
Just theories. But, fortunately, he can't kill anything. He is, after all, just a TV commentator.
Pan,
I believe I've laid out my case as to why the opt-out will not succeed. Can you address Adverse Selection? Please explain how you intend to overcome that.
The Baucus Bill has no price controls built into it, and this ndoes make it possible for Insurance Companies to increase copays, thereby passing on any additional costs they incur to the participants in the Exchange.
Now, I addressed your question. Will you answer mine? Prag refuses to. It makes him uncomfy.
To clarify: Yes, I think that a public option compared to existing private insurer plans would start out being cheaper. I'm just wanting to be convinced that they'll still be cheaper in new plans that are price structured to snatch up health young people.
Jacob:
Even if for some reason the lowest-tier public plan began at higher than market rates, most of the minimum-wage or loan-burdened people selecting it would be getting subsidies from the government. Couldn't HHS just offer higher subsidies to enroll in the PO?
No, they couldn't. The whole drive behind this public option is that it has to pay for itself. Once you start to give higher subsidies for the PO than for private insurance, you're into a whole different philosophical area. You do this, and the people arguing against the PO saying it will take away your current choices in private insurance will actually be right.
It's hard enough arguing with people who already think that's what the public option is.
Jacob…
As I understand it the premiums for the public option would be based strictly upon what it would cost to run the program, as I outlined above. I picked the $350 a month figure out of the air—in fact it would probably be considerably lower. My Medicare costs $93 a month, and remember that Medicare is currently solvent and that it also serves the highest possible risk pool (the elderly and the disabled).
Why else would GOP senators and congressmen cry so pitifully that they’re afraid a public option will drive private insurers out of business?
The idea that a public option would attract only the worst possible pool, and thus end up the most expensive option anyone could pick, is completely unsupportable.
There's a fascinating dynamic going on here.
The insurance lobby and the right wing are arguing that we shouldn't have a public option because it will drive all the insurance companies out of business, that it can undersell them all, and that it is, therefore, a trojan horse for a universal single-payer plan (bad! socialism!)
And here we have supporters of healthcare reform arguing that the crafty insurance companies will be able to drive the public option out of business.
Clearly, the insurance companies are scared of a public option. Why should they be scared, if all they have to do is offer crappy plans and let the market run its course? They're offering crappy plans already. They wouldn't even have to change much.
Seems to me, that despite all the argument, the insurance companies are honestly scared. I could be wrong - maybe they are supersmart, and are using reverse psychology on us. ("O no! Don't institute a public option! Please!" "You think it's working, Snidely?" "Yeah, they're buying it. They think we don't want a public option.")
Personally, I think if we're not going to get universal single-payer, this is the best shot we've got to improve things. I say, let's go with this, and improve it as the next few years go by.
Statler:
Sorry but the main reason I didn't answer your question was because I didn't disagree with you. :)
I definitely think there is a real concern with Adverse Selection. As I said before, I'm for the public option. I'd love a plan that was independent of my employer (which is about to change plans for the third time in almost as many years, which means yet another round of switching doctors) and which didn't do a lot of stupid B.S. like refusing to pay for a tetanus shot after a co-worker cut himself on a rusty nail (seriously, this happened). I want a plan that is designed more from the ground up to have the primary purpose of providing healthcare rather than squeezing every cent of profit from me. I'd love if we could try single payer, but I just don't see it happening with the political makeup of this country anytime soon.
So, I am for the public option, but I'm not yet convinced it will work. I'd like to give it a shot and see if we can make it a success. It's possible that all the other positives will make it economically sound and it will get a large variety of risk categories. It's possible that by cutting out the profit motive it can become a much more efficient bureaucracy than the current private bureaucracy.
But I'm sure as hell wanting to go into this with my eyes wide open. I don't want people telling me certain things aren't risks based simply on their opinion. I'm willing to take some of those risks, considering that the alternative is no forward movement. But I sure as hell want to know what they are so if they start being a problem we can recognize them before they get totally out of control.
@ Pan
Good point. There would be far too much political fallout from a move like that.
@ Prag
Yeah I agree completely. But I'm not sure that cost variations alone would drive private insurers out of business. In Canada's full fledged single payer system, there is still a strong private supplemental insurance market. Hell, in Medicare's full fledged single payer system there is still a thriving supplemental insurance market for the elderly.
Pan…
Read my post again, because you missed most of it.
Under reform insurers won’t be able to offer the kind of “crappy plans” that you describe. As I said—the most barebones plans out there currently cost $700 a month from a private insurer. Under reform, which puts new costs onto insurers, there is no way these premiums will decrease.
I repeat—I pay $93 a month for excellent coverage under Medicare, a system that has the worst pool of members possible, and is currently solvent. (I.e. my $93 a month, along with everyone else’s in the program, covers all the money Medicare pays out.)
There is no way a public option based on the Medicare model will be more expensive than any private insurance plan that will include the mandatory features that will come out of reform.
shrinkers:
Why should they be scared, if all they have to do is offer crappy plans and let the market run its course? They're offering crappy plans already. They wouldn't even have to change much.
They're scared because offering a cheap crappy plan to all their lowest risk customers would severely cut their profits. They currently get a lot of those lowest risk customers through their employer at extremely high premiums.
Yes, they're offering crappy plans already. But they're not offering cheap crappy plans.
Here in Texas We're going to end up with no insurance thanks to this compromise.
Every politician, Republican or Democrat, is going to be scrambling to get on the soap box and claim they're against "big gummint" , "tax and spend" and "death panels" and everyone is going to scurry to vote to opt-out.
Being stupid always wins here in Texas.
Well, can you explain how it is that the Public Option will sustain itself if you accept that Adverse Selection is a real problem? How do you intend to keep the costs down with a high risk pool?
Pragmatus:
Under reform insurers won’t be able to offer the kind of “crappy plans” that you describe. As I said—the most barebones plans out there currently cost $700 a month from a private insurer. Under reform, which puts new costs onto insurers, there is no way these premiums will decrease.
Yes, you keep saying it, but we've asked you over and over to show it and you have a sudden attack of deafness.
Show us where the bill puts a fixed price on all the various copays that's at the same price you'd expect the public option to charge. That's it, plain and simple. Show us.
Pan…
As I understand it, under any reform plan you can keep the insurance you have. All the public option will do is offer another choice.
The way things stand now, your employer can continue to play musical chairs with your insurance, or even drop it altogether, and there would be no recourse for you.
Ask anyone on Medicare what they think of it compared to private insurance. Ask me any question at all about it—I am a battle-scarred veteran of both systems, and private insurance is a @#&$% unsalvageable mess which will only get worse.
There are provisions in all the bills before Congress to control the costs across the health care spectrum. All these will be addressed, but it’s not necessary to have every last thing taken care of before we make any attempt at reforming the insurance aspect.
Pragmatus:
Again, you haven't shown me anything. You've just told me what you think you know. I'm not talking about existing employer plans. I'm talking about new plans the private insurers can offer with higher copays that will be cheaper than current plans. Again, show me how this isn't going to be possible under the rules in the new bill(s).
Second, since when does Medicare pay for itself? Seriously. My understanding is that Medicare premiums (your $93/month) are supplemented by other tax revenue. I really don't understand how you can compare a subsidized plan to a non-subsidized one (in that both the public option and the private insurers will get the subsidies under the new healthcare proposals).
Pragmatus:
There are provisions in all the bills before Congress to control the costs across the health care spectrum. All these will be addressed, but it’s not necessary to have every last thing taken care of before we make any attempt at reforming the insurance aspect.
I'm fine with simply saying "this has not yet been addressed" or "this has not yet been taken care of." But don't blow smoke up my ass and claim it has without being able to back it up.
Once again, I'm in favor of the public option. I'm just also in favor of honesty!
Pan…
OK this will contain very few sentences so there will be no chance to misunderstand.
The lowest, lowball sleazebag private insurance policies available now cost at least $700 a month. This you can check out for yourself. After reform, these premiums will only go up.
Medicare, which has the absolute worst risk pool imaginable, being composed entirely of senior citizens and the disabled, pays its own way with my $93 a month premium. The public option, even with the worst imaginable risk-pool, will be based on Medicare, so how could it possibly cost anywhere near what private insurance costs?
Fixed prices on copays, Adverse Selection, any other complaint or worry has absolutely nothing to do with what is laid out very simply above.
Pan…
Last word, because you are making me dizzy—
If a public option passes and you don’t like it, repudiate it and buy private insurance. Nobody will force you to go into any program you are opposed to.
What could be simpler than that?
I don't know if someone mentioned this yet but I saw some discussions of hypothetical public option costs.
CBO estimates of other public option plans had estimates of 10% less. I think they estimated something like 15 million moving onto the public plans being floated.
If you remember TheLewinGroup, funded by UnitedHealthGroup, then you might remember their estimates of 110 million moving over to the public option being echoed by Republicans on the hill. They overestimated the saving and estimated a 20% less cost of a public plan.
Just thought I'd mention that.
Pan,
From what I read, there are no mandatory price caps in the Baucus Bill.
Interestingly, there are price caps on pharmaceuticals in Canada. Since they have USP, they have an incredible amount of negotiating power with Big Pharma, much the way that Medicare has alot of muscle on negotiating drug prices. If you have an Exchange, pharmaceutical manufacturers can always tell you to fuck off, that they'll charge whatever they want so long as there are other insurers that will pay what they demand and its tough titties for you if you want them to lower their costs. Medicare can muscle them around because the overwhelming majority of seniors are on Medicare, and therefore there is no place else for Big Pharma to go for customers. Well, not enough to stay solvent, anyway.
USP is not the perfect system, but tis a damn sight better than this.
As far as the political will goes, I think the opposition stems from the approach used by this Administration to address the plan. Daschle and Sibelius were not the people Obama should have named to DHHS to push this thing-Dean is. Further, they dragged their butts and relied on a legislative body headed by the famously inept Harry reed to craft a plan they should have had written and ready to go the same morning they announced it. That gave the insurance companies all the time they needed to concoct 'death panels' and similar scare tactics aimed at veterans and the disabled. These people are snakes, they're amoral and hell bent on protecting what they see as threatened, and all too willing to destroy anybody that gets in their way, you can't give them time to come at you. If you haven't knocked them out in the first round, you're in for a long fight with an opponent that fights dirty.
That aside, the Obama team is now so desperate to get anything that has the word 'Reform' in the title passed so they can save face, they're dodging USP out of fear of being called socialists.
none of this has anything to do with what's going to actually work or not. Its just a cheap political stunt these days, on both sides-the GOP doesn't give a fuck if people can't get care, and the Dems are just trying to save face. They don't see pragmatic considerations like 'hey, is this thing sustainable?' as important.
That's why Prag wants to play rope-a-dope with you and me. He and the other folks primarily focused on Democratic Victory don,t care if this bill is stir fried shit on a plate or not. They just want to win elections. That,s all they've ever cared about.
Pragmatus:
Medicare, which has the absolute worst risk pool imaginable, being composed entirely of senior citizens and the disabled, pays its own way with my $93 a month premium.
I just don't believe that's true. I want to believe it because that would be great. But I just don't because of what the information out there says:
http://health.howstuffworks.com/medicare4.htm
Medicare Part B is partially (about 25 percent) paid for by premiums and co-pays.
http://en.wikipedia.org/wiki/Medicare_%28United_States%29#Costs_and_funding_challenges
All the information here seems to directly conflict with what you're saying. Basically, the reason Medicare is solvent is because there are 3.9 taxpayers paying in for every 1 getting money out.
A little research also dug up that in 2007, they started charging more to higher income users of Medicare Part B which also means they are subsidizing the lower/mid-income users.
And none of that included a drug plan, which went FAR overbudget.
Now, I've provided you with links for information that backs up what I'm saying. Please provide me with links backing up your claim that Medicare "pays its own way with my $93 a month premium."
"If a public option passes and you don’t like it, repudiate it and buy private insurance. Nobody will force you to go into any program you are opposed to."
I can only assume you haven't been reading my posts or are getting me confused with someone else. I've said time and again I'm for the public option. What I'm not for is arguing for it based on misinformation. And yes, I think your claim about Medicare paying it's own way (among other things) is complete and utter misinformation.
Pan…
Medicare is solvent now and will be through 2019. (Current estimates have adjusted the 2019 figure.)
So—complete and utter misinformation?
Regardless, Medicare is far more expensive than any public option will be, because the risk pool in a public option will be better, simply because you can’t get a worse pool than Medicare’s.
I urge you, don’t accept the public option if it is voted in. You seem sure, based on what I can’t imagine, that it would be terrible for you.
There are plenty of private insurers who will welcome you with open arms. I mean it. The public option would be a very bad fit for you.
:o) :o) :o
This debate has never been about people, its never been about practicalities or about what's best for the disadvantaged. Its about two machines, one red and the other blue, fighting it out to see who,s top dog.
That's why so many of you don,t care about GLBT people either. To you, the only thing that matters is how many votes you can get to sustain your machine. I'll bet if we represented 30 or 40 percent of the vote, you'd be all about Equal Marriage. Or maybe you'd stop calling it same-sex marriage, or putting it in quotes- 'marriage'.
Maybe if the people who don't have any health insurance in this country were rich enough to buy you off, you'd care about whether or not the health care reform bill has the ability to lower their healthcare costs and could deal with problems like Adverse Selection. Maybe you,d care about whether or not its sustainable enough to survive the end of your first term.
And maybe, just maybe if those GIs out there in Iraq and Afghanistan came from upper to middle class suburban families with lots of money to blow on campaign dollars, you'd bring them home so they doN,t have to die for some ambiguous cause or a victory nobody seems able to describe, as to what exactly would be victory.
Maybe if you could think beyond your next re-election campaigns you'd pass a carbon tax bill, and who cares how much hell the GOP would give you for it, because in another 50 years cities like mine could be underwater.
We're all just gears in the machine to you. And the thing about machines is,
"Machines operate on oil and grease; they're dirty, dehumanizing, and too often unresponsive to any needs but those of the operator"
Those are the words of a hero of mine, probably that last politician that ever lived who was worth admiring. I'm not like him yet, but someday I will be, and I'm coming after your machines, both of them, the red one, the blue one-and I'm going to break them both for the benefit of this country which I love.
And maybe then we can put all you cheap hacks out of a job and replace you with people that give a damn about somebody other than themselves.
Pragmatus:
"Medicare is solvent now and will be through 2019. (Current estimates have adjusted the 2019 figure.)
So—complete and utter misinformation?"
That would be great, but that's not what you said. Here's what you said, repeatedly, to back up your argument: "Medicare, which has the absolute worst risk pool imaginable, being composed entirely of senior citizens and the disabled, pays its own way with my $93 a month premium."
Those two things ARE NOT THE SAME.
It is solvent because it is being paid for by tax money from people not currently in the Medicare system.
The public option will not be paid for by people not using the public option (at least, no more than the private insurance will be).
Medicare has low premiums and copays because SOMEONE ELSE IS PAYING YOUR BILL.
Do you really not understand this? I can't believe I've actually taken your arguments seriously and asked you to back up some of your claims so I could research them when you don't even get this incredibly simple difference.
The concern about high deductibles etc. and low premuims on a private plan competing with a public option seems to me a legitimate concern. Also a pretty obvious tactic. I find it hard to believe the people who crafted the three plans in the House and the HELP plan in the Senate would not have considered this issue. Specifically, Chris Dodd and Teddy Kennedy are/were devious and pretty clever. I'm willing to wait and see what's in the final bill to address this possibility. Perhaps someone could even write to a senator or congressperson and ask if this problem has been considered?
shrinkers:
Agreed, I'm willing to wait and see as well. I just don't like people claiming they already have the answer when it appears they are just making it up. Especially now that I realize just how poorly Pragmatus understands how his OWN insurance plan works.
Wait....
your answer to a difficult problem, is, "Oh, I'm sure somebody must have thought about that already"?
Oh come on!
Pan…
Again I urge you to reject the public option. There’s no way of assuaging your fears.
Pragmatus:
You're ridiculous. It's pretty obvious that I've shown that you don't know what the hell you're talking about when it comes to Medicare, even once I've given you the information from 3rd party sources.
Why should anyone in this forum listen to a thing you have to say?
Nope, Statler. My answer is, since you're concerned about it, write your congresscritter and ask about it. Personally, I don't see it working out that way, and I'm not worried enough to look into it further.
Pan,
Medicare for all would actually succeed. Not just because of distributed risk, but because the working population (who would also be users of the system) are generally healthy people. Seniors are generally unhealthy, but (as you describe) they do not pay their own way. However, then you look at the percentage of very unhealthy people in this country who cannot or do not work compared to the working population, their number is relatively quite small.
The people using USP would be also (largely) the people paying for it, yes. However, that population will not need the same amount of care.
I fully support Medicare for All. I think that is exactly what thsi country needs. Its sustainable, it drives down costs, it allows the government to negotiate drug prices and the cost of care.
The biggest reason has to do with reason for existence. A for profit insurer is mandated by federal law to be solely responsibly to its shareholders, not its clients. To them, its all about profits, and any good you derive from that as a client is purely accidental.
A government plan is controlled by.... us. If we don,t like the way an administration is handling it, we can fire them. The Board of Cigna, you can't fire them. The POTUS, you can fire that guy. Therefore, he has to take your needs into account in a way that Cigna never will.
My objection is not with whether a public plan will work-I'm quite convinced it will-but whether the plan now being debated has enough rocket fuel to get into orbit.
Statler:
Please don't misread my comments as any attack on Medicare or single-payer, etc. I'm simply baffled that he either can't seem to admit he was colossally wrong about how his premium works in Medicare or that he actually doesn't understand it even after I've shown him. As such, he is completely invalidated from having his arguments considered when they are not backed up by actual provable facts. He can't make such a huge mistake and then just expect people to trust he's right without a fact check.
Love this public option option to opt out by state. Allowing people state by state democractic rights on this is great. I often thought the problem with the irrationality and lack of common knowledge in the health care reform discussion was the lack of a local, U.S. examples of various systems for health care for all ages. Obviously we have Medicare and VA system, but expanding those to everyone gets way way too much entrenched interest resistance and cultural resistance. Canada got their single payer system not by methodically adding age groups but because one province started it and others saw it worked and overall was the better option in their minds. Less scary when the state next to you did it and everyone lived to tell.
We have no good state example of single payer, or universal health care with a insurance exchange and a robust public option.
Letting states opt out is perfect way to see how the public option effects states that do use it, adn let other states initially skeptical opt out, and then if it looks okay, later opt it.
I agree, this is compromise I can live with...it would be better to have robust public option for all citizens, because Lord know we could use something to fight back against private insurers running amok, but if one must compromise, much better to let those in states opposed miss out then letting the public option itself be watered down to in-effectiveness on a national level
Blogger Statler N Waldorf said...
"This debate has never been about people, its never been about practicalities or about what's best for the disadvantaged. Its about two machines, one red and the other blue, fighting it out to see who,s top dog.
That's why so many of you don,t care about..."
Statler, sometimes it is hard to tell whether you're addressing your post to the people who are reading it or directly to the DNC.
I'm pretty sure no one here controls the national policy of either party, so don't attack our motives for holding our positions. Most of us support GLBT rights, USP health care, environmental protections, and withdrawal because we support them, not because they are good for the Democratic party.
And many of us support politicians who work toward these goals and oppose those who don't even if they're not moving nearly fast enough or going nearly far enough. Not because we love to see "our" machine in power but because that's how we believe change is best achieved.
You think adverse selection could be a problem for the public option. Fine, it's a legitimate point. Pragmatus seems to think it's absurd to pose it as a problem, and I wouldn't go that far, but I don't think it will imperil the PO once it's in place. Nor do many other posters here, given the dynamics of the public plan and estimates of who will opt for what plan.
Shrinkers is right, you should contact your congressman (Cao, right?) and if he won't give you a straight I would be happy to contact mine (who is a supporter of USP).
But no one is arguing with you because they don't care about a genuine solution to the problem. I don't think USP is possible right now, though I wish it was; and I think that we should absolutely point out flaws with any plan that is in congress (though I don't think that adverse selection will be one--my amateur opinion, I would leave it to genuine experts to answer the question definitively).
It's a good question, but if your post is actually directed at national Democratic leaders, you should take it to them.
Run for office or form an advocacy group and take your grievances to people who are actually holding them back. In all seriousness, you are clearly smart and eloquent enough to do that. Don't hold back.
@Prag
I think you may be confusing Chris Mathews (MSNBC) with Chris Wallace the zombie douchebag at Fox.
wv: woomps. as in WOOMPS! Der it iz
Throw you hands in de air, and wave 'em 'round like you don't have health care!
I suggest all of you read Jack and Jill Politics - www.jackandjillpolitics.com for another view of opt-out.
I'm sure you're all too young to remember that when Social Security was proposed FDR couldn't get all he wanted, so Black folks had to wait.
Opt-out will happen most likely in the southern states, which means that Black folks will be paying for health care they aren't getting, even after this bill passes.
Health care is a right, not a privilege and we all need to start acting that way.
Huh boy, these comments are deep but there are other things to consider, and Another Scorpio just touched on one: Assumptions about southern voters always "choosing" Repubs or Blue Dogs. Where there are many black and/or brown people, there is immense racial profiling, subsequent incarceration, probation, parole - all of which disenfranchise otherwise eligible voters. It's not a choice for most of these folks to not vote - they are ineligible, so until you've fought to enfranchise people w/a record, you can't count on those votes. Thanks to still-segregated education (poor/middle/rich income-determined now) they aren't the best educated and certainly not the ones most getting outreach from political operatives (most often educated and white). Predominantly black/brown areas get the least resources, have the highest preventable death rates for health problems, etc.
Second, this will be yet another reinforcement of states' rights over federal laws. With a majority conservative Supreme Court in place to take this to the limit. We already have women's choice in-name-only thanks to states' laws (plus a conservative-pushed law to deny any federal funds for abortion), plus the refusal to recognize gay and sometimes even straight civil marriages in some states, and right now a battle to overturn city and state gun laws to bow down to the 2nd Amend. formulated when we had to hunt and farm to eat and there was no law enforcement to speak of - and no gun dealers to the level we have now, legal and illegal.
Third, talk to the elderly about Medicare rates. The fundamental problem is pay-for-procedure at lower-than-avg rates, rather than pay-for-outcomes at avg rates. Again, all states are not reimbursed equally, thus doctors and hospitals congregate where the higher rates are. What hospitals/doctors remain can and do refuse to accept "new" Medicare patients. This impacts elders who move seeking less dangerous (ice) weather, or to stay close to their kids, or for whatever reason. Even if they don't move, at any moment, their provider can decide to refuse Medicare.
Fourth, portability. A common cause for medical bankruptcy is out-of-provider emergency care, esp where every Q-tip costs $100. Opt-out states are very dangerous to subscribers to public option in opt-in states. Lobbyists will do all they can to make sure it's dangerous and to make you sign up with a natl private insurer.
Fifth, the same lobbying that's occurring at the natl level will occur at the state level, where there are cheaper campaigns, and some states with more trees and cows than people. IOW, it'll be cheaper to buy those legislators and ads, and again, to sway uninformed voters that "govt health care" will "kill grandma".
Sixth, when private insurers draw away PO subscribers w/lower premiums/co-pays/deductibles, they promptly raise all the above the moment the PO is no longer viable or has been opted-out of. This will absolutely be the most sensible long-term tactic they can take. They're already doing it w/Medicare Part C.
Please continue to fight for the national public option, no opting out. Fight to take leadership away from uncooperative Blue Dogs. Promise Reid you'll help him in his very tough reelection campaign in NV if he herds these cats. Hell, promise you'll support the Blue Dogs if they let themselves get herded. As another said, there will be other issues to build their campaigns on, and a strong public option, quickly put in place but especially with strong regulations and pay-per-outcome made law right away, will help them get reelected if they cooperate.
Opting out is a dangerous compromise once you expand your thinking beyond the beltway.
@V Cubed: You raise several valid concerns. At this time, "opt out" is just a concept with no legislative language. I imagine most of the issues that you raise would be addressed in hearings, debates, and legislative language.
I am also concerned about "out of network" services, and how de facto, if not de jure, this could become an awful mess for people who are moving or even just traveling from state to state.
But I am sympathetic to this compromise if it addresses several issues that you raise and ameliorates the possible effects.
Another Scorpio:
"Opt-out will happen most likely in the southern states, which means that Black folks will be paying for health care they aren't getting, even after this bill passes."
No, no, no. The subsidy is not part of the opt-out. The subsidy will still be available even if the public option isn't. The public option isn't being paid for by taxes, the subsidy on ALL insurance is.
And you might say "well, these poor black folks will be paying in but then won't be able to afford any high priced private insurance plans which are the only kind available." Well, the subsidy comes from federal income taxes. Poor folks (black or white) don't pay those.
Any discussion of a so-called public option saving money continues to shortsightedly ignore the waterfall effect of the government chronically underpaying providers and shifting costs onto the private sector. The proportion of government pay has been steadily growing over the years, so at some point the government actually will have to pay in proportion to the resources its beneficiaties actually consume. If it had done that already, there would be no insurance crisis.
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