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Saving more than just face

If you’re at all interested in the health-care debate, especially if you’re coming from the progressive/liberal side of things, Ezra Klein’s reporting on his blog for the Washington Post is just essential. Klein just owns this beat, and every day he posts something from academia to think tanks to Congress that makes me think.

One recent post is especially outstanding. Most people know that the big debate right now is over the public option. Most liberal and progressive Democrats — and, um, more than half of all Americans — want some kind of public health care plan available. Some want a really robust plan, and want to fight for it; some just want something, anything, that could compete with private plans and maybe be built on for later. But most moderate Democrats and Republicans — and, um, the health care industry — don’t want the federal government in the health care business at all. So they are working to either strip the measure out of health care reform completely, reduce the scope and availability of the plan to make it as toothless as possible, or holding out for some other bribes concession to health care interests in their states.

But even if the public option has the highest profile of health-care reform measures (whether for or against), there’s lots of other less-sexy stuff that boosts access and reduces costs/prices. A little while ago, Klein asked an important question: if you give away the public option, what do you get? The thinking here is that a super-stripped-down state-run plan that can’t bargain like Medicare and is only available to a handful of people years from now isn’t automatically worth going to the mattresses for just to have something that bears the name “public option.” So instead of fighting for that idea (which the Republicans and many Democrats insist on fighting tooth-and-nail against), you use it as a bargaining chip, trading it away from something that can offer more bang for your political (and actual) buck.

For instance, instead of a state option for people on the exchange to buy into, which can’t negotiate like Medicare, Congress could allow everyone over the age of 55 to buy into Medicare itself. Klein:

The older you get, the tougher it is to find affordable insurance. Private insurers avoid you like the plague or jack your rates sky-high. Some of that will change with health-care reform. Insurers won’t be able to reject older Americans outright, for instance. But they’ll still be able to charge them quite a bit more than younger Americans pay.

One way to ease the situation for older Americans would be to let them buy into Medicare. Medicare negotiates far better rates than private insurers, making it a potentially cheaper option. Moreover, folks over 55 will be in Medicare fairly soon anyway, so this allows for not only better insurance, but more continuity in insurance, which means more continuity in doctors, preventive treatment, etc. This idea was present in Max Baucus’s original white paper, and even in Howard Dean’s 2004 health-care reform plan. It’s due for a comeback.

Another idea (none of these are either/or, by the way): you could likewise expand Medicaid, to cover everyone who lives below 150 percent of the poverty line. In those two strokes, you’ve extended Actually Existing Single-Payer Health Care to the two groups of Americans (the old and the poor) who have the hardest time finding and paying for decent private insurance.

But what about small businesses, and the self-employed? They have a hard time bargaining for good insurance too. Here’s another idea, that achieves all of the goals of the public option without being called or strictly structured as a public option:

Currently, insurance plans are regulated by the states, which means they’re different in every state. That makes it hard for them to achieve certain efficiencies of scale or maximize their leverage against providers. But back in September, I noticed a promising provision in Max Baucus’s draft that would allow for national insurance plans, so long as they met a minimum level of federal regulation. That seemed like a potentially huge change, but I never heard another word about it, so I let it go.

The compromise being discussed is built atop that provision. The idea is that the Office of Personnel Management would choose nonprofit plans that met national standards and offer them on every state exchange (unless states opted out). These plans would be private, but the OPM would act as an aggressive purchaser, ensuring that they met high standards and conducted themselves properly. It’s a private option with a public filter, essentially. But more importantly, it’s a menu of national, nonprofit plans, which would be much more interesting from a competitive standpoint than state-based, public plans.

There’s a great scene in The Fog of War where Robert McNamara talks about how he and the other folks in Kennedy’s war room realized that Khruschev didn’t want to go to nuclear war; he just wanted a scenario where he could say, “the United States was going to destroy Cuba, and I prevented it!” The US didn’t need to invade Havana or drop bombs on Stalingrad to get that result. They could get greater concessions more safely if they didn’t do those things.

Likewise, I wonder — if we give those punk-ass anti-reform moderates the ability to say, “the Obama administration was going to institute socialized medicine, and I prevented it!”, would that be worth it if we could actually get more people better health care more cheaply without it? I think I might take that deal. I bet the pragmatic tactician in Obama might, too — which is why even as he’s pushed for the public option, he’s always left himself some wiggle room.

December 7, 2009 / Uncategorized

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