Stoopid Stuff

Going Public

Amidst all the hollering about Obama's plan for health care reform and the "Public Option", it's becoming easy to lose sight of the larger picture. So perhaps a few random thoughts are in order. First, when we discuss the public option, we are NOT talking about "Socialized Medicine", nor are we talking about a "government takeover of health care". We're talking about a government sponsored not-for-profit insurance company. One that will be able to dictate the rates it pays to providers and will serve as an insurer-of-last-resort for people who for whatever reason cannot get private insurance. This is all good. When we talk about health care, our concern is for the health of our citizens, families and their children, not for the profits of private health insurance companies. If they can't find a way to compete, who cares? This isn't manufacturing or retail, this is about the health of Americans.

Second, when it comes to health care reform in the US, we need to think in larger terms than just the public option or any other component part. Here's what I mean. When we talk about health care reform, we're really talking about three things:

1. Insurance industry reform.
2. Universal coverage.
3. Health care cost controls.

Industry reform addresses some of the more egregious practices of the private insurance industry, including refusal to cover people with pre-existing conditions, cancelling policies when someone gets sick, capping payments either yearly or lifetime, charging different prices to insure different people, etc. There is pretty universal agreement around these reforms, and along with universal coverage they form the heart of health reform in the US. Universal coverage is simply that. Providing a set of mechanisms whereby everyone in the US can get health coverage. This can be a combination of industry regulation, subsidies and expansion of Medicaid.

The last part of the reform policy structure is cost controls. From a policy standpoint, this is the most critical part, because if nothing is done to control health care costs, it is clear that within a few decades the cost of health care will be untenable, and at that point will require draconian action to avert national bankruptcy. Cost control measures under consideration include employer and individual mandates, tax policy, Medicare reforms and the so-called Public Option. That's right. The public option is nothing but a cost control measure. It isn't necessary for either insurance industry reform nor for universal coverage. It would serve to drive down the cost of health care delivery, and would provide incentives for the health care industry to reduce its administrative and operational costs. One of the oddest things about the whole imaginary "debate" over health policy this year is that the people who position themselves against a Public Option are typically people whose stated opposition to any policy is it's cost. For them to be specifically against a cost control measure, and to so blatantly choose to support industry profits over their own constituents and the national interest is eye opening to say the least.

The third thing that perhaps needs some further exploration is this broad assumption that it's up to Obama how this plays out. What's he going to say, is he going to present a plan, is he willing to drop the public option in negotiations? Look. It's fair to say that without the election of Barack Obama health insurance reform might not be on the table, we might not have as progressive a set of proposals in congress, and a popular and charismatic president can have a powerful effect on public opinion. But this legislation will live or die in the legislature. In the House of Representatives, depending on the structure of the bill, Obama could lose support of the Blue Dogs on the one hand, or the Liberal Caucus on the other. And in the Senate, with it's history of yielding to the demands of Senators from tiny rural states, with it's arcane procedural roadblocks and absolute lack of Democratic Party discipline, there are a multitude of veto points, resulting in a huge bias to retain the status quo.

For me, the public option is desirable, but the industry reforms and universal coverage are what this fight is all about. If we achieve those goals, the cost controls will come. The public option will come, medicare reforms will come, tax policy reform will come. Why? Because they HAVE TO. Because at some point, even a body like the US Senate will be forced by reality to act. So do the good now, and let reality drive the rest. But here's the thing. If you're going to give something up in negotiations, you have to GET something for it. What will the Republicans and Blue dogs agree to in exchange for taking the Public Option off the table? Unfortunately, they very likely feel like they don't need to offer anything, because so far the Obama administration has been negotiating with themselves. Anytime the Republicans or their delusional minions throw a tantrum over some health policy provision, Obama just agrees to scrap it. They have won every point, without argument, without pushback. That SHOULD be the real value of the public option - a hammer with which to drive agreement on the core elements of reform, to gain enough Republican votes in the Senate to prevent a filibuster, and to act as a lightning rod to provide cover for other somewhat less controversial provisions. There is no indication that the Obama administration is prepared to seriously defend ANY provision - indeed, they appear to be happy with any simply passing a piece of legislation, checking the box and moving on, perhaps to immigration. Obama's leadership might make a difference in the outcome - we will see if he's just too craven to take the political risk.

posted by mikey @ 12:10 PM