New compromises to replace the public option

by Jay McDonough

It seems like, at this point, the best case public option health care scenario to be passed by Congress would allow states to opt out and without the advantage of being able to negotiate for lower cost Medicare payments to providers.

So, it begs the question; can Congress pass a public option that will do more harm than good?  Won't a public option that ends up being so compromised in Congress and, as a result, be too expensive do damage to future progressive reforms? 

It's certainly where I am.  The objectives going in were to provide more access and lower costs.  While all the proposals to date have provided health care to some percentage of folks now uninsured, the efforts to effectively lower costs have been stymied, either by Congressional heebie jeebies over pissing off health care lobbyists, Republican stonewalling, or concessions to conservative Democrats.  

But politics is nasty and accomplishing half the objectives doesn't mean partial success but, instead, mostly failure.  There won't be any pats on the back about insuring most or all of the 45 some million folks who currently do without.  Instead, there will be recriminations and "I told you so's" from the GOP and conservative Democrats that the exorbitant costs weren't reined in and any opportunities to make additional improvements will be gone.

Ezra Klein notes a number of Congress members are starting to worry about it and, even at this late date, hoping to negotiate some compromises dump the public option but maintain the spirit of reform.  Those proposals include:

1) Medicare buy-in: 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.

2) Medicaid expansion: The House health-care reform plan lets Medicaid cover folks up to 150 percent of the poverty rate. The Senate bill hits only 133 percent. Bringing the Senate bill into line with the House bill would ease the financial burden -- and assure more comprehensive insurance -- for the very poorest Americans, who are most in need of help anyway.

3) Subsidy expansion: The Senate bill costs about $850 billion, and most observers agree the subsidies are too low. An easy compromise would be to resuscitate the president's idea to cap itemized deductions at 35 percent of income (actually, he wanted 28 percent of income, but never mind), which would raise a bit more than $100 billion, money that could go to expand the subsidies.

4) Tighter regulation of insurers: This could take a number of forms. Allowing less discrimination around age and geography could be one. Another would be a tight cap on the so-called medical loss ratio, which is the amount of money that goes toward paying claims, as opposed to the amount of money that goes to profits, compensation, advertising,and everything else. The bill, for instance, could force insurers to use 87 percent of every premium dollar to actually pay for medical care, which would force the plans to act more like liberals want the public option to act.

5) Open exchanges: Chartering national non-profits to compete with the for-profit insurance market isn't a bad idea, but it's not going to have much of an effect if less than 10 percent of the population is allowed to purchase from them. That, however, is the current situation, as the exchanges are locked to most Americans. Opening them to larger businesses would be the first step toward creating a more competitive insurance market, and allowing something along the lines of Ron Wyden's Free Choice amendment, which gives individuals who don't like their employer's insurance the ability to take their money and choose something better, would be the second.

Any plan to make a significant reduction in health care costs will ultimately have to address provider costs.  There's no reason in the world why U.S. hospital stays should be two or three times more expensive than a European hospital.  Disincentivizing doctors from prescribing unnecessary treatments and tests and adopting the Mayo Clinic model of salaried health care workers is, ultimately, how costs are reduced.