Senator Harkin says he wants to resuscitate the public option sometime in the coming congressional session, but before we decide whether or not this is a good idea, it should be worth considering whether the kind of public option which the Senate could create, either by miraculously getting sixty votes, or by passing it with fifty votes. And what do we want the public option to do? I personally would like to see the availability, to a large number of people, of a non-profit insurer to provide real choice in the insurance market, regardless of who runs it, just so that it exists and is competitive.
The weak public option was on the table for quite a while, and even though Lieberman (and others) killed it, back in oh, September, it seemed like he wanted to break up healthcare reform into several pieces of legislation. But is a debate over the weak public option worth the Senate’s time at this point, when it already has something of a backlog to deal with in terms of legislation coming from the house? I don’t think it is, since the Senate’s current reform proposal includes a non-profit plan through the Office of Personnel Management which would presumably be cheaper than for-profit private insurance (someone correct me on this if it wouldn’t be), and so that’s probably better than the weak public option, which was going to be more expensive than for-profit private insurance. The weak public option, because of its cost, seems fairly useless as long as rescission and denial of coverage based on preexisting conditions aren’t allowed, given that one goal of reform is to provide insurance which is more affordable than existing plans. I guess the people on the weak public option could receive subsidies, but at that point why not just subsidize a more affordable private plan? Given the expense of the weak public option, and the fact that the current legislation already creates at least some form of non-profit insurance, I don’t think it’s worth doing this whole painful process over again for something which will be expensive and redundant just so we can say we have a public option.
What then about expanding Medicare, which seemed to be the compromise for several days last month? Expanding Medicare to everyone would of course be fantastic, but would premiums be adjusted for income, or would some people’s premiums be subsidized, or would it be funded by new taxes (thus becoming single-payer), who knows? Any of these ways would probably be better than the system in place now, but since single-payer hasn’t really been on the table in the current debate, it might be wishful thinking to expect it this year. That leaves the possibility of a do-over of the proposal to sell Medicare to people ages 55-64. This may be a step on the road to single payer, if we look at the road to single payer as a slippery slope, but really it is an uphill battle, and extending Medicare to a high-risk pool and giving it high premiums does not strike me as a big step up the hill. If we’re going to extend Medicare it should be to a diverse pool of enrollees rather than to the highest-risk pool possible, and it’s hard to see how the creation of a plan with high premiums for one segment of the population will endear people to a government insurer.
At this point, a brief note on co-ops. I don’t think they ended up in the final Senate bill, which is probably fine. Maybe congress could do something interesting with this in the coming year, but the final option I’m about to discuss would seem to be both more effective and more easily imple-mented, given that people at least know how it would work.
The strong public option is, out of the possibilities I’ve discussed here, the only one which I see as being a good use of the Senate’s time in the coming session if they want to put some kind of public option into action (unless of course they miraculously passed single-payer). Making the public op-tion available to a very large pool, i.e. anyone who wants to buy in, whether they have insurance now or not, should help hold down premiums compared to the weak public option, presumably, since it would be non-profit, and with as diverse a pool of enrollees as most private plans, to a cost below private insurers in their current form. Whether private insurers could meet the competition is a moot point; if they can’t and subsequently fail, I doubt many consumers would mourn their parting. I mentioned people who might buy into it; who might they be? Besides the currently uninsured, I’m guessing that if the tax on “Cadillac” plans is here to stay, employers who offer those plans might try to switch to the public option, assuming that it’s a good plan and would be just as cost effective as switching to private plans which don’t cover as much as it would, or if employers didn’t switch, I wouldn’t be surprised if their employees got tired of paying the tax and demanded to switch to the public option. I wonder how much unions with strong coverage now through private insurers would advocate employers switching to the public option? Now, how would the Senate pass the public option, supposing a strong one comes up for debate, which I think is the one kind worth debating based on how the current legislation turned out? Based on the past several months, it seems nearly impossible that it would just sail through with sixty votes, but reconciliation would appear a good approach here. For one thing, if people who are given subsidies to buy private insurance under the current legislation could enroll in the public option instead, they would subsequently either no longer need a subsidy, or would need a smaller one, in order to buy cheaper insurance than the subsidized private plan, and so by reducing the amount paid in subsidies by the federal government, I guess the strong public option would reduce the deficit.