My Thoughts on Health Care, Part I

What You Need To Know: A Summary For You Lazy Asses

·         My first choice for universal health care in this country is expanding Medicare to cover everybody (known as “single-payer” or, my preferred term, “Medicare for All”).  It’s the best solution on the merits and it satisfies my ideological preference for government directly handling its duties to the people.

·         Failing that, we need some kind of government-run insurance program available to everybody that competes alongside private insurers (“public option” being the term for the provision authorizing and creating the government insurance program, “public plan” referring to the program itself).  Ideally such a program would be available to everybody (“universal accessibility”) and would use reimbursement rates pegged to those of Medicare’s.

·         Unfortunately, the ideal public option has already been compromised to lose universal accessibility and Medicare rates, and there’s a better-than-even chance that it won’t even show up in the final bill.  At this point I’ll be happy just to get some public option, but it has to be a real public option, meaning no triggers and no co-ops.

·         If I were a member of Congress, I would vote for a health care bill ONLY if it had a real public option, meaning it had NO trigger mechanism and was NOT a co-op.  I would vote AGAINST a bill with a trigger and/or with co-ops.  I acknowledge the unfortunate fact that this would also mean a rejection of the good insurance reforms in the bill.

·         My insistence on the public option is based on practical and ideological reasons:

o        Practical: It’s been explained endlessly that having a public plan on the marketplace would “keep insurance companies honest”, hold down costs and provide a lower-cost, higher-quality choice for consumers.

o        Ideological: My general preference for government directly servicing the people instead of relying on private sector for-profit entities is well documented.  I strongly believe that health insurance is something that government should handle directly, and something that the private, for-profit companies are extremely ill suited to provide.

Additionally, because the bill will have an individual mandate requiring individuals to have health insurance, an individual mandate without a public option would amount to government forcing people to buy private insurance, with no choice of a lower-cost, more reliable and more moral government insurance plan.  This strikes me as not only a boondoggle for the insurance industry, but as a callous, immoral, and unconscionable edict on the part of the federal government.



There’s a lot I’ve been meaning to write and update about, but right now, with the legislative agenda of the past few months and President Obama’s “big speech” scheduled for September 9 2009, the big issue is health care and I want to weigh in.  I’m first going to talk about what I ideally want from health insurance reform, and then I’m going to comment on what we’ve gotten out of the process that has been going this past year, and where we should go from there.


Medicare for All


Ideally the system I’d want is Medicare for All; that is, to extend Medicare, a government-run insurance program, to cover everybody.  The extension of Medicare is often proposed to be phased in gradually, i.e. age eligibility for Medicare, starting from around 65 right now, would drop by ten years every x number of years, until everybody is eligible and covered.  This approach is often called “single-payer” because it’s assumed that government would be the sole payer of health care under such a system; however, that’s not necessarily true.


The current Medicare for All bill, H.R. 676, would make Medicare the sole payer for most health services because it would outlaw duplicated services from private insurance companies; the logic behind it being that everybody needs to pay in to Medicare in order to keep it financially stable.  While I agree with the logic, I don’t see the need to ban private companies from providing the same services, as long as everybody, rich and poor, is still paying into Medicare.  If some rich guy wants to buy expensive private insurance that gives him exactly the same thing as he gets under Medicare for whatever reason, that’s his choice and he has the right to make it, as long as he’s still paying his fair share into Medicare (whose services, of course, would be available to him at any time, just as it would be to everyone).  That said, I would not vote against a Medicare for All bill such as H.R. 676 solely over this one provision.


Various proposals have been made on how to finance an expanded Medicare, which is especially important since Medicare’s finances are currently in trouble.  I imagine the system can be funded through a small increase, perhaps progressive in nature, in payroll taxes on employees, and a much larger increase in payroll taxes on employers.  While this may technically be a tax increase for businesses, they would now be relieved of the burden of having to pay for health care for their employees, so they would at the very least be paying about the same and in many cases they’d be paying less under Medicare for All than they are now.


The practical reasons for Medicare for All have already been documented and explained ad nauseam – it’s more efficient, less expensive, holds costs down, etc.  There are two interlinked reasons, one practical and one ideological, that don’t get as much attention but are my biggest reasons for supporting it.  The practical reason is that Medicare, contrary to popular conception of government as being wasteful and incompetent, actually provides the best quality of care.  And a big part of that is that Medicare actually provides care, period – no denial of coverage because of preexisting conditions, no yanking of coverage out from under you (“rescissions”), as private companies do.


The difference in attitude and action between private and government health care leads to my second, ideological reason: Government has a responsibility to provide for the well-being of its people, and a big part of that is by directly ensuring that everyone has health care, through a government health care program that is controlled and run directly by the government.  Why is it so important for governmet to do health care instead of letting the mythical “free market” handle it?  Well, ideologically speaking, I generally prefer government to handle its duties directly instead of subcontracting it to rapacious private interests, which is why, for example, I support government directly providing health care to people instead of, say, giving people tax credits to buy private insurance for themselves, or any of these other approaches on the table that all to some extent rely on the private industry to deliver health insurance.


There’s a big difference between government and private companies in health care, as well as other industries that are usually handled by government for good reason.  Private companies are out to make a profit, and they don’t give a damn if people are screwed over in the process.  If people die because private, for-profit insurance companies turn them away, as often happens, or if people go bankrupt and lose their savings because private, for-profit insurance companies refuse to pay for their treatment, as often happens, private companies say to themselves, “hey, as long as the money keeps coming, the more people get fucked over, the merrier.”  That’s not something they do just to be evil; that’s something to do because that’s how to make money, and that’s their job – making money, NOT taking care of people.  Government’s job, on the other hand, is to take care of people.  And that’s the big difference between government and private industry.


So with private insurance, you get to shell out tons of money to people who don’t give a shit about you and are constantly looking for ways to screw you over.  With government, you get to pay less and get better insurance, whenever you need it, run by people whose job is to make you happy.  Maybe that’s why Medicare is very popular among those who receive it and politicians, even conservative Republicans who otherwise denounce “government-run health care”, will do nothing other than sing Medicare’s praises.

Which leads me to the political realities of Medicare for All.  Even though Medicare is incredibly popular and the idea of extending it to everyone has widespread support, everyone just assumes that Medicare for All is “politically unrealistic” and “won’t pass Congress”.  And as a result few people want to fight for it.  That to me seems like a self-fulfilling prophecy: it’s politically unrealistic because people make it so.  It has been argued that it’s politically unrealistic because H.R. 676 only has 86 cosponsors in the House of Representatives, with 218 votes needed to pass a bill.  That seems like a silly argument because it assumes that if the bill was actually put up to a vote with no alternative, only those 86 people would vote for it.  I think that if Medicare for All was put on the table as a serious candidate for discussion, it would get a lot of votes – maybe not 218, but definitely more than 86.  At the very least, it would have made it easier to “compromise” to less liberal solutions like the public option.


But Medicare for All was completely off the table in the Senate, thanks in large part to centrist asshole and insurance industry puppet Senate Finance Chairman Max Baucus (D-Mont.).  In the House, Medicare for All has some life; it’s been championed by Rep. Anthony Weiner (D-NY-9) and some members of the Congressional Progressive Caucus, who have fought hard enough to get debate time and a vote on it this month.  While this is way better than the total silence that Medicare for All advocates have grown accustomed to, it’s clear that the best idea was and is only going to be a side dish to the main event.  And so it was the powers-that-be that control Congress (as well as President Obama, who abandoned the idea of Medicare for All when he ran for President because he felt it would be “too disruptive”), not the individual members of Congress, that decided that Medicare for All would be “unrealistic”, because they decided it was so.  Now that Medicare for All is mostly rejected in favor of the public option, it is politically unrealistic because we’re too far along the process, unless we blow up the whole thing and start over.


The Public Option


So if Medicare for All won’t pass, what will?  In their 2008 campaigns, all three major Democratic presidential contenders – John Edwards, Barack Obama, and Hillary Clinton – called for a “public option”; that is, a government insurance company that would operate and compete with private ones.  While this wasn’t Medicare for All, it was a surprisingly government-heavy proposal to come from “mainstream” modern Democrats, and a huge improvement over what we got in 2004, when the most liberal proposals (aside from Dennis Kucinich carrying the Medicare for All torch) were to pay employers to give insurance to their employees (Dick Gephardt) or to let people buy into private insurance for federal employees (Howard Dean, John Kerry).


There are actually many different kinds of public options, ranging from “weak” to “robust”.  Jonathan Walker of Campaign for America’s Future does a great job laying out the different types of public options.  Obviously, I support the more robust variants.  A Medicare Buy In, in particular, makes the most sense to me as a public option – shouldn’t the public option utilize an existing public plan?  The government can create a new “Medicare Part E” or whatever for those not currently eligible for Medicare, who would pay a low premium (in addition to the Medicare taxes they already currently pay) to use all the services that Medicare recipients currently enjoy.  If the premium is low enough and the government provides sufficient subsidies to those who need it, I can envision this as a long-term or possibly even permanent solution, in lieu of straightforward Medicare for All (I most likely would still prefer Medicare for All, however).


Absent that, however, the strongest public options we have right now are the “Medicare Rates Plus With Opt Out” from the House Education and Labor and Ways and Means Committees.  The House Energy and Commerce Committee and Senate HELP Committee have produced “Level Playing Field” public options that will not be able to take advantage of Medicare rates.


I have always been leery of the Level Playing Field idea, because I’m worried that such a public option would simply be another insurance company, one that might have lower administrative costs and provide better and more reliable care, but might also become a “dumping ground” for the sickest and poorest that the private companies slough off, and would potentially collapse under the weight of its customers.  At one point in the health care debate I was against the Level Playing Field out of fear that when such a program collapsed, it would not only have failed its customers but would also be used as an example of “see, government sucks” by anti-government conservatives.  A minimum of Medicare Rates Plus With Opt Out public plan could at least offset the added costs of supporting the country’s sickest by spending less money paying doctors.


At this stage, though, it seems like the public option is in such serious trouble (though the conventional wisdom on that may very well be extremely exaggerated) that I’ll take any public option, even a Level Playing Field one, just to get one in there and then hope that Congress will improve it later.  That Congress can alter/tinker with the public plan later on is one of the four key features of Chris Bowers’s idea of a public option becoming a slippery slope to Medicare for All, the other three being guaranteed existence, funded through premiums (really, longhand for existence), and universal accessibility.


Of course, if I were in Congress I’d continue to fight hard for the strongest possible public plan all the way to the bitter end.  However, if the question is where liberals and progressives should draw their line in the sand for the purposes of the public plan in the current health care bill, I would follow the first two of Chris Bower’s principles and put it thusly:


1.      The public plan must be government-run and controlled, and accountable to Congress.  This is vital for making sure that the public plan can be improved later on.  This means that I oppose all co-ops, including the “National Semi-Independent Non-Profit”.


2.      The public plan must be available unconditionally, or else it may never come to exist.  This means that I oppose the “trigger” proposal that would create the public plan only in the event of certain market failures on the part of the private companies.


In summation, in order to win my support, any health care bill must have, at minimum, a public option that is government-controlled (NO CO-OPS) and guaranteed to come into existence (NO TRIGGERS).  I will oppose any health care bill that does not meet this condition.


There are two issues arising from this line in the sand.  One is, what about the public plan’s universal accessibility (i.e. everyone can get it) and ability to use Medicare’s lower rates?  Both of those provisions are near and dear to me and are vital for the public plan’s success.  However, since the conventional wisdom is that the public option probably won’t even make it to the final bill, we need to make sure we get a public option first.  As such that makes universal accessibility and Medicare rates optional for the time being, since once we get a public option in, we can always add those things later.  Of course, knowledge of conditions on the ground in D.C. may change my assessment.  If I knew that the public option was not only alive and kicking but universal accessibility and Medicare rates were attainable, I’d make a public option with universal accessibility and Medicare rates my new line in the sand.  Also, if I knew that adding in those things in the future was not politically feasible (as it may very well not be) then I would demand those things now, since a public plan would be very weak, and may not even be able to survive for long, without them.


In any case, I would draw my public lines in the sand as ambitiously and to the left as possible.  I would always demand the most leftist, liberal solution acceptable to me (e.g. Medicare for All) with the expectation that it will be compromised and watered down during the legislative process.  This is something I think Democrats failed to do this time and I think it was a huge mistake and a huge missed opportunity.  The failure to ask high initially, I think, has made the fight for the public option significantly more difficult, as the public option has become the “liberal demand” instead of the “sensible compromise” from Medicare for All.


The second issue is the more fundamental one that divides the real liberals from what I call “standard liberals” – that is, those who have liberal ideals but are willing to go along to get along and allow themselves to be completely dominated by “political reality”.  You may be asking, “Kenneth, the health care bill is chock full of good stuff besides the public option – no discrimination from preexisting conditions, insurance companies have to take everybody and charge people at the same rate, etc.  Would you really vote against all this good stuff just because there’s no public option?”


Of course I support the insurance industry reforms, and in fact it may be more politically feasible to pass them through the Senate independently of the public option.  But would I abandon them if there’s no public option?  Yes, and I’ll explain why.  Written in all the proposals is an individual mandate – a requirement for individuals to buy and have health insurance.  No one is talking about dropping that; in fact, it’s couched as an “exchange” in return for health insurance companies having to service everybody. (I love how the insurance industry is treated as some kind of equal partner that has to be coddled and placated.) But if there’s an individual mandate with no public option, that would basically amount to the government telling everyone, “You are required by law to spend money on private insurance” – the same private insurance that literally screws people over and leaves them to die or go bankrupt for a living.  What’s more, now that people are forced to buy insurance, money would be flowing to private companies, either directly from people or through government subsidies (which in turn come from people paying taxes).  In other words, an individual mandate with no public option would amount to a huge corporate bailout for the insurance industry.  No wonder all the major insurance companies and associations are lining up in support for this legislation like hungry dogs panting over a juicy steak.  You can often tell how good a bill is by who is for and against it, and if the insurance industry is for something that’s we all originally thought would hurt them, you know something is wrong.


There’s also the bigger ideological reason.  Like I said earlier, government, not private companies, is ultimately responsible for the well-being of the people.  That means that government should always be a provider of last resort.  So when all else fails and private insurance isn’t working, there should always be government insurance – a public plan – out there that every American can count on, especially if that same government is the one that’s making you buy insurance to begin with.  This is my ideological reason for insisting on having a public option and a public, government-run insurance company.


Of course, there’s also the small matter of a public option keeping insurance companies honest and holding costs down by not allowing private companies to charge sky-high rates and collect more government/individual money.


If all the bill had were industry reforms I’d support it.  But so long as there’s an individual mandate there has to be a public option.  No public option, no individual mandate, no bill.  I refuse to support any bill that has an individual mandate without a public option.


I’ll leave my commentary on the legislative process and selling of health care to another entry.  For now I’ll just say that President Obama’s big speech on September 9 is supposed to define the health care debate for the rest of this year.  I really hope he comes out, strongly and unambiguously, in favor of a public option.  If he doesn’t, and ends up signing a health care bill with an individual mandate but no public option, he will have failed not only everyone who fought to make him President, but future generations of Americans living in a country that will be basically dominated by the insurance industry.