The rumble regarding healthcare reform is upon us. Those of us who support single-payer healthcare financing have essentially been locked out of the discussion, but that's not the point of this diary (although it is a very sore point).
The point is, where do any of us interested in reform draw the line between active support and outright dissent in healthcare reform? What exactly constitutes an acceptable change to the way we finance healthcare in this country? (I purposely leave out the consideration of improvements to healthcare delivery, as these are really secondary to the fundamental problem in our system which is all about how we pay for our healthcare.)
I am deeply interested in the progressive perspective on this - that means your perspective. If we all add our $.02 together we might even wind up being able to finance this baby!
NPR had a good report on this recently.
Whether to create a new government-sponsored health plan to compete with private insurance is rapidly becoming the central issue in the ongoing debate on how to reshape the nation's health care system.
Many on this site have drawn their line in the sand at the "public option". The crux of this issue is, then, what exactly is the "public option"?
As Jacob Hacker points out, you can basically design the public option to be as aggressive and effective at crowding out private insurance as you want, because there is essentially no way that private insurance can compete with a single-payer-like entity. For example, Medicare has been made even more costly and inefficient with the introduction of the privatized Medicare Advantage plans (which, contrary to Jacob Hacker's assertion in the NPR story, are pitiful at competing with the public plan).
On the other hand, you can make it just another weak sauce private PPO provided insurance plan like all the just like the federal employees' insurance plans (FEBHP, which are heavily taxpayer subsidized to boot).
Thus, it would behoove us to come to some consensus as to what constitutes a reasonably acceptable public option, if there is such a thing. It would at a minimum be useful to think about these things before getting wildly antipathetic or sympathetic to whatever congress is concocting!
Let's first just be honest and admit that there really is no useful role for private insurance if we had a well-designed single payer system. Correction: there is no need for private insurance except for those items which may not be on the publicly funded single-payer plan (extended travel insurance, elective cosmetic surgery, private hospital room upgrades, and so forth).
Absent this ideal (sigh), we are left with a range of options for including these plans in competition with the public option in a fragmented and possibly multi-tiered (wealthier people getting better access at the expense of the less wealthy) system.
I recently asked a long time single-payer advocate who is also acutely aware that there needs to be support for the public option lest all be lost, what exactly they would need to see, and here is the response:
You're right that the plan is vague, but there are a number of people, including me and others who understand the potential of single payer, who are in the process of designing (detailed) public plans that can be politically viable now, quickly extend insurance to all Americans and that include structural elements which build a platform for future modifications that will take us toward a single unified national health plan.
In my mind, the most important elements to fight for in the plan at this point, are a broad eligibility policy that could rapidly create a large, cost effective risk pool and tools to avoid excessive high risk in the public plan such as requiring all insurers, public and private to share the cost of excessive risk in any one plan. Absent that, the private insurers can incentivize people with high medical expenses to choose the public plan, which could doom the plan early on. I mention this as an example of what single payer supporters could fight for now in Obama's plan.
This sounds to me like sage advice. It is certainly going to be a most entertaining battle! I'm not exactly sure where my line is, but most likely I'm more picky than you.
I would add that the reform, whatever it is, needs to be fiscally responsible as well, especially in these times. The painful truth is that a true universal single-payer system would actually save money, there is simply no disputing this fact. One might argue that we need to do whatever it takes regardless of cost, and I am sympathetic to that argument but not won over. Certainly we can do better than that! And please note that being fiscally responsible doesn't mean covering up healthcare financing losses with gains in healthcare delivery - those gains can be made under any system (although single-payer is the most ideal environment).
UPDATE: this just in (pdf) from the Lewin Group regarding the fiscal evaluation of the public option (as near as they can determine it to be)
The gist:
If Medicare payment levels are used in the public plan, premiums would be up to 30 percent less than premiums for comparable private coverage. On average, the monthly premium in the public plan for a typical benefits package would be $761 per family compared with an average of $970 per family in the private market for the same coverage.
If the public plan is opened to all employers as proposed by Senators Clinton and Edwards, at Medicare payment levels we estimate that about 131.2 million people would enroll in the public plan. The number of people with private health insurance would decline by 119.1 million people.
Medicare premiums would be lower than private premiums because of the exceptional leverage Medicare has with providers. Medicare pays hospitals about 30 percent less than private insurers pay for the same service. Physician payments are about 20 percent less than under private coverage. Also, because Medicare has no allowance for insurer profits or broker/agent commissions, administrative costs for this population are about one-third of administrative costs in private health plans.
Assuming Medicare reimbursement rates and eligibility for all individuals and employers, provider net income would decline under this public plan proposal, even after accounting for reduced uncompensated care and increased utilization for the newly insured. Net hospital revenues would fall by $36 billion (4.6 percent), and physician net income would fall by $33 billion (6.8 percent).
What is your line in the sand?