You should definitely go and read Ezra Klein's handy guide to the various public option compromises that are working their way through the Senate. One thing to bear in mind however is that the public option compromises are really being discussed along two dimensions.
One dimension concerns implementation: when and how does the public option come into being? Does the public option come online right away ("right away" in this instance meaning 2013)? Will it come online immediately, but states are allowed the right to opt out of it? Alternatively, might states have to affirmatively opt into the public option? Or might the public option be implemented only by a trigger?
The other dimension concerns the public option's operation. Will it operate as a federal program charging Medicare (or Medicare +5%) rates? As a federal program that must negotiate its rates in the market? As programs run by state governments? Or as non-profit co-ops, operated on a state-by-state basis, but not run by state governments themselves?
If you drew a grid of these issues in two dimensions, then almost every box would be filled by some or another version of the "public option". Actually, let's go ahead and do that...
The yellow triangle represents the sort of "Zone of Compromise". I'm pretty sure that a co-ops provision, with immediate implementation, could pass the Senate (or at least not be filibustered by it). Likewise with Olympia Snowe's trigger. A strong-ish opt-in amendment proposed by Maria Cantwell was approved by the Senate Finance Committee along party lines, but did not get Snowe's vote; it might or might not pass the full Senate.
Basically, any square that is overlapped by the triangle seems like a plausible outcome. The most robust public option available is probably a federally-run program that states would have the right to opt out of and which would have to negotiate its rates in the market. The worst-case scenario is probably state level programs with an extremely stingy trigger, as proposed by Snowe. (This is assuming, of course, that health care reform as a whole will pass, which people may be a little bit too sanguine about.)
This is not a perfect representation of the alternatives by any means. Co-ops and government-run programs are not necessarily mutually exclusive. A "loose" trigger could conceivably be more robust than an opt-in provision, or even an opt-out provision, although in practice Snowe's proposal is not. Moreover, state-level options and triggers could be combined in various ways: maybe states have to opt in initially, but they'd be enrolled automatically if a trigger kicks in. An final complication is is that certain of the options -- for instance, a state-run opt-out -- do not make particularly much sense. Still, it should provide a reasonably useful schematic.
Note: Chuck Schumer's position has been clarified in the chart based on some helpful feedback from his office.
10.22.2009
The Public Option Playing Field, in Two Dimensions
@ 8:19 PM
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We need single payer, I think opt-out Medicare gets us closest in this chart, thus lets hope we get that.
This chart saddens me because it's probably realistic.
being in a state (Oregon) that seems to overwhelmingly support this, I'm happy to see that the compromises will probably let me get some form of public option
This chart merely represents two of the multiple dimensions involved in a final bill.
You also have to consider the following:
1) Will purchase of insurance be mandatory and what will the penalty be for not purchasing insurance?
2) Who will be eligible for some form of assistance to purchase insurance and how generous will that assistance be?
3) How will such assistance be funded?
4) What types of procedures will be required to be covered by the "basic" policy?
The fact that supporters of health care reform have to be vague in their description of what the bill will do as to all six of these dimensions is a major factor as to why opponents have been so successful in their attacks on health care. If you are unwilling to consider that any reform might work, you don't need to consider the alternatives and can attack away without regard for details. If you think that health care reform could work, the details matter.
I really like this site, so I've never wanted to write anything like this before, but the zone of compromise you've drawn is completely spurious.
The reason is that all options are not equal, or equally different, in political acceptability. For instance, why is an opt-out less politically palitable than an opt-in? It's not. In fact, it may be more so. The spectrum you drew, with some things closer to none and other things not is a neat concept, but practically useless, and probably downright misleading.
Maybe you should rethink this method of analysis, as you yourself recognize that these things don't fall on a spectrum.
Thanks for posting this. It looks about as realistic as one might get on laying out the debate. I think "opt-out" makes the most political sense right now to reform advocates, because it forces conservatives to take their case directly to the voters. They'll find that the voters don't particularly like the conservative position. Schumer's position is ideal, but negotiated rates looks like a more realistic option.
Why is the left-most corner of the yellow triangle drawn from the bottom of the (Federal Program/Medicare Rates, Opt-In) box, when the other two corners of the triangle are drawn from the centers of their respective boxes?
Given that the Cantwell opt-in amendment is "strong-ish," I would think that corner would be located further up along the Implementation Mechanism axis.
I have a feeling that the final push will be for an "opt-out" proposal. Liberals will be lining up with Schumer to push for it, and while a lot is made of the few democrats who are blue dogging the whole process, there will probably be 50 democrats who want either universal or Opt-in.
Whether opt-in will pass the senate is another issue. I have a feeling though that it will be good cover for the blue dogs, being able to argue state's rights. I have no illusions that it would draw republicans, but it most definitely has a good shot at drawing in more or less all the democrats.
Except Lieberman, but with all do respect (which is to say none at all) "f*ck Lieberman."
This is where some fenangling might have to happen with the plan, especially since Snowe, the most liberal republican, doesn't really want to give up her trigger, and Lieberman won't get on board with any public option.
In the end we might end up with a senate bill very low in the triangle, a house bill very high, and a compromise bill either in the schumer plan or negotiated costs + opt-in.
Great post though Nate. Keep up the good work.
Ben - Simply put, I think you are completely wrong here. yes, some things don't work in spectrums, but your example was terrible. Opt-in is closer to "nothing at all" than opt-out because it is more attractive to people that want "nothing at all". It forces the people to vote it in in a state-by-state basis, which means that more states won't implement it than would if the program was opt-out. It is a totally appropriate spectrum here.
Another important issue: will the public option be available to all individuals and employers, or just those that meet some criteria?
IMO, you have been consistently too pessimistic in evaluating HCR and the public option, and the chart reflects that nicely.
A robust opt-out public option with medicare+ rates presently has a better chance of passage than state run co-ops or a trigger. Opt-in seems unlikely as well. Yet your chart appears to give it more chance than opt-out.
Reid and Obama know their own futures hinge on how this plays out. They would have disposed of the public option long ago if they thought they could do so politically. Pelosi seems to agree since she is going for the gold.
I just think you are misreading this one.
Opt-in seems unlikely as well. Yet your chart appears to give it more chance than opt-out.
I think that is misunderstanding his grid. The only thing that's "outside the triangle" with those two are Opt-out @ medicare rates and Opt-in w/Co-op [only?]. The former assumes an Opt-out is given up for Opt-in to allow freedom from private interests engaging in market manipulation. The later assumes that that bird just isn't going to hunt with the core of the Democratic caucus, that they realize there are far better deals to be had and they won't settle for that.
Perhaps you are reading in significance of how much the triangle overlaps a given grid square? You have to keep in mind that once you get past median great the darker the grid the less likely, at this point.
Caleb- You miss the point. I'm not talking about public policy--I'm talkign about political acceptability. The gap in acceptability between opt-in and opt-out is small compared to, as you pinted out, the difference in policy outcomes.
My main argument, which is that this is ridiculous and misleading to put on a chart you did not address.
Fortunately, at this point this is in the hands of people who actually understand that distinction. A better idea would be to rank these ideas on a chart of political acceptability vs. policy effectiveness and that, I think, would show the opt-out proposal as the strongest of the plans.
Even this chart doesn't show all the dimensions. There's also the dimension of who would qualify for a public option, if there were one. Most plans now only make it available to people who don't otherwise have a plan. That's a pretty poor option really, and gives insurance companies much less motivation to treat their customers fairly.
Somebody's thinking too hard trying to find a scenario that might work politically, if the math worked. But the math doesn't work under any scenario. Slim's already left town and he ain't comin' back.
So here's a thought: How can the CBO deliver an accurate accounting in an opt-out scenario without knowing what states will opt out? I mean won't the whole shebang depend on the total number of people participating? And how will that affect the costs with states missing from the equation?
@Mr. Universe
The Opt-in part is the part that doesn't really cost much, right? Lots of money may change has but the idea it would be at or near zero net.
Besides, just counting all 50 states as in is likely to be a rough approximation of what it'll shake out to within a handful of years.
The longer President Obama and the congressional Dems endlessly hem and haw on health care reform the worse it gets for them.
The president's approval ratings are dropping hard and this Fox News fixation is going over like a lead balloon.
Meanwhile, real and important matters like "What To Do About Afghanistan?" languishes with a soupy, Hamlet-like morass of Obama's own making...
Obama, make a decision on Afghanistan, pass a sensible health care bill, and stop being petty in regards to your critics.
Who would have ever thought that Bush had a thicker skin than Mr. Wonderful?
Walker said...
Meanwhile, real and important matters like "What To Do About Afghanistan?" languishes with a soupy, Hamlet-like morass of Obama's own making...
~~~~~~~~~~
Again, in my best Reverend Jeremiah A. Wright voice, No, No, No as Rummy, in a less publicized incident, declared an end to major combat operations in Afghanistan on May 1, 2003
So 6.5 years later Afghanistan certainly can't be a major concern, eh as cheney/bush/rummy/condi said not to worry way back when ...
own making my ass!
btw Walker, I'm braking my own "new rule" to ignore you ;) but your off-topic nonsense was wayyy too easy to jump on and destroy!
btw, how's Missy doing :)
winger conservatives repeat after me ~ the Afghanistan war will and always will be a party of No! war, this is your reality!
The White House is expending quickly depleting political capital on...Fox News??
Are you kidding me??
Just because one, solitary news network doesn't give the president daily, ritualistic, Charles Gibson-esque hot oils and salve rubdowns (Gibson: "Golly, Mr. President, ins't it just so wonderful being you?") the most powerful person in the world has petulant little pity sessions, sending out his minions to do hi dirty work.
What a class act this guy is!
Unbelievable.
Liberals, pipe up! Who will admit that this Fox News is a good strategy??? Come on, I am goading you.
I love how the GOP is in the "None" area of the health care plan chart.
>> Who will admit that this Fox News is a good strategy???
Anything that frothes you into a state of blathering incoherence can't be bad, can it? :)
On Afganistan, what's the big rush from Dick? He sat this puppy on the backburner for nearly 2 terms. An extra 2 1/2 weeks is that critical? Of course it's blatantly obvious Obama has put Karzi on notice not to embarass the US or they are apt to leave his ass in a sling.
There's nothing wrong with calling out who farted. And Fox News these days is one, long, 24/7 gaseous emission.
Walker = Pete Kent?
Awesome chart, Nate! Way to simplify a very complex set of negotiations. This is exactly why I come to 538
Simplifications aside, this is a really cool way of looking at the public option. First of all, it's a simple way to understand everything. Secondly, it'll help us understand how good a job Obama/Democrats are doing at getting the most they can with the cards dealt to them.
Just because one, solitary news network doesn't give the president daily, ritualistic, Charles Gibson-esque hot oils and salve rubdowns (Gibson: "Golly, Mr. President, ins't it just so wonderful being you?")...
Liberals, pipe up! Who will admit that this Fox News is a good strategy???
I will. The conservative agenda has clearly been to undermine and subvert any media source other than Fox at every turn, as your first paragraph is entirely devoted to doing. This exact same mantra, that every network on the face of the planet except for Fox is in the pocket of Big Liberal, has been deliberately and openly used repeatedly by Fox News and conservative politicians/ideologues to cow the mainstream media into reporting on what they want reported.
Yet now, when that exact same strategy is being applied to Fox News, suddenly you're up in arms. Could there be any more of a double standard? You spend an entire paragraph trashing every channel but Fox, and then you spend the rest of your post trashing Obama for trashing Fox.
1. LOVE the Fox News 'strategy' (i.e. speaking the simple truth that they are a propaganda firm rather than pretending they're a news organization). Truth is usually a good move.
2. Yesterday's Medicare compromise that significantly changes the way reimbursement is done to favor results over number-of-tests will change the dynamic of the debate further (as well as CBO numbers, possibly).
3. Opt-in is a terrible idea (as stated above, that's why the "no public option at all" crowd loves it); opt-out is a pretty good compromise. I don't think opt-in is in serious contention right now.
4. Amazing to me that everyone is perfectly happy to leave $50 billion (the amount CBO feels med-mal reform would reduce costs by) on the table. We Americans are so enamored of suing... it's so important to us that on the off-off-off chance that someone we know is truly harmed by malpractice, that they can get a bazillion dollars; we're fine with the fact that in return for that right, I now have to order a bazillion tests on you every time you set foot in my ER, irradiating you for no good reason and causing unnecessary cancers down the line. I would be so happy if there was a deal saying that doctor's malpractice premiums will not decrease ONE CENT, but there is med-mal reform. People don't realize it's not the malpractice premiums we care about (unless you are an OB-Gyn doc); it's the being unable to get through the day without ordering 20 unnecessary tests.
P.S. this is a pretty nice graph in that it lays out the debate-- though the upper left x-axis should say "Medicare +5%" rates since that is much more 'popular' at present. The Yellow triangle doesn't represent the most likely outcome, but it does delineate the "compromise options" currently out there and where they fall in relation to "no reform at all".
The president's approval ratings are dropping hard and this Fox News fixation is going over like a lead balloon.
Oh Walker, Texas lounger. Go get back on the couch with Missy. Martha Stewart is coming on TV.
Last I checked the President's approval ratings were rising to; what, we're at %57 now? And let me be one of the first in a long list of liberals to say that I'm glad somebody besides Olbermann had the cajones to call FOX the propaganda machine that it is. I doubt that the WH will expend a great deal of time worrying about it though I imagine FOX will. Remember when Obama swatted that fly? Kinda like that.
And really, we're supposed to feel bad after the eight year conservative echo chamber Bush created. Even Perino came out and said they purposely ignored MSNBC.
Echo what shiloh said. Cheney had plenty of time to get Afghanistan right. Did he? Really? DID HE!?
Come back whenever you have a substantive argument.
Cool. A graphical way for people to predict the worst possible result.
lolol!
Chart built by liberal democrats for liberal democrats. The chart just shows the Democratic platform on healthcare. Republican have other positions than NONE. Many believe in reform, regulation, subsidsies, cross state competition. But labeling NONE is the democrat way.
@dmambrose
The chart is for "public option".
So, both sides should be lining up governors/states behind the scenes. Any evidence this is going on?
This graphic makes a good, simple, case for where the smart money should be targeting a public option compromise with the biggest bang for the buck that will leave most stakeholders with a winning hand.
The level-playing-field (Federal Program, Negotiated Rates) Public Option with an Opt-Out mechanism is exactly where we should be setting our sights.
A Federal Program paying Medicare +5% is problematic for a number of reasons especially in that the markets where the effects of Medicare cost shifting are strongest would be even further disadvantaged by this arrangement, possibly leading to unsustainable systemic breakdowns. (And yes, I recognize that the status quo is leading us toward unsustainable systemic breakdowns.)
Additionally, some markets may indeed see drastic unintended consequenses from a public option, and so the ability to opt-out without a federal shutdown could actually be beneficial (as well as an incentive for the public option to benefit every state). This is a bit counter-intuitive in that this scenario is actually only more likely in locations who are probably the most pro-public option philosophically; while the states who are most certain to depend on a viable public option are the most likely to oppose it on a referendum or a state legislature (ideologically at least).
Be that as it may, such a public option really would have a large enough market share to be considered robust, and has a very interesting, very seldom discussed Actuarial advantage over just about any other private health insurance.
Namely, Private insurance plans can only expect to keep their members for a finite number of years. Most of these members are through employer groups whose employees turn over at a fairly consistent rate. This turnover rate means that investing in preventative care today can only pay off in ten or fifteen years if that member is still employed by that firm and insured by the same company. (Of course, often times members leave and come back to the same company - but not enough and as predictably as necessary).
But a public option has a high likelihood of keeping a member for a long time as many of these members will be in lines of work which will not be employment dependent, (some will come in and out of course) but most relavantly, everyone will end up in Medicare!!
Because everyone ends up in Medicare, the public option can actually become incentivized by saving future Medicare money by investing in longer-term health and wellness prevention. This is an absolutely critical connect-the-dots exercise.
The other critical piece is that the Individual Mandate needs teeth. The insurance companies were dickheads when they came out with their reports a couple of weeks ago, but they were right on the point about how critical it is that an individual mandate be an actual mandate. Self-selection is just too obvious an insurance problem and with the lengths we are going to make insurance affordable and accessible to everyone, we need to make it unacceptable to choose to go uninsured.
Having the public option negotiate rates and contracts seperate from Medicare will allow better innovation along these lines (although we should expect the public option to probably base its fee schedule off Medicare as it enters into contract negotiations.)
dmambrose
Two points -- First, there is a Republican option on there. Last I checked Senator Snowe was a Republican.
Second, the Republican leadership has been saying for ten months now that they were about to introduce a reform plan but to date have yet to propose one. Those of us in Missouri have been waiting with baited breath for the plan that is supposed to be coming from wanna-be Senator Roy Blunt, former Republican Whip, but despite all of our requests to Show Me, he keeps on postponing the release date.
If the Republican Party has a proposal, it's for the federal government to preempt state law on insurance regulation (so much for the Republcan's supposed fidelity to limited powers and the Tenth Amendment) and then give everyone a tax credit leaving us to the tender mercies of the insurance industry.
I'm still waiting to here a good reason from a policy perspective from a Dem on why they oppose a public option.
I've LOVED, throughout the process, that the LIBERAL option, the one BLUE DOG, conservative, fiscal moderate Democrats don't is cheaper and /less expensive!
The government is spending much less money to providers. Imagine the Blue Dogs saying it like it is:
We want the health care bill to pass, but if it passes like Pelosi wants, we want to pass a stimulus bill with lots of checks to doctors and hospitals to make it fair. Nice and liberally, of course.
EmonOkari said...
There's nothing wrong with calling out who farted. And Fox News these days is one, long, 24/7 gaseous emission.
Correct, Emon, as demonstrated here:
http://www.youtube.com/watch?v=YDR47EKTrCQ
One question this begs is: if a robust public option is in the bill, which Democrats will actually join a Republican filibuster and how long will they stick with it?
Speaking of co-ops, they aren't really doing as well as they should, or so it seems after reading this: http://www.pressdisplay.com/pressdisplay/showlink.aspx?bookmarkid=CCWQCPQ3IMZ7&preview=article&linkid=70aa9269-2c26-4655-9872-f542b1e291ff&pdaffid=ZVFwBG5jk4Kvl9OaBJc5%2bg%3d%3d. Either way, you're the expert, so I'd like to hear what you have to say as well.
Sincerely,
MediaMentions
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