Jacob S. Hacker is the Stanley B. Resor Professor of Political Science at Yale University. An expert on the politics of U.S. health and social policy, he is author, coauthor, or editor of numerous books and articles, both scholarly and popular, including The Great Risk Shift: The New Economic Insecurity and the Decline of the American Dream (2006; paperback, January 2008) and Health At Risk: America’s Ailing Health System and How to Heal It (2008).
As the Senate debates the health care bill put together by Majority Leader Reid, the scramble is on to come up with a new compromise regarding the public option--the public health insurance plan modeled after Medicare that will be offered within the new health insurance exchange to Americans who lack workplace health insurance (and to workers in small firms that decide to buy coverage through the exchange).
The goal of the current effort is simple: to get sixty votes to overcome a filibuster and pass a bill. Four of the sixty Senators who caucus with the Democrats have expressed, with varying degrees of certainty and specificity, that they don’t like the public option in the current bill. So the search is on for a compromise, any compromise, that will bring on these four, or allow one or two of them to be bypassed by picking up the support of Republican senators Olympia Snowe or Sue Collins.
The public option in the Senate bill, it should be emphasized, is a compromise of a compromise already. The first compromise was to have the public plan negotiate its rates directly with providers, rather than set them based on Medicare’s rates. This compromise meant that the Congressional Budget Office was unlikely to score the public plan as producing the huge savings that it projected for a plan that used Medicare-based rates. Whether CBO was right in discounting the negotiated-rate plan’s savings is another matter--as I have written on this site, it’s likely underestimating the cost-containment potential--but the CBO’s numbers rule on Capitol Hill.
The second compromise was to allow states that did not want to have the public plan operating within their borders to “opt out” with the passage of a state law. How many states will take advantage of this option is unclear, but it’s certain to reduce the impact of the public plan even further. Indeed, the CBO is now projecting—again, pessimistically in my view--that only a few million Americans will enroll in the public plan. Yet none of this has apparently appeased the handful of hold-outs. Emboldened by the White House’s lack of clarity and pressure on the issue, they are digging in their heels and spewing false claims about the public plan (for example, that it’s a budget buster when there are no special government subsidies for it and the CBO projects it will exert downward pressure on private premiums, thus lowering the price tag of reform). Hence the new push to find some kind of middle road.
The problem is that the “middle-ground” ideas that are currently flying around aren’t in the middle at all.
They represent abandonment of the public plan idea altogether. One proposal that is being floated, for example, is the chartering of a national nonprofit plan, similar to the “cooperatives” that Senator Kent Conrad has advocated. But the whole point of the public plan is to create a plan that is up and running quickly and constructed on the existing infrastructure of Medicare so that it can create competitive pressure for insurers and serve as a backup for consumers on day one. In 35 states, after all, the largest private insurer enrolls more than half of privately insured patients. Many of these plans are nonprofits already--the problem is that they don’t face a credible alternative.
Another, even stranger idea is to offer the nonprofit plans available in the Federal Employees Health Benefit Plan (FEHBP) within the exchange. Since the FEHBP is itself a form of exchange, this amounts to offering a new set of private plans within a new set of private plans. How is that going to provide real pressure on private insurers in a consolidated insurance market in which nonprofit plans already have a large presence (and often act little differently from for-profit plans)?
In short, the new compromise proposals are anything but. They represent calls for advocates of the public plan to eat their crumbs and be happy. But a majority of Senators support the public plan. At least two--Senator Bernie Sanders, an independent from Vermont and Senator Burris of Illinois--have said having a real public plan in the legislation is a precondition for their support. Those who believe in the public plan—and, more important, who believe in the principle it embodies: that no American who lacks access to good insurance should be forced to buy coverage from the private plans that got us into our present mess--should stand firm in the face of these non-compromises.
This includes President Obama. He made the public plan part of his promise of change in 2008. Now he needs to put his weight and influence behind the public plan and its essential goals, rather than allow them to be gutted. This is in our nation’s interest. It is also in his and his party’s political interest. A bill that forces people to take private insurance but doesn’t create competition or a public benchmark is a prescription for unaffordable coverage, runaway costs, and political backlash. The “middle ground” is nowhere to stand if it’s going to crumble beneath you.
Update: Timothy Jost isn't too happy about this idea, either.
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COMMENTS (7)
"The public option in the Senate bill, it should be emphasized, is a compromise of a compromise already." Oh horseshit, I am tired of this formulation. For abortion foes, eliminating late term abortions isn't a compromise, you are either opposed to abortion or you aren't. We have a handful of Conservative Democratic Senators who are flat out opposed to the Public option, whining about how this is a compromise of a compromise is meaningless. Even without the Public option the Health care bill would be a substantial success, it is not crumbs, maybe to you who already have your own pie, but to the people without insurance, and who will be able to get it, and to those with pre-existing condition ... view full comment
"The public option in the Senate bill, it should be emphasized, is a compromise of a compromise already." Oh horseshit, I am tired of this formulation. For abortion foes, eliminating late term abortions isn't a compromise, you are either opposed to abortion or you aren't. We have a handful of Conservative Democratic Senators who are flat out opposed to the Public option, whining about how this is a compromise of a compromise is meaningless. Even without the Public option the Health care bill would be a substantial success, it is not crumbs, maybe to you who already have your own pie, but to the people without insurance, and who will be able to get it, and to those with pre-existing conditions forced to stay in unfulfilling jobs because they can't leave, they will be protected.
What you lack is imagination. There is nothing anywhere that prohibits individual states, or a compact between states, from setting up their own Public option. Get off your ass and agitate for that instead of threatening to screw over the millions of Americans who will assuredly benefit from this bill because it doesn't fit your own pre-conceived notions of what is acceptable.
Shame on Burris (that is if the nut could actually experience shame) and shame on Sanders too. A couple of old fools. Let them sabotage it all and then go back to the people in their states and explain how another generation has to be screwed. We all know the Conservative Democrats don't care so it would be no loss for them.
By the way, shame on you too for advocating getting into a pissing match that will fuck over millions of Americans. Take what you can get, and then improve it.
Right on. Many TNR and other articles--and comments on the articles--make the explicit or implicit assumption that any "compromise" weak bill that passes with some "insurance reforms" and little else will be an irreversible winner for health care in general and Democrats in particular. Could be, but I'd bet against that assumption if costs of health insurance for those that already have it are not obviously reduced. A strong public plan is NOT a sine qua non for health care cost containment, but a weak public plan or weak Co-Ops or whatever as alternatives are a likely recipe for health care cost increases and subsequent significant problems for future health care legislation and Democrati ... view full comment
Right on. Many TNR and other articles--and comments on the articles--make the explicit or implicit assumption that any "compromise" weak bill that passes with some "insurance reforms" and little else will be an irreversible winner for health care in general and Democrats in particular. Could be, but I'd bet against that assumption if costs of health insurance for those that already have it are not obviously reduced. A strong public plan is NOT a sine qua non for health care cost containment, but a weak public plan or weak Co-Ops or whatever as alternatives are a likely recipe for health care cost increases and subsequent significant problems for future health care legislation and Democratic political fortunes. Combine weak compromise health care reform with weak compromise stimulus package, weak financial regulation, and an Afghanistan war policy that is nether in nor out (but is costly) --- and you have a set of political gifts to Republicans that bolder actions would have avoided.
blackton. A modified senate bill that doesn't make AFFORDABLE insurance more available to those who dont have it and can be gamed by the insurance industry on coverage for pre-existing conditions is a disaster.
blackton. A modified senate bill that doesn't make AFFORDABLE insurance more available to those who dont have it and can be gamed by the insurance industry on coverage for pre-existing conditions is a disaster.
Tell it Blackton! Well said.
Tell it Blackton! Well said.
gdbittner, so what then? scrap it all and let the system continue on as is? of course Democrats want a public option, but without 60 votes what most Democrats want is utterly beside the point.
how on earth do you propose to force Lieberman, Lincoln, etc. to vote for cloture? Dems have 56 votes. And don't start talking about reconciliation, it is fast approaching the new year, there is no way in hell they are going to go back to square one just for the Public option, especially since Republicans will gum up the works on that for months, and then we will have the mid term elections, Dems will then get clobbered, and we are back to HSA's and other assorted goodies for the wealthy and well ... view full comment
gdbittner, so what then? scrap it all and let the system continue on as is? of course Democrats want a public option, but without 60 votes what most Democrats want is utterly beside the point.
how on earth do you propose to force Lieberman, Lincoln, etc. to vote for cloture? Dems have 56 votes. And don't start talking about reconciliation, it is fast approaching the new year, there is no way in hell they are going to go back to square one just for the Public option, especially since Republicans will gum up the works on that for months, and then we will have the mid term elections, Dems will then get clobbered, and we are back to HSA's and other assorted goodies for the wealthy and well connected.
Look, I would love the public option, I find it offensive that tax dollars will go to people who will then be forced to give it to the Insurance companies or face fines. But your choice is to give them nothing, make sure they have no insurance at all just to show THEM. You are fucking with peoples lives. I have little problem with pissing away money if the poor get health coverage. Insurance companies will get richer, but we will just tax them. And yes, the subsidies will come from taxes, but who do you think will pay the bulk of them? The upper Middle class and the rich. Are you really weeping for them?
As to other health care costs, medicare and medicaid or fed. programs, getting rid of medicare advantage is a great start to controlling those costs.
The Democrats gave up their leverage long ago when they accepted the mandate as the correlary to health insurance reform. I've said it many time: call the insurers' bluff, pass health insurance reform without the mandate and see what happens to the public option. It won't happen, of course, but don't pretend that the public option was vitiated for other reasons. The Democrats decided early to protect the insurers, and that got us to where we are today.
The Democrats gave up their leverage long ago when they accepted the mandate as the correlary to health insurance reform. I've said it many time: call the insurers' bluff, pass health insurance reform without the mandate and see what happens to the public option. It won't happen, of course, but don't pretend that the public option was vitiated for other reasons. The Democrats decided early to protect the insurers, and that got us to where we are today.
raylward, good point.
one last thing regarding the public option, since it is such a weak cup of tea, applying to a very small subset of people, people who are in the low economic strata, these people are going to have a hell of a time dealing with all the bs that comes with the Federal Government. Case in point, when my last son was born in the US, the hospital got his birthdate, name, and mother's name all wrong, and this was passed on wrong to his birth certificate. Since I only visit the states on vacations I spent my summer vacation straightening this out. For one, they spelled his middle name Franics instead of Francis, so I changed that on his certificate, they got his date wrong so I ... view full comment
raylward, good point.
one last thing regarding the public option, since it is such a weak cup of tea, applying to a very small subset of people, people who are in the low economic strata, these people are going to have a hell of a time dealing with all the bs that comes with the Federal Government. Case in point, when my last son was born in the US, the hospital got his birthdate, name, and mother's name all wrong, and this was passed on wrong to his birth certificate. Since I only visit the states on vacations I spent my summer vacation straightening this out. For one, they spelled his middle name Franics instead of Francis, so I changed that on his certificate, they got his date wrong so I went to the hospital for the correct date report, but the Fed. agency wouldn't accept it from me, only from the hospital, so I saw my state Rep. who thankfully co-ordinated that for me. So 2 out of 3 done, finally the maiden name of my wife was wrong (they left off the surname) so I provided them with out Wedding license issued in China and her birth certificate, this is in English and Chinese both and notarized by the agency. They wouldn't accept it unless it was translated (now, it already had English on it) and notarized by the embassy in China. Also, the women at the office also told me the name order was wrong, I told her that in China the Surname came first, then the given name. She told me she could not take my word for that (15 seconds on google would confirm this). This from a person who must deal with names all the time, to be so stupid is astounding. At this point there is nothing I can do so my son's birth certificate has only the given name of his mother and not the family name.
The lesson is, does anyone really expect millions of Americans to deal with the hassles of the assholes who will invariably work for the Public option? The government essentially told my wife and I we don't know her name.