Is There A Fair Trade For Giving Up The Public Option?

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To achieve anything in politics or anything else in life one critical factor is to have a clearly defined end state. Without this you can not know when you have actually crossed the finish line. We all know, either from watching politics or being involved directly, how easy it is to get so focused on the fight you lose track of the over all goals. It seems to the Dog this has become the case with Health Care Reform in general and the Public Option in particular. Over the last few months the Netroots has been strongly engaged in trying to get a version of the public option enacted as part of the over all health care reform.

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The Dog has his own reasons for this, as he is looking long term to get to a system something akin to France’s where the government either directly pays for services or you pay and the government reimburses you for the out of pocket costs. Given this end state the Dog has argued everything else is negotiable as long as the public option is preserved, since it is the required first step to getting to a fully national health care system. Sadly no one has really asked the Dog (well at least none of the people writing the HCR bills).  This is frustrating to say the least, but it has made the Dog think about the flip side of the equation, what would be a fair trade in the other things on the agenda for this major concession?

While we as Progressives and Liberals have already compromised on Single Payer and are being asked to compromise again on the Public Option, we should not over look the many things we have wanted for a long time and are in reach of regardless of how the fight on the Public Option plays out. Below are a few the Dog feels are particularly important.

Individual And Employer Mandates – These two, as long as they are implemented together are key. This is a big part of actually getting to 98% or 99% of the nation covered with insurance. The big selling point is it will bring in younger healthier folks who will make the pool lest costly. This is true as far as it goes, but there is more.

If all employers over a certain size had to cover their employees or pay the government an equivalent cost it would cover many of the working poor we know are uninsured now. This would drastically shrink the number of folks who would be caught up in the individual mandate and reduce the cost of subsidizing them so they could afford coverage.

It also flattens the cost curve in an unnoticed way. Those younger folks who we assume are cheaper to cover, well there are not as cheap as we think. People in their 20’s are generally healthier, this is true, but they are also more prone to things like car accidents and recreational accidents. If they do not have coverage, they are treated at hospitals and emergency rooms and that cost is far more than if they had some kind of coverage.

As a matter of public health they are the population group most likely to contract STD’s from syphilis to herpes to HIV/AIDS. Some of these diseases are easy to treat, some require life long treatment. All are easier to treat if they are caught early.

Which leads us to the issue of preventative care and long term health. If younger folks have access to a full level of care in their twenties, they are more likely to leave their twenties with a higher over all level of health than is the case today. Being healthier earlier in life sets the stage for a healthier middle and old age. This will reduce the cost of care going forward for the nation as a whole. It is true it is not going to be a major effect for several decades, but once the trend takes hold it is unlikely to reverse itself.

No Denial For Preexisting Conditions – This is a huge step which Liberals have wanted for a long time. By making it impossible for Insurance Companies to deny coverage for those with preexisting conditions we do a couple of things. First off, and most important, those who suffer chronic conditions will be able to get the care they need. Second it will make workers less dependant on their current employment. Being tied to a job because of your or your partner’s illness is part and parcel of the wage stagnation in this country. It is not all of the causes, but any time you can not tell your employer “Take this job and stick it!” your negotiation position on wages and compensation is severely diminished.

No Lifetime Spending Caps  – This is another long term desire for reform that prior to this debate seemed to be going nowhere. One of the reasons people do go bankrupt even with health insurance is they run up against this cap and then they are required to pay for everything themselves. It is insane that an Insurance Company can take your money for decades and once you reach an arbitrary number you are finished, for life. Ending this will help greatly to reduce the number of health related bankruptcies.

Comprehensive Digital Medical Records – It is strange, but an act to protect our privacy actually increased the cost of health care. HIPAA, the Health Insurance Portability and Accountability Act was intended, in part, to protect consumers from Insurance Companies using preexisting conditions to deny care. The unintended consequence of this act is a massive increase in the number of tests run. Since the bar is so high for getting records from one doctor to another, a specialist is more prone to just order any test she might rather than try to get the information from the same test another doctor ran. By removing preexisting conditions as a reason fro denial of coverage  we can also move to digital records which go with the patient. This will help to reduce the duplication of expensive tests and lead to a better overall outcome. These two factors will decrease the cost of care by a significant fraction.

All of these are important issues we have been wanting for a very long time, they are among the uncontroversial aspects of bills in the House and Senate. So the question becomes do are we as Progressives and Liberals willing to give up on these massive improvements to the system of Health Insurance in this country for the Public Option?

Now the Dog is a fan of the Progressive Caucus standing strong for the Public Option, to do anything else will assure there is not only not a Public Option but no real reform of any kind. We are seeing that there may be some kind of Public Option, but it seems if it happens it will be with a trigger. Given that, is it time to put achieving the Public Option out a few years and use this huge bargaining chip to lock down the other important changes?

What if Liberals and Progressives agreed to the following:

First off, this trade is all or nothing. Any changes mean a reversion to voting no on Reform from the Progressive Caucus and killing of reform.

Employee and Individual Mandates (yeah this is going to give the Insurance Companies a lot of money, but that was going to happen with the Public Option too, even those being subsidized would have had their choice and some would have chosen existing Insurance Companies). Employers who don’t offer coverage will be charged the per person average for their Insurance market for each employee.

Subsidies up to 400% of the poverty level.

End preexisting conditions as reasons for denial of coverage.

End life time spending caps.

Limit to 20% the amount of money that can be spent on Administration by Insurance Companies.

Requirement for all medical records to be fully digital in five years, no exceptions.

The Dog knows many of his fellow Progressives and Liberals have a visceral hate of the Insurance Companies, the Dog shares this but it should not distract us from our goal of covering all citizens. It should also not prevent us from making a good deal with the knowledge we will be coming back to this issue, and this deal would surely mean that.

If we could get this set of reforms in place it would not only preserve the issue of the public option for the future, it would gain us allies in business. Once every company has to pay for insurance one way or the other, they would immediately be looking for ways to reduce the cost. After four or five years we could come back to the issue of the best way to reduce the cost to everyone is increase the level of competition. What is the best way to do that? The Public Option of course.

So, are a few arguments for what might be gained if we were willing to bargain away the Public Option. It is up to you to decide if you think it is worth it or not. There are issues with the Democrats having problems with standing strong, but if the President where to agree to no changes it would go a long way to getting it down. In any case whether you decide to stand on the Public Option or not, you now can make a more informed decision. If No public option equals no reform to you, then you know what that means. If you think that a triggered public option is not worth anything, now you have some ideas for what you might get instead.

The Dog suspects you will hear something very similar to this in the Presidents address to the Joint Session of Congress on Wednesday. Before you reject it out of hand, take a couple of days to think the whole thing through. What is your goal for health care reform? What trades are you willing to make and what your walk away point is. Once you have made your informed decision, you will not only be able to stick to it, you will be better able to argue for it.

The floor is yours.  


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  1. the reasons I detailed, but if we are going to get a public option with a trigger, how is that better than trading it now and coming back to it later? At the very least we don’t have to have the fight all through the trigger period to prevent it from going into effect. If we could lock down some serious progress and still be able to come back to the public option in the future, that might be worth it.  

  2. okay, just kidding.

    Ill try to re-read, but at the moment Im feeling quite contrary. 🙂

    Tell me… Where in this “package” is there any assurance that me, you, jane or joe average, can afford health care, and/or HC Insurance? and where is some assurance that, for my buck, I get all the bang I need? i.e. quality care.

    P.S. Now, not later.

  3. Subsidies up to 400% of the poverty level.

    End preexisting conditions as reasons for denial of coverage.

    End life time spending caps.

    Limit to 20% the amount of money that can be spent on Administration by Insurance Companies.

    Requirement for all medical records to be fully digital in five years, no exceptions.

    That does anything at all to reduce the cost of private Health Insurance, and then we’ll talk.

    Until then, all these proposals are shiny baubles that merely distract from the primary goal of affordable care.

    Besides, we are still going to get these things regardless of whether we get the public option or not, so where exactly is the benefit here?

  4. … give a corporation a guaranteed income stream, from a customer with limited market power, and we know how they will act. They will spend whatever is necessary in order to be allowed to abuse the mandated individual customers as much as they can.

    And a cozy duopoly is, of course, little better in most markets than a monopoly.

    However, a public option is an effect “price maker” for coverage, and if they squeeze too hard, they squeeze themselves out of the market. So with a public option in place, they do not have the same profit motive to buy the right to abuse their customers from the government, since they no longer have a captive market.

    An individual mandate without a public option is WORSE than no individual mandate at all.

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