Finding Common Ground Between Public Option Advocates and Single Payer Advocates

by: Ian Welsh

Mon Jul 27, 2009 at 13:30


A heated argument is going on about the right health insurance model between those those who believe in a public option and those who believe in single payer.

Or perhaps I should say between those who are willing to take what they can get: public option; vs. those who want to hold out for what they consider the best option: single payer.

By way of reconciling what differences can be reconciled, let me ask a question of each side.

A Question for Public Option Advocates

Do you want to eventually have a single payer or a comprehensive system like the French have?  If not, why not?

A Question for Single Payer Advocates

Are you willing to fight for a public option which could eventually lead to single payer or a comprehensive system like the French one? If not, why not?

At this point what I'm seeing is both sides retreating into moralistic screaming.

The public option folks are saying: "It is better to save some lives than none, and if you single payer purists don't support a public option which will save even a few lives, you're responsible for those deaths."

The single payer people are saying: "The public option is so watered down that all it will do is discredit real public reform, aka single payer.  You public option folks are settling for so little that the few lives you might save are outweighed by all the lives you won't save and the damage to the chance at real comprehensive health care reform."

Both sides are assuming the other side is operating in bad faith.  The public option folks assume the single payer folks just want to be pure rather than saving lives, the single payer that the public option folks are just sell-outs shilling for a bad bill.

But what I'm seeing, as someone with a foot in each camp, is that both sides are (mostly) sincere.

Now there is one group that can't be reconciled.  People who want a public option so weak it either won't survive, or can't be used as the basis for a comprehensive system.  The usual suspects like Insurance company executives, for example.  But also some people in the Obama administration, such as Health Secretary Katherine Sibelius, the health secretary, who said that the plan would be drafted specifically so that it could never become single payer.

But for everyone else, for those acting in good faith, there should be some common ground from which we can work together. Let's start by recognizing that the battle over public option vs single payer is a distraction away from what we could accomplish if we worked together.

United we stand a chance.  Divided, we will lose our chance at health care reform.

(Minor edits made 3 am July 26th for clarity and style)

Ian Welsh :: Finding Common Ground Between Public Option Advocates and Single Payer Advocates

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Finding Common Ground Between Public Option Advocates and Single Payer Advocates | 112 comments
I consider myself a single-payer advocate (4.00 / 2)
And yes, I'm willing to fight for a PO that could lead to single-payer. The problem is, I'm not sure such a PO exists. Or it exists, I'm doubtful that the POs under consideration could, or, more importantly, would.

What I'm expecting is that if Congress passes a bill with a PO, it'll be designed in such a way to favor private insurance companies, thereby undermining the public health insurance cause.

What I'd love to hear from a PO advocate is how, in both logistical and political terms, the POs under consideration would lead to single-payer.


I don't think a truly (4.00 / 2)
viable PO can be created that doesn't eventually lead to single payer or something like what the French have, actually.  If it is created in such a way as to allow it to drive down costs it will take over market share inexorably.  If it is limited enough to make sure it can't control costs, then it's almost certainly not viable.

Mind you, this is medium/long game stuff.  It would take 12 to 16 years, at a rough guesstimate.

[ Parent ]
But doesn't it also (4.00 / 2)
depend on strong (and unprecedented) regulation that prevents insurance companies from cherry-picking. My fear is that insurance companies--guaranteed a steady stream of customers by the mandate, which will require millions of people, including the generally healthy, former "free riders," to get insurance--will be especially merciless and diligent in denying coverage to "unprofitable" customers.

Here's Himmelstein and Woolhander:

A quarter century of experience with public/private competition in the Medicare program demonstrates that the private plans will not allow a level playing field. Despite strict regulation, private insurers have successfully cherry picked healthier seniors, and have exploited regional health spending differences to their advantage. They have progressively undermined the public plan - which started as the single payer for seniors and has now become a funding mechanism for HMOs - and a place to dump the unprofitably ill. A public plan option does not lead toward single payer, but toward the segregation of patients, with profitable ones in private plans and unprofitable ones in the public plan.

http://www.pnhp.org/blog/2009/...

[ Parent ]
That's the irony (0.00 / 0)
I can make a case that the PO is not going to fail because that is where the private insurance companies will drive the truly sick.  People with Chronic conditions are going to wind up on the PO because they are not profitable.
[ Parent ]
What's the mechanism? (4.00 / 1)
We know how the insurance companies do this now. But how would they accomplish it under the specific provisions of HR3200?
[ Parent ]
I was wondering that too (4.00 / 1)
if pre-denial (existing conditions) and post-denial (rescission) are both outlawed what will those bastards do?
[ Parent ]
The burden of proof is the other way, Bruce (0.00 / 0)
All other things being equal, it's always more profitable to collect the premiums and deny care. That's not because the insurance companies are run by bad people; it's because they have a fiduciary responsibility to their shareholders to make a profit.

So those are the incentives, and today there's an entire consulting industry devoted to figuring out how to game the existing system to deny people care who have already paid for it; see Wendell Potter's interview on Bill Moyers.

The incentives will not change. What will change is that the existing legislation will be replaced by an extremely complex, entirely unproven bill that's (as of this writing) over 1000 pages long (in great contrast to HR676, which is 73 pages long). Moreover, if the Democratic leadership and "progressives" have their way, this legislation will be passed NOW NOW NOW, a process unpleasantly reminiscent of AUMF, USA Patriot Act, and TARP. And that's before we get to the conference committee.

Now, if you want to argue that an complex, unproven, 1000-page-plus piece of sausage-making done in a rush isn't going to be gameable by the highly paid consulting firms who are very successful at doing just that, then knock yourself out. Have at it, say I.

But the burden of proof is on you.

NOTE The solution, of course, is to get profit out of the system. That's what single payer does.

I am in earnest -- I will not equivocate -- I will not excuse -- I will not retreat a single inch -- AND I WILL BE HEARD.  

[ Parent ]
The proof is in the pudding (0.00 / 0)
HR 3200 is long because it does a lot more than just set up a public option. Almost all of the relevant sections are in the first 75 pages making it comparable to HR676 in practice.

The questions is not about incentives or fiduciary responsibilities, it is whether HR3200 if enacted has sufficient regulatory barriers to prevent Insurance companies from continuing their current predator practices. On my reading it will. On what appears to be a non-reading you assume it doesn't. Why?

The relevant portions of the bill are not that complex. You just have to take a little time to follow the link and read them in the context of the claims that are being promoted. I am finding that most of the characterizations floating around either from the people who want to kill health care outright or from those who want to hold out for some vision of perfection are not in fact supported by the text of the bill. All I am asking is that people who oppose HR3200 lay out there arguments with some degree of precision as opposed to some pretty flabby platitudes about how the Man has always screwed us over and always will.

The idea that this bill is a rush is just as stupid as the idea that the stimulus bill was a rush, as is apparent if you read both. Each are the product of years of staff work that was just on the shelf waiting for the opportune time. Kennedy and his people haven't been siting around for thirty years scratching their asses, this bill is carefully crafted and the craftmanship shows. But only if you are willing to slowdown and examine it.

The burden of proof is not on me because I reject your premises. Show me that this was actually just knocked out over the course of a few days and we can talk. But as noted much the same claims were made about the pork in the stimulus bill, when push came to shove the Republican Senator's list of pork came to 2.19% of the bill much of which was for spending on Homeland Security. The rest of it was from proposals that had been on the drawing board for months and years.

This wasn't done as a rush, it is the culmination of an agenda put together by FDR seventy five years ago, attempted by Truman, partially accomplished by LBJ and now maybe ready to go a stage farther.

Carpe diem does NOT in fact mean 'Bitch about the day'.

[ Parent ]
Boy this is going to be repetitious (0.00 / 0)
Read the bill
http://edlabor.house.gov/docum...
The relevant part of the bill is Title 1 Subtitle B "Standards Guaranteeing Access to Affordable Coverage" which are then detailed in Secs 111-116 on pages 19-25. Sec 111 prohibits screening by pre-existing condition, Sec 112 prohibits post-diagnosis rescission except for non-payment or outright fraud (and not as defined by the insurance company). Sec 113 sets strict limits on rating by age or area or family size, and in any event no one can be excluded by that alone, and perhaps most interestingly Sec 116 sets floors for 'medical loss'. If a company somehow dodges the limitations of Sec 111-115 and cherry picks the pool in a way that their ratio of payout ('medical loss ratio') drops below a set level  of premiums the company is compelled to issue rebates for the difference.

Now there may be loopholes in the language, and you can bet the insurance company lawyers will be looking for them, but they simply shouldn't be able to get away with the abuses they do today with such things as Medicare Advantage.

[ Parent ]
I understand what the proposed PO says (0.00 / 0)
(And we'll see that if a PO passes, it still includes that language.)

My question is whether there'll be the political will, money, bureaucracy, etc to enforce the regulations.

[ Parent ]
QHBPs are contracts (0.00 / 0)
Which is why the word "Qualified" is in there. If you want to sell insurance through the Exchange you have to qualify your plan in advance via negotiations with the Health Choices Administration and show that you are meeting all the Access, Coverage and Affordability provisions. So to that degree most of the enforcement comes up front. There doesn't seem to be a lot of room to slip provisions undercutting actual coverage after the fact. And after the initial round of set up I don't see that there is a huge bureaucracy needed.
[ Parent ]
I think David's reply still stands (0.00 / 0)
There are a couple questions here:

1. Will Washington have the political will to enforce this?  Will they have the political ability to?  Nothing we've ever seen from Washington shows they will.

2. What will the final bill look like?  Because I can guarantee it will change from whatever's in there now.

Bottom line: there can be good and bad bills that contain a public option.  The California Nurses Association is very proud to have killed Arnold Schwarzeneggers 2007/8 healthcare reform bill...it would have been a massive public giveaway to insurance corporations, and would have included an individual mandate, which is certainly a poison pill, and huge subsidies to insurance corporations.  

So one important question for whatever bill emerges is if it will follow the California model...which would have resulted in a spike of more customers, revenue, and medical influence to insurance corporations, which was on-its-face a bad deal for patients.

If on the other hand, the bill that emerges will result in insurance companies losing over 100 million customers, as Karen Ignani was quoted as saying earlier this spring, that would be great for the public health.  But somehow I doubt with all the access that AHIP has in Washington that it will be the case.  

National Nurses United (AFL-CIO) is America's RN union, representing 150,000+ nurses from all 50 states.

[ Parent ]
Just to clarify: "Simply shouldn't be able to get away ... (0.00 / 0)
doesn't mean "won't be able to get away."

Check out Wendell Potter for a dose of reality on this topic.

I am in earnest -- I will not equivocate -- I will not excuse -- I will not retreat a single inch -- AND I WILL BE HEARD.  

[ Parent ]
I know it is against the law (0.00 / 0)
but I am very skeptical that they won't find a way to game the system. Maybe I am wrong and this won't happen, but the incentives to do it strike me as significant.

Sorry if I am repeating an argument made here many times before.

[ Parent ]
Medical providers would game Single Payer (4.00 / 1)
Just as many do Medicare today. That would not be a sufficient reason to reject Single Payer, nor should arguments from gamesmanship be allowed to argue against the Public Option.

People cheat on their taxes, business owners do the occasional (or continual) end runs on health and safety regulations. That kind of comes with the territory of government, it doesn't mean we just throw up our hands because we know the cheaters are out there.

[ Parent ]
They can't cherrypick (0.00 / 0)
they have to allow anyone to enroll at the same rates as everyone else.  (Well, there are some backdoor ways to cherrypick, but I think they aren't large enough to overcome the advantages of a properly done PO).  What they can do is screw people when they get sick: delay giving care etc... That can be dealt with clawbacks (ok, if someone drops your plan and comes to the public plan, you pay us the last five years of their premiums).
[ Parent ]
Don't be too sure (0.00 / 0)
Again, check out Wendell Potter.

I am in earnest -- I will not equivocate -- I will not excuse -- I will not retreat a single inch -- AND I WILL BE HEARD.  
[ Parent ]
Your point? (0.00 / 0)
I was familiar with Wendell Potter. In the interview he was pointing out the weaknesses, greed, and outright criminality in the current system. But I didn't see much of a hint that he was advocating Single Payer as opposed to Universal Coverage. If anything he spoke favorably about including a public option.

We know the current guys are crooks, I don't see that that fact says anything about Ian's argument.

[ Parent ]
Bureaucratic methods (0.00 / 0)
I can think of any number of ways that an insurance company can poison the user experience so badly that chronically ill patients will choose a no-bull manure public plan and get off the books of the insurance company.

Consider aggressive slow-walking of every claim. Objecting to every expenditure and asking for more information. Placing critical (and strategic) meds on the list that must be approved by an insurance co doc. When the patient gets enough claim-denied bills and trips to the pharmacy where they can't get their meds, they will look for something that is less painful.


[ Parent ]
That's one path to Single Payer (0.00 / 0)
I expect the private market for individual insurance probably will dry up pretty quick, HR3200 is set up in a way that insurance companies can't make windfall profits from individual , the better they are at cherry picking the more exposed they are to the rebate provisions of Sec 116.

There is little doubt that the Public Option will initially take on the bulk of the chronically ill. Then again a lot of those people would be on track to getting covered under Medicare after qualifying for Social Security Disability or for Medicaid if they were no longer able to work. In fact some of the savings in HR3200 are explicitly from keeping people insured and out of direct government programs.

As to playing games with prescriptions Sec 122 (b) (5) requires that they cover "prescription drugs". And Sec 121 (c) states "(c) NO RESTRICTIONS ON COVERAGE UNRELATED TO CLINICAL APPROPRIATENESS.-A qualified health benefits plan may not impose any restriction (other than cost-sharing) unrelated to clinical appropriateness on the coverage of the health care items and services."

Insurers have to provide a certain level of care simply not to trigger the rebate provisions of Sec 116, this should counteract this effect to some degree. But given that my long term goal is to move everyone to the Public Option and then transition that to Single Payer I am not too concerned about people being shoved into the Public Option by whatever means.

[ Parent ]
I seriously doubt (0.00 / 0)
That Sec 121 (c) abolishes insurance company formularies. So make sure meds for critically ill patients (inhaled meds used by COPD patients, for instance) are not in the formulary so they have to be approved by an insurance company doc (see CLINICAL APPROPRIATENESS). This can be made very annoying and even fatal if the insurance company is lucky.

There's nothing initial about this plan, the public option doesn't take effect until 2013, and as I've said in the past, I think they will manage to kill it prior to implementation even if the house bill passes (which it won't).

I don't see anything you've written that prevents an insurance company from cherry picking by just making the service too slow and painful to use. This is facilitated by getting rid of as many group plans as possible (see taxing company-paid insurance plans), since individual policyholders have zero leverage with the insurance company.

[ Parent ]
Who said it would be viable? (4.00 / 1)
See Ezra Klein here. It's not viable.

Now, the cost frame is just horrible, but that's the ground the administration and the public option advocates chose to fight on, and they can't seem to win even on ground of their own choosing, for pity's sake.

* * *

As for 12-16 years... If that timeline is a "from the zeitgeist" trial balloon on how long the the public option to single payer conversion will take -- assuming that such a thing is even possible, which no public option advocate I've seen has shown (links welcomed), then that's farcical. I mean, three Presidential election cycles? Remind me again why we gave the Dems control of the House, the Presidency, and a filibuster-proof majority in the Senate?

That's a "Yes, but no" answer. Farcical.

I am in earnest -- I will not equivocate -- I will not excuse -- I will not retreat a single inch -- AND I WILL BE HEARD.  

[ Parent ]
Who made Ezra KIng? (0.00 / 0)
I don't find appeals to authority absent some substance particularly compelling. Can you summarize Ezra's arguments or at least point at what sections he finds troubling?
[ Parent ]
Some things (4.00 / 3)
take time Lambert.  Market forces are amongst them.  My current long term economic forecast runs about 20 years, for example.  I predicted the current crisis back in 2003, 5 years ago.

What I'm reading from you is that no public option is acceptable to you.  That's fine.  It is to me, however.

The current one, however, is not.

[ Parent ]
Then don't rely on the market. (0.00 / 0)
The market is the problem.  Without stricter controls, it will refuse to do what's right every time.  This is because in a market system, things only happen if they benefit the market.  If they don't, then the market ensures those things never happen.  This is true on everything from health care to the environment.  That's why we put laws and regulations in place to keep the market under control, to prevent or alleviate its abuses so that the rights of the public are protected.  Waiting twelve or sixteen years we simply don't have for a fix that will never come if the market has any say is foolish.

And yes, Mr. Welsh, the public-option advocates are operating in bad faith.  The single-payer advocates aren't.  Believe it or not, there is such a thing as right or wrong.  Not everyone can be right.


[ Parent ]
Then you're reading me wrong (4.00 / 1)
The public option advocates have both said and allowed people to continue to think that public option would and could evolve to single payer. (Along with arguments that Obama secretly wants it, and so on). Fine. Put up or shut up, and show me how. That's why I wrote:

Now, if a public option advocate wants to outline a plausible path from point A (9 million covered) to point B (130 million covered) -- and put some skin in the game by whipping for it and continually posting on it -- I'd be glad to listen, but so far I've seen nothing at all like that.

Show me!

I am in earnest -- I will not equivocate -- I will not excuse -- I will not retreat a single inch -- AND I WILL BE HEARD.  
[ Parent ]
If it's cheaper (0.00 / 0)
it will take over.  I outlined the logic in my first post here at Open Left.  Granted, this PO plan can't do it, but that doesn't mean no plan can.
[ Parent ]
Well, your question says "the" public option, not ANY public option (4.00 / 1)
And as I said in my comment, I thought your post was the best approach I've heard. It was also heavily, heavily qualified (though that didn't prevent the public option advocates on-thread from stripping the qualifications and presenting it as a done deal).

I love ponies! But I've already got several on back order, and I don't need another one.

I am in earnest -- I will not equivocate -- I will not excuse -- I will not retreat a single inch -- AND I WILL BE HEARD.  

[ Parent ]
Okay I'll show you (0.00 / 0)
HR3200 takes a lot of the fun out of being a private insurer. In the current system they make big money by selling insurance to people who probably won't need much coverage over the short term, denying it to those who will, and then finding ways of denying care to the former pool if and when they get sick. Or maybe just kick them off the rolls for non-disclosure of something that happened twenty years ago. Under HR3200 very little of that is possible and none in the blatant way they operate today. The deep well of profits dries up and companies are reduced to the position of auto and home insurers competing mostly on price.

Under HR3200 there are still incentives to shoving off high cost customers to the Public Option but in exchange their margins suffer. They cannot make money serving a totally healthy risk pool, no payout means failing the medical loss ratio test and triggers rebates. The same dynamic applies to small employers, right now a single employee with a special needs kid, or an older employee who comes down with cancer throws the employers premium through the roof. I suspect that more and more of them will figure out that 8% of payroll is not that bad a price to never have to worry that an unexpected employee illness will result in a double digit increase in annual premiums. As group customers with high risk enrollees are squeezed out of private coverage and into the Public Option once again margins are squeezed. And in these cases the Public Option benefits by taking in the health members of the group. Over time private insurers will find themselves primarily in the roll of serving large employers who are ultimately self-insuring while losing their individual and group customer base to the PO. At some point if they are not making double digit profits insurers will bail out of the market all together just as they did when the HMO movement largely petered out.

At some point the Public Option would gain enough market share to be practically indistinguishable from Medicare with the self-employed paying a premium and most of the employed subsidized by a few on their employer. It is a pretty short move changing those fees to something very close to current Medicare contributions and just calling the Public Option Medicare for All.

I am not saying the process is totally seamless, just that the system is designed purposefully or not to drive people out of private insurance onto the Public Option. Which is to say opponents of the Public Option coming from the Right are quite correct. They know that ultimately they will not be able to compete on price with the PO and will ultimately find profit rates too low to stay in the market.

In the meantime 97% plus of the population has health insurance.

[ Parent ]
It won't (4.00 / 1)
The question that I have not heard answered by the single payor only side is this:

If the plan that passes the House gets to say, 97% coverage, how can it be morally opposed?  Put another way, there is a moral imperative to get access to people who do not have it.

It isn't really a PO vrs non PO issue: I don't that is the real dividing line.  

Put simply, the real question is this:  To what extent are we willing to defer structural reform to address the moral imperative of siginificantly expanding access to health care?

[ Parent ]
It's a moot point. (0.00 / 0)
The so-called public option will never come close to covering 97%.  You're using an argument similar to what advocates for torture use: that if there's a chance that we'll get done what needs to be, then shouldn't we go with this?  Never mind that your argument is based on a fantasy.  We're not taking the bait, and we're through ceding ground.  We've given up so much already.  We haven't got anything left to fork over.


[ Parent ]
yes torturing someone is just like expanding their (0.00 / 0)
access to health insurance.  sometimes, analogies don't work because their moral content is just entirely incommensurable.  
[ Parent ]
It's the same principle. (0.00 / 0)
It's using a fantasy scenario that is so unlikely to happen it's not even worth joking about in order to convince opponents to accept the notion that nothing is somehow better than something.  That's what the so-called public option is: nothing, which is being gutted so we get less than nothing.


[ Parent ]
Sorry... (4.00 / 1)
Ian, you ask:

Single Payer advocates:

Are you willing to fight for a public option which could eventually lead to single payer or a comprehensive system like the French one.  If not, why not?

That's a hypothetical, since the original public option as conceived by Hacker is not on offer; I don't regard HCAN's principals as meaningful, since they they could turn out in legislation to mean anything or nothing.

The true comparison is between HR676 and S703, and HR3200 watered down to whatever the Senate will pass.

Now, if a public option advocate wants to outline a plausible path from point A (9 million covered) to point B (130 million covered) -- and put some skin in the game by whipping for it and continually posting on it -- I'd be glad to listen, but so far I've seen nothing at all like that. (Your carefully couched post on "could" comes closest, and one post doth not a whipping make. Posting for health care as the welfare system -- means test + subsidy == welfare -- doesn't cut it.) All I hear (and I do grant this possibility) is that we have to pass the bill NOW NOW NOW, so STFU and get in line. Forgive my skepticism of a manufactured atmosphere of crisis for a bill that doesn't kick the public option in 'til 2013. And I can think of plenty of examples where NOW NOW NOW didn't work out very well in policy terms: USA Patriot Act, AUMF, and TARP, to name a few.

* * *

Ezra Klein in WaPo chat today:


Newton, Mass.: Do you expect a "public option" that under current House and Senate proposals, the CBO expects to see enrollment of 0-10 million to be robust enough to create downward pressure on insurance premiums?

If the "public option" as envisioned by Hacker was supposed to start out with enrollments of 123 million, does a public option with CBO expected enrollments of 0-10 million create the same market forces of the original public option concept?

Ezra Klein: Not really. I don't think the public options being considered will have a huge impact one way or the other, and certainly not in the short-term. For one thing, they can't use Medicare rates over the long-term. For another, a very small number of Americans can buy in, because the public option is only on the Exchange, and the Exchange has limited enrollment.

That's not to say they're not a good policy, and couldn't prove important in the long-term. But at the outset, I'm not expecting much from them.


Remind me again why the urgency?

NOTE Out of deference to your statement on "good faith," I'll postpone one or two posts I have in draft...  but what I will say is that exhorting people who aren't getting health care to take one for the team, so that when the shit sausage passes they can have the privilege of pressuring Congress sometime in 2013 for the care they still aren't getting seems, well, possibly not the most effective or unifying strategery. Surely it's possible to do better than this?

I am in earnest -- I will not equivocate -- I will not excuse -- I will not retreat a single inch -- AND I WILL BE HEARD.  

Did you read my last (0.00 / 0)
article? Or this one.  I said "a plan which leads to comprehensive or single payer".  I did not say the current House plan is one of them.
[ Parent ]
I'm answering the question posed in this post (0.00 / 0)
n/t

I am in earnest -- I will not equivocate -- I will not excuse -- I will not retreat a single inch -- AND I WILL BE HEARD.  
[ Parent ]
I sympathize. (0.00 / 0)
[ Parent ]
I'll repeat my question (0.00 / 0)
Who made Hacker king? HR3200 provides an 'option' operated by a 'public' governmental entity. Hence 'public option'. That Hacker describe a different plan in some research paper and called it 'public option' does not mean he gets a trademark on the phrase or the right to say that Waxman's PO is not 'really' a PO because it is not Hacker's PO.
________________________
http://edlabor.house.gov/docum...
The CBO estimate of only 10 million covered by the public option implicitly assumes that the private plans will play ball sufficiently for people to freely choose to enroll and stay enrolled in their plans at their cost points. If they drive their cost points up to much there is no barrier to people switching to the public plan during the annual open enrollment period.

And Ezra would need to explain exactly the extent to which "the Exchange has limited enrollment". Rules concerning the Exchange are laid out in Title 2 of which Sec 202 defines "Exchange-eligible individuals and employers' on page 73. Sec 202 REQUIRES individuals to enroll via the Exchange unless they are enrolled in a QHBP or 'other acceptable coverage'. 202 (c) 'Transition' lays out certain limits for employer enrollment in Y 1 and Y 2 but allows all employers to participate by Y 3. For individuals 'other acceptable coverage' is defined in 202 (d) (2) in seven categories (A)-(G). They are: QHB plan, Grandfathered under Sec 102, Medicare, Medicaid, Military/Tricare, VA and 'Other coverage' as approved by the Secretary. Where exactly is the 'limited enrollment' here? Given that employers have to bring their plans up to QHBP standards within 5 years or enroll in the Exchange I just don't see where Ezra comes up with "very small number of Americans can buy in". If you don't have coverage you HAVE to buy in or pay a penalty.

[ Parent ]
hey bruce (4.00 / 1)
do you know if the PO proposal has any medicaid-like asset provisions? I'll paste from my previous post so you can see what I mean better:

I know a few people that while eligible for medicaid  they don't enroll in it due to medicaid's assets policies like no more than $2,000 in the bank

I wouldn't like the PO to adopt the medicaid rules


[ Parent ]
I didn't see any asset limits (0.00 / 0)
Only income establishing subsidy levels
[ Parent ]
Er, the public option advocates made Hacker king (4.00 / 1)
That's where the idea, and the phrase, originated. See Sullivan here on the intellectual pedigree, and Digby, here, for an example:

And for those who [that would be me] say the public option is bullshit and nobody really knows what it is, read this by Jacob Hacker, one of the people who conceived of the idea in the first place.  He isn't an insurance company hack, he's a progressive professor at Berkeley.

That's the bait and switch right there. Hacker's public option (the bait) was envisioned as a Medicare-style plan that covered 130 million. The current public option is CBO-scored at covering only 9 million (the switch).

So, again, I'm very willing to have the public option advocates show how we get from 9 to 130 million and how long it will take. Details, please!

Clue stick: Letting the magic of the marketplace work for 20 years is not a showing.



I am in earnest -- I will not equivocate -- I will not excuse -- I will not retreat a single inch -- AND I WILL BE HEARD.  

[ Parent ]
. (0.00 / 0)
I'll go a step further and say I don't even mind the public option being on the chopping block as long as the compromise involves a very heavily regulated insurance industry with one federalized standard (why not the netherlands instead of france?).

I mean the truth is there are other ways to provide universal coverage and control costs outside of single payer AND the public option. I've always seen the public option more as a way to make the pill of the individual mandate easier to swallow. But not as an overall effective cost cutting provision.

As for the why's and why nots, because of the political landscape.

So no, if I'm a congressman I'm not really willing to fight for either. Well, I'd fight just enough to extract what compromises i want out of the insurance companies.

re: other ways (4.00 / 1)
Do you mean like Germany's? They do have universal healthcare without single payer, but their public insurance which covers 85% of the population is so highly regulated that it may as well be single payer:

In the public system the premium

   * is set by the Federal Ministry of Health based on a fixed set of covered services as described in the German Social Law (Sozialgesetzbuch - SGB), which limits those services to "economically viable, sufficient, necessary and meaningful services"
   * is not dependent on an individual's heath condition, but a percentage of salaried income (typically 10-15%, depending on the public health insurance company one is in, where half of that is paid by the employer)
   * includes family members of any family members, or "registered member" ( Familienversicherung - i.e. husband/wife and children are free)
   * is a "pay as you go" system - there is no saving for an individuals' higher health costs with rising age or existing conditions.


http://en.wikipedia.org/wiki/H...
[ Parent ]
Yes, this is an alternative path (0.00 / 0)
Perfectly acceptable to me to turn the health insurance companies into regulated public utilities. Heck, we should do it for banks.

I am in earnest -- I will not equivocate -- I will not excuse -- I will not retreat a single inch -- AND I WILL BE HEARD.  
[ Parent ]
. (0.00 / 0)
I specifically said the Netherlands but Germany also works as an example. So does Switzerland.

I like single payer because it's simpler but I was never married to the idea. And like i said, the public option to me was always the thing to make that makes the medicine go down easier but never the means to an end.

[ Parent ]
The problem with the "spoonful of sugar... (4.00 / 1)
... that makes the medicine go down" becomes evident when there is, in fact, no medicine.

I'm suspicious of a bait and switch on "universal" just like "public option" when universal turns out to mean several million uncovered, as now.

That said, Germany, the Netherlands, sure. But that's not the debate we're having. One very nice thing about single payer is that Canada uses it, so there are plenty of success stories from actual people (and not right wing hacks) in a North American and English-speaking context. Another nice thing about it, from the purely pragmatic standpoint -- and you thought I couldn't do that -- is that there's no National Health Service involved. It's single payer. Period. And finally, we've got both Medicare and VA to point to. It seems to me that if there's any system that could take root here, that was truly universal and could be shown to work, single payer would be it.

Would have been nice to have had that discussion in 2008, but nobody with a big megaphone thought that was important.

I am in earnest -- I will not equivocate -- I will not excuse -- I will not retreat a single inch -- AND I WILL BE HEARD.  

[ Parent ]
Thing about the Netherlands (4.00 / 1)
They have individual mandates and a regulated basic insurance plan, but look at what they get for their money.

The basic insurance plan has no deductibles, no co-pays, and full prescription coverage, and the private premium costs about 100 Euros a month. 100 Euros a month is well under the pain level of most household budgets, and the government assistance for low income people is also set at a reasonable level.

Massachusetts tried a similar public/private hybrid plan, and the state minimum plan is high-deductible junk insurance that's more expensive.

[ Parent ]
I am with Ian here (4.00 / 2)
I don't think Sebelius was fairly reported, nor is the Administration at this point writing the bill. My ultimate goal is Single Payer and I believe that at least the House version HR3200 is cleverly designed to drive people over time into the Public Option. Nor is the Public Option as outlined in HR3200 really as watered down as the Single Payer people are suggesting. In fact much of the language is in my view so distorted as to be deliberate.

I posted a couple of longish comments in Lamberts diary so don't want to repeat them at length. But frankly I get more than a whiff of a Heighten the Contradictions strategy coming from too many people pushing the Single Payer Now! message.

In particular they seem to suggest that there is no fundamental difference between the private plans that will be offered under the Exchange and private plan provisions that operate today and that all this is just a trick to lock people into the captives of the predatory private insurance companies. While I don't disagree that they are predatory to the point of criminality today HR3200 does strip out most of the pure and borderline evil profit centers.
HR3200 Text http://edlabor.house.gov/docum...
The relevant sections are 122 & 123 on pages 26-30 of the bill. And if you read them you can see that the private insurance companies are fairly tightly hedged in and the kinds of horror stories currently being floated about this "water down" PO just don't match the reality. What I would like to see is a discussion actually based on the bill language and not be some vague third hand descriptors.

It is not that hard, most of the pure policy pieces relevant are in the first 75 pages or so of the bill which like all such bills are double spaced with short lines of actual text. It is not like reading 1000 pages of War and Peace.

Actually (4.00 / 2)
I think the current house bill is too weak to lead to single payer.  What I am suggesting is that both SP and PO people work to make it stronger.
[ Parent ]
I'll get there (4.00 / 1)
I meant 'agree' in the sense of having a foot in both camps.
[ Parent ]
It might help if you listed suggestions for how that's to happen. (0.00 / 0)
At this point, the only thing that will make public-option advocates happy is a bill that is so watered down it'll be completely useless except as a means of killing any future chance for getting single-payer.


[ Parent ]
I'm just a simple soul (4.00 / 1)
And I think the way to advocate for single payer is to, well, advocate for single payer.

And I get this "I'm really for single payer, but, ya know, I'm changing the shock absorbers on my car today, so I can't really get to that now" flummery from public option advocates all the time. So I'm not really impressed with the woulda/coulda/shoulda stuff, or the appeal to inner and and unknowable mental states or purity of heart.

I've said elsewhere on this thread, and I'll say it again to you now: If you believe that HR3200 can evolve into single payer, what's a plausible series of steps and what's the timeline? Show me! I'm more than willing to listen!

Or, if you want to substitute the question of how HR3200 can evolve into a German-style system of highly regulated insurance companies, do that.

That's your winning argument. So why not make it?

NOTE Nice picador work on "heighten the contradictions." Conservatives smear us as "socialists", but "progressives," so much smarter and smoother, do the same with nods and winks....  

I am in earnest -- I will not equivocate -- I will not excuse -- I will not retreat a single inch -- AND I WILL BE HEARD.  

[ Parent ]
your final bit would have bite if 'socialist' were actually (0.00 / 0)
a bad word around here.  
[ Parent ]
your final bit would have bite if 'socialist' were actually (0.00 / 0)
a bad word around here.  
[ Parent ]
agree, to speak truth to power (4.00 / 1)
you have to actually speak it

National Nurses United (AFL-CIO) is America's RN union, representing 150,000+ nurses from all 50 states.
[ Parent ]
Another persepective (4.00 / 2)
I've had to deal with both, especially the single payer purists. I'm volunteering on the single payer campaign in California and also support the federal public option. I have a slightly different perspective.
PO is where the battlelines are drawn now. We need to take a stand and pass a strong PO to show we have the power to organize and get our agenda through. If we fail, it'll be 1994 all over again, and the insurance and drug lobbyists will show how they still have the power. If we succeed, it can only be spun as a victory for the forces of reform which gives us momentum to pass single payer at the state level and further reform at the federal level.
I don't buy the argument that PO is being set up to fail because the insurance lobbyists would much rather kill it completely or delay it with a trigger. PO won't have time to prove itself either good or bad before we start the push for state single payer.
Push for state single payer, yes. However -- (4.00 / 3)
It's not at all clear that public option advocates support this. They ought to be whipping for it (speaking of good faith).

I am in earnest -- I will not equivocate -- I will not excuse -- I will not retreat a single inch -- AND I WILL BE HEARD.  
[ Parent ]
Maybe they are just realists (0.00 / 0)
Not all of us are just shills for the insurance companies. I don't see Single Payer as viable and don't feel like whipping a yearling. When the horse gets big enough to ride then we will see.
[ Parent ]
You're losing a high profile opportunity (0.00 / 0)
for public education and political organizing, then!

National Nurses United (AFL-CIO) is America's RN union, representing 150,000+ nurses from all 50 states.
[ Parent ]
I don't support it (0.00 / 0)
I'll be honest, I do not support single payer at this time...there is no way for it to be deficit neutral, now is not the time to be eliminating an entire industry in the middle of an economic and jobs crisis.

And even if it will lead to more savings, which i don't doubt it will, when Republicans come to power in the next election because the public is angry over our adding another trillon dollars on the deficit, costing 250,000 people their jobs in the insurance industry, and forcing them off their healthcare, they will gut the single payer system before it even has a chance to work and what we would end up with would be worse than what the Democrats are proposing now.

The public option weens the public off the private system, shows them that a government option could work and lays in place a system that would allow us to modify it to a single payer if conditions warrant them in the future

[ Parent ]
This is disengenouous (0.00 / 0)
This is disingenuous, there is no chance at all that there will be a transition. There is no way single payer will pop into existence, in any bill, and certainly not pop into existence in such speed as to affect the present recession , and the business analysts will certainly conclude that single payer, even public option, adds to business viability.


Change
"We must break up the banks and never again let them get so big that they distort our politics and take down the economy.
[ Parent ]
PO Is critical, as is universal coverage, but not necessarily SP (4.00 / 1)
I do believe a PO is mandatory, and I would support it eventually evolving into a SP system. I don't think however that a SP system is absolutely necessarily from the start either.  First there is simply no way to get a SP system through congress when many democrats are still opposing a PO.  Further I appreciate the need to there being a evolving transition from private to public.

Personally I still believe the best system would be a universal healthcare voucher based system.  In short have a minimal public plan funded by a specific healthcare tax.   Cover everyone with that plan by default, but allow individuals to choose instead to have that tax credited back and applied to a private plan which provided equal or greater coverage than the public plan.  Couple this with a single payer system where the public agency acts as clearing house for all payments so providers only deal with the public agency and the public agency determines if they pay the bill or forward it to a private insurer.

Further I'd completely do away with employer pooling for coverage, which is why I like the Insurance Exchange concept.  Make insurance coverage completely independent of employment. This to me is the the most critical reform that is lacking from all the plans I read.  

Regardless what I object to in all the current proposals is that none truly offers universal coverage.  There are just too many loopholes for those that are unemployed, between jobs, etc...  Nobody talks about what happens when that one person that for whatever reason isn't insured shows up in the ER.

I think it's time for several case studies both of how these plans might evolve over 10-20 years, as well as what it would look like to individuals at various income levels.  

6 months into the Democratic trifecta (4.00 / 1)
And the Medicare Part D "no bargaining" abomination is still on the books. While not directly relevant (or is it?), this is the sort of crap that makes me doubtful that anything even half-decent will come of this.

I'm just fine with a strong public option. I just don't believe that Obama and his corporatist buddies in Congress give a hoot about a strong public option. While I welcome them to prove me wrong, please note that Dennis Kucinich has suggested that he will vote against any healthcare bill without his state-based single payer amendment. :

AMY GOODMAN: And so, what is happening right now, Congressman Kucinich? The latest, the possibility that the bill will not be passed by August, which some have taken to mean it's going to give more time for Republicans and the Blue Dog Democrats to water it down. But they're not even with the public plan. I'd like you to explain what is being offered, even coming close to the idea of single payer.
REP. DENNIS KUCINICH: Well, it's not close to the idea of single payer. It's mandating that people buy insurance. And it's telling insurance companies they have to sell insurance. Well, you know who wins in that deal.
The fact of the matter is, this debate is all skewed right now. You know, there are-both political parties are in trouble on the issue of healthcare. Our political system is failing the American people, and it's a bipartisan affair. So, what we have right now is a mishmash, which is being offered up as reform. Well, no wonder it's in trouble from all sides.
I mean, if people were offered a clear choice of a single-payer plan or not and told what the advantages are of having the government paying the bills, eliminating the overhead, enabling all Americans to have not just basic coverage with doctor of choice, but vision care, dental care, mental healthcare, prescription drugs, long-term care, all covered, if people knew that was the choice they could have, there wouldn't even-there wouldn't be much of a debate at all.
But we're falling back on old ideological arguments, when the fact of the matter is the insurance companies are running Washington and we have to break their hold. And that's why the single-payer amendment that I offer that gives states an option is a small step in the direction of trying to give states the ability to be able to determine their own destiny, and then hopefully America will be able to see in these laboratories of states that we can have a single-payer plan that can save people money and protect people's economic security and their health. Healthcare is a basic right. We still don't hear of that talked about in the major debate here in Washington about the bill that is being presented.
AMY GOODMAN: But do you think that a public plan, that's being proposed, could lead ultimately to single payer? Because most people would opt for the public plan, which is the health insurance companies' greatest nightmare, and ultimately would go in that other direction.
REP. DENNIS KUCINICH: I don't know that, Amy. I mean, right now what I see is a public plan that gives the insurance companies the option to pick the people's pockets. As long as you have a public plan, which now is going to be supported by what? Cuts in Medicaid, on the other hand? And undermining benefits to the elderly? Are you kidding me? I mean, this is-the balance that's being constructed right now indicates an inherent flaw in the proposal, to begin with. Now, I will vote for it, if we can keep the single payer in, because I think it would be worth the price. But without the single-payer provision in it, I don't know what's in the bill that would really be worthy of supporting

(emphasis mine)

DemocracyABC.org
TheRealNews.Com
http://www.pdamerica.org
Link for DemocracyNow quote (0.00 / 0)
[ Parent ]
AP concurs with Kucinich: The bills are an insurance company bailout (4.00 / 1)
Here; search on "guarantee".

I am in earnest -- I will not equivocate -- I will not excuse -- I will not retreat a single inch -- AND I WILL BE HEARD.  
[ Parent ]
And Kucinich says that despite a large number of flaws, (0.00 / 0)
Now, I will vote for it, if we can keep the single payer in,

And I thinks important.

Let us all remember folks! Canada's Health System was introduced in One Province, single payer, and then forced on others as the Party driving gained power. It was mixed across the land, and became the law only later after much struggle and the threatened defeat of the Liberals.

It has grown (and shrunk) as time has progressed, it requires not one great effort, but constant care and constant wariness and constant pressure.

Now that it is in. No One, not one single political party even  offhandedly suggests real change to single payer. Attempts to remove the right to health are met with withering public scorn and sure defeat in the polls. The most right wing polictal actors in recent Canadian history, the present Bushite toadies the Harper conservatives, promised formally live on coast to coast television that would not even think of touching a blanket or bottle or entitled person.

Change
"We must break up the banks and never again let them get so big that they distort our politics and take down the economy.

[ Parent ]
It's not a bad idea (0.00 / 0)
but as a Canadian I will point out something: Canadian provinces are much more fiscally strong than American states.  Much more.  
[ Parent ]
Saskatchewan was destroyed! Destroyed by the previous Conservative governemnt. (0.00 / 0)
They broke th province, emptying its bank accounts, and indebting the province to banks in Chicago and New York. Sound familiar?

Tommy Douglas, peace be upon him, found the books on the first day in office and was crushed, as he was intended to be crushed, about any plans he had for the province, let alone provide a single payer system. he went to the people, and read this well my conspiracy minded friends and let the people know that the books were destroyed and he was going to fix the books, then hold another election, then put single payer in.

That is what happened, there was another election, and that was the first Province to have SP.

Change
"We must break up the banks and never again let them get so big that they distort our politics and take down the economy.

[ Parent ]
Saskatchewan solved their budget problem (0.00 / 0)
By becoming the farmer's insurance provider. They offered cheaper farm insurance, saving many a farm incidentally, saving the rest much needed liquidity, and creating a large funding stream. This allowed them re-negotiate their loans, and set the Province on the road fiscal health.

The Provinces have greater revenue streams, but the federal govt. paid half of the of the provinces Health coasts once the national plan was established.

Change
"We must break up the banks and never again let them get so big that they distort our politics and take down the economy.

[ Parent ]
Yep (0.00 / 0)
So it would be nice to see the public option advocates whipping for it, ya know?

I am in earnest -- I will not equivocate -- I will not excuse -- I will not retreat a single inch -- AND I WILL BE HEARD.  
[ Parent ]
Kucinich will only vote for it if his amendment passes... (0.00 / 0)
...or if the Weiner amendment passes, i suspect.  otherwise, he won't support the bill.


[ Parent ]
Medicare Part D is on the books (0.00 / 0)
Because some people thought maybe it was important to first fix the system for the 50 million people who are not covered, rather than for a 50 million or so that are already covered under Medicare. Part D was deliberately written to benefit Big Pharma, but it is a hell of a lot better than the Nothing it replaced. The demand that Congress should have diverted attention from near Universal Health Care to address this in context narrow issue to some degree ignores the time tables involved.

Plus I don't agree with Kucinich's characterization of the plan. It doesn't jibe with what the actual bill text reads. Once again appeals to authority kind of leave me cold absent the substance behind the argument.

And I don't even understand the argument laid out in bold. Either the health system is Single Payer or it isn't, I don't see what "if we can keep the single payer in" even means here.

Maybe someone can help me out, the passage honestly confuses me.

BTW "undermining benefits to the elderly" is pure demagoguery. Rep Kucinich needs to lay out how that actually is in play. Reducing dollar expenditures on Medicare does not necessarily mean less care. The right is currently hell bent on selling this same message, that universal coverage means cuts to the elderly. I don't like it from them but I hate it when it comes from the Left. As if the elderly don't have an interest in having their kids and grandkids have medical care.

[ Parent ]
Kucinich is clear enough (0.00 / 0)
It's colloquial English in context. When Kucinich says if we can keep the single payer in," the context is his single payer amendment. That's the plain meaning if you look at the context. In fact, that amendment is the only place in the House where single payer is "in", since Weiner's amendment is being bottled up, and HR 676 is an entire bill. Does this help?

I am in earnest -- I will not equivocate -- I will not excuse -- I will not retreat a single inch -- AND I WILL BE HEARD.  
[ Parent ]
I think Kucinich means (0.00 / 0)
by "Keeping Single Payer In" keeping his amendment allowing STATES to institute Single payer in the bill.

The overall system nationally would not be single payer but in some state that hypothetically would take advantage of it, it would be.

sTiVo's rule: Just because YOU "wouldn't put it past 'em" doesn't prove that THEY did it.

[ Parent ]
Yes that's correct (4.00 / 1)
Maybe we should think of healthcare as something the laboratories of democracy should experiment with...e.g., the states.

National Nurses United (AFL-CIO) is America's RN union, representing 150,000+ nurses from all 50 states.
[ Parent ]
That's certainly how I took it (4.00 / 1)
Don't see how any other interpretation is possible.

DemocracyABC.org
TheRealNews.Com
http://www.pdamerica.org
[ Parent ]
A possible bridge both for: passing a bill, and for going to single payer (0.00 / 0)
A guarantee of Health care, a right to healthcare, an addition part of the Bill, a signing statement, a lawful promise of the Right To HealthCare for every American, included in, or before any bill that provides a measurably robust PO, as Ian so thoughtfully laid out. I urge its reading.
What the Public Option MUST Have To Survive    (+)
by: Ian Welsh

The engagement and promise to the American people that have that right, not to some health care, not to an ambulance ride until they find out you have no money, but a right to the provision of health care for health reasons, sick? get care!
I wrote this last night to response as to "what must be done" - this as an administration speech, and a law, would cover the sets of expectations that lead, like veterans care has, inexorably to public provision of care.

There is only one thing that is important to work for in America and that is an engaged citizenry, knowing it's rights, its constitution and dedicated to democracy.

Tell people to contact their reps and senators and demand that the legislature aim the medical system toward single payer by recognizing the right to healthcare.

Veterans are covered in health care because their right to care is assumed, its obvious.

The economy deserves medical care, because businesses, small businesses are getting bills for insurance at $1,400 a family for each employee, every month. And its climbing at twenty % a year. A public option, single payer, reduces or eliminates that cost to every small business in the country.

Americans and American small businesses have a right to healthcare.

Mom has a right to healthcare

The veterans administration doesn't use private medical insurance, because they can't afford to waste that much money, and because their commitment to a veterans health, their promise of caring, won't let them veterans be treated the way insurance companies treat their 'customers.'

Americans have a right to healthcare,

because we can take care of each other, better, much better, more cheaply, much more cheaply as a nation, and with real care, even love.

Americans have a right to healthcare,

because, millions of people are ruined, ruined financially by the arrival of a devastating, or even commonplace medical emergency, that is as rare in Canada and Britain as it is common in America.

Americans  have a right to  healthcare.

Because president Roosevelt said we had a right to freedom from fear, and millions of Americans live in fear of what is covered, what will be denied, what will be delisted, what bill will be returned unpaid with coverage lost. What procedure wont be offered, fear of choosing which hand to save because he cant afford both.

Americans have a right organize their society so that health is a right of every mother and son, every business and school and every city and state

Louisiana has a right to healthcare. New York has a right to healthcare, Minnesota has a right to healthcare Alabama has a right to healthcare

If everyone knows that they are citizens in a democracy, if everyone knows they have a right to demand, if everyone knows that their child and their father have a right to be cared for, and if they say that it is time; it will happen just as bills get paid, just as taxes come, and babies get born, it will be time to deliver



Change
"We must break up the banks and never again let them get so big that they distort our politics and take down the economy.
Sure, I like a rights-based approach (0.00 / 0)
Give the ombudsmen in HR3200 power conflict resolution powers (which they currently do not have, unlike the typical ombudsman) and we might get somewhere. Otherwise, another 20 years for the Brown v. Board or Roe v. Wade of health care, to enforce the rights? No thanks.

(Incidentally, if the public option advocates accepted this, they wouldn't be calling a solution that enrolls 97% of the people "universal." So I think in the so-called realist camp, your idea is a non-starter.)

I am in earnest -- I will not equivocate -- I will not excuse -- I will not retreat a single inch -- AND I WILL BE HEARD.  

[ Parent ]
The 98% was not the maximum that any anyone wanted, it was an (0.00 / 0)
estimation of the numbers actually covered, with the formulas installed. And if you care to remember when. Obama last talked about those numbers, he postulated what would be done to finish the coverage outside the model.

The so called realist camp is attempting to determine not waht least can done, but aim and shove for that Bill that will [pass, and it will, that has 51% of the votes in the senate on reconciliation.

Because in real life, when you have children in the car, you don't throw away a steering wheel.

Change
"We must break up the banks and never again let them get so big that they distort our politics and take down the economy.

[ Parent ]
Feh (0.00 / 0)
We both know there are children in the car.

And it's the public option advocates who are fine with dying children until 2013.

So don't try that rhetorical trick, and maybe we can talk about policy.

I don't notice a response to my ombudsman point. Anybody whipping for that? Or for rights?

I am in earnest -- I will not equivocate -- I will not excuse -- I will not retreat a single inch -- AND I WILL BE HEARD.  

[ Parent ]
You keep speaking to people as if you are a child demanding a treat from their mother. (0.00 / 0)
Organize the whip yourself. Who do you suspect you are discussing with my little tantrum friend? Ask for assistance. Go for it.

Change
"We must break up the banks and never again let them get so big that they distort our politics and take down the economy.
[ Parent ]
As a single payor advocate... (4.00 / 1)
particularly in light of the Sebelius remark and the fact that PhRMA and insurers are lining up (feigning opposition in my view), I wonder:

1.  How premiums will kept under control?

2.  What about high deductibles for those with pre-existing conditions that effectively mean one pays for health care individually?  I cannot be denied insurance because of a pre-existing condition, but at what price?

3.  The overall question of underinsurance.

I don't think the PO advocates act in bad faith, but in the rush to get something I think they may settle for something that will end up worse than what now exists, a captive audience mandated to pay insurers and providers who get a huge windfall.

I also wonder how they can push forward with the knowledge that single payer or Medicare Plus or true national health insurance does not even get a hearing in the court of public opinion, especially since the public seems to approve of this solution beyond all others.  

I said I would be repetitious (4.00 / 2)
Read the bill
http://edlabor.house.gov/docum...

Your 2-pre-existing conditions:
Sec 111 prohibits exclusions based on pre-existing conditions (p. 19)
Sec 113 prohibits varying premiums based on individual health condition. Premiums can be varied a) by age as long as the ratio doesn't exceed 2 to 1 b) by area c) by family composition (i.e. you can charge a family of five more than a single, within limits) (p. 21)

I see no provision for charging higher co-pays and deductibles for pre-existing conditions. If I missed something in the bill please point it to me (I learn something new about HR3200 every day.)

Your 1-premium control
Sec 116 Insuring value and lower premiums
"A qualified health benefits plan shall meet a medical loss ratio as defined by the Commissioner. For any plan year in which the qualified health benefits plan does not meet such medical loss ratio, QHBP offering entity shall provide in a manner specified by the Commissioner for rebates to enrollees of payment sufficient to meet such loss ratio."
Meaning if they jack the premium up past what turns out to be a set ratio of actual costs, they have to rebate the difference. Though not explained as such this prevents windfall profits and price gouging across the plan as a whole.

Your 3-underinsurance. Sec 102 allows you to grandfather yourself into underinsurance, but Sec 101 mandates that you won't be allowed to underinsure yourself via a new policy after Jan 1, 2013 unless you are willing to pay a penalty of 2.5% of your income.

If I was really settling "for something that will end up worse than what now exisists, a captive audience mandated to pay insurers and providers who get a huge windfall." I would feel appropriately chastised here. But I am doing my very best to chase these concerns down through examination of the bill language.

As to why we push forward? On this topic some of us are realists. You go to policy war with the Congress you have, not the Congress you want to have. And we can't wait for the latter to eventuate and in fact fear that not moving on health care this year means we will never get to the ultimate goal (which I at least share with you). And might lose both the public and control of Congress along the way.

[ Parent ]
Thanks for relating it to the actual bill (4.00 / 2)
There may be counterarguments to some of these points but this is the discussion we need to be having.

sTiVo's rule: Just because YOU "wouldn't put it past 'em" doesn't prove that THEY did it.
[ Parent ]
What's there to find? (0.00 / 0)
The advocates of taking whatever crumbs the powerful deign to throw us won't be happy until they've seen health care reform killed.  As a single-payer advocate who knows something about the French system, I'd love to have something like it (modified to weed out the flaws, of course - that system, as good as it is, is still costly compared to the rest of Europe).  But at no point am I going to settle for something that doesn't exist beyond vague promises of considering thinking about maybe deciding whether or not to try to pass single-payer at some unspecified - and distant - future date.  Too many people are dead or dying who shouldn't be.


I think single-payer is by far the best solution (4.00 / 1)
but I don't see any way at all the current bastards at the Senate will support it, so I'm also supporting the public option
Show me how we're not worse of (4.00 / 1)
EricD above:

in the rush to get something I think they may settle for something that will end up worse than what now exists, a captive audience mandated to pay insurers and providers who get a huge windfall.

Yep; Ian (and lambert).

In fact, I'd say that's the baseline scenario.  

I am in earnest -- I will not equivocate -- I will not excuse -- I will not retreat a single inch -- AND I WILL BE HEARD.  

[ Parent ]
Why? (0.00 / 0)
Because Ezra and Dennis say so?

Why can't you engage on the substance of the bills as we have them rather than what seem to boil down to a combination of second hand opinions and vague feelings?

[ Parent ]
Yawn (0.00 / 0)
You're a newcomer, bruce; I really don't have the time to recapitulate every argumentative thread for you. Do a little homework, and you'll find plenty of analytical posts from me.

Incidentally, I like quoting Ezra because he's a former blogger and well-in with the progressives. See, everything isn't aimed at you, mkay?

How's that timeline for transition from public option to single payer coming?

I am in earnest -- I will not equivocate -- I will not excuse -- I will not retreat a single inch -- AND I WILL BE HEARD.  

[ Parent ]
I should say... (0.00 / 0)
Relative newcomer to this topic. Sorry.

I am in earnest -- I will not equivocate -- I will not excuse -- I will not retreat a single inch -- AND I WILL BE HEARD.  
[ Parent ]
Gosh who knew Open Left (4.00 / 1)
Was the center of the Universe?

I have a three digit UID at dKos only because I slept in the morning the day they introduced Scoop. I was posting on MyDD BEFORE Jerome put it on hiatus in 2004. And most all of that posting has been on entitlements, primarily Social Security but also Medicare. I have been addressing the HELP bill and the Tri-Committee bill on a text based basis mostly from my perch as a front page poster at econoblog Angry Bear, generally starting from the moment the texts were released and/or the CBO scoring was released.

I guess it is too bad I have not spent enough time on OL comment threads to establish my bona fides with you, but with all respect to the founders it is a big blogosphere out there. Ian asked a question about a subject I know something about so rather than pass by as usual I spent a morning visiting. Maybe you too should get out more, because you pulling rank on the basis that I am somehow a newbie just shows some narrowness in blogging experience. In blog years I am older than dirt.

[ Parent ]
Wow. did your parents give you permission to talk like that? (4.00 / 1)
Is this something you learned in prep school?

Or is it, just television.

Change
"We must break up the banks and never again let them get so big that they distort our politics and take down the economy.

[ Parent ]
The question I have (0.00 / 0)
on the realist vs purist axis

is

Since the Public Option now being proposed is not robust and inadequate*, would it possibly be better to pass something mildly ameliorative this year that explicitly does NOT call itself "the public option" and come back fighting in one, two, four years for real single payer than to pass a hobbled "public option" that might discredit the idea of universal health care for another generation?

*I'll only caveat that I haven't read the 75 pages that Bruce Webb has, and I could still possibly be convinced that the current bill with "public option" is not that bad.  But I'm not convinced yet.

sTiVo's rule: Just because YOU "wouldn't put it past 'em" doesn't prove that THEY did it.

The discourse has become a tad shopworn... (4.00 / 1)
... and the advocates of the only solution which is both embodied in legislation (HR676) and proven to save both lives and money in every country it's been tried are called "purists," and the proponents of a complex, unproven, and Rube Goldberg-esque system that guarantees the insurance companies a market are called "realists."

I am in earnest -- I will not equivocate -- I will not excuse -- I will not retreat a single inch -- AND I WILL BE HEARD.  
[ Parent ]
Well Lambert (4.00 / 1)
let me just put the question to you.

Assume for a minute that Single Payer has no chance of passing this year.  A fairly safe assumption, I think.  Never mind why, we could argue that forever and we don't need to.

If you are forced to make that assumption, which of the following two alternatives would you prefer?

1) The current HR3200 with a watered down, crippled "public option" and various other provisions that may be somewhat ameliorative of some of the worst problems of the current system

2) A still further watered down bill which no longer calls itself "public option" but otherwise contains those ameliorative bits and pieces of HR3200 and possibly a few more (trades for public option).

Which is better?  An inadequate bill that claims to be more than it is or an inadequate bill that makes no such claims?

Because 2) is what I believe we are going to get.  The comparison of the original Hacker proposal and current Public Option plans combined with Obama's obvious unwillingness to bet the ranch on Public Option convinces me that he always viewed it as a way to shake a few apples out of the Insurance tree - and nothing more.

It's not altogether clear to me that 1) is better than 2).  It may, in fact, be worse.


sTiVo's rule: Just because YOU "wouldn't put it past 'em" doesn't prove that THEY did it.

[ Parent ]
I think we should cross that bridge when we come to it (4.00 / 1)
I think the current approach is going to force several million people to buy junk insurance and won't cover them when they need care. In that case, obviously the bill shouldn't pass. And why negotiate with ourselves and make the bad outcome more likely?

I am in earnest -- I will not equivocate -- I will not excuse -- I will not retreat a single inch -- AND I WILL BE HEARD.  
[ Parent ]
Yeah I know (4.00 / 1)
and Edwards will get nominated.

Thanks for playing.

sTiVo's rule: Just because YOU "wouldn't put it past 'em" doesn't prove that THEY did it.

[ Parent ]
It is ironic (4.00 / 1)
that if he would think about it, Lambert might realize that the question I'm posing actually leans more to his side of the argument than to the other side.

But by insisting that only those willing to fight to the death for single payer NOW are worth listening to he cuts off his nose to spite his face.

 

sTiVo's rule: Just because YOU "wouldn't put it past 'em" doesn't prove that THEY did it.

[ Parent ]
Well, as I said above... (0.00 / 0)
... I'm a simple soul.

If what you say is true, why not make the point all on your own, instead of trying to deke inferior material such as myself into making it?

I am in earnest -- I will not equivocate -- I will not excuse -- I will not retreat a single inch -- AND I WILL BE HEARD.  

[ Parent ]
"They shall become as little children" (0.00 / 0)
[ Parent ]
Yes, you have. (0.00 / 0)
So grow up already (this goes for Webb and the others).


[ Parent ]
Realist vs purist (0.00 / 0)
Is a political calculation and not a judgement on the merits of the public option via single payer.

I wish every American had six weeks of paid vacation (fairly minimal by European standards) and a 35 hour work week. But I am not holding my breath until I turn blue because nothing like that is on the current horizon.

If wishes were fishes we would all cast nets.

A Social Democratic America is a work that has been in progress for about a hundred years now starting really with the imposition of the Income Tax and direct election of Senators. And the last close to thirty years actually saw us retrogressing. Sometimes you can't get what you want, but if you try sometimes you just might find you get what you need. (Gee that has a familiar ring).

I don't have health insurance. I need health insurance. I will take the path that gets me and about thirty million other Americans health insurance. And really don't give a rip if you see that as retreating an inch.

[ Parent ]
Er, what Americans need is not health insurance... (0.00 / 0)
... but health care. (And that's what you need, too, Bruce.)

Just to frame your argument in a way that actually can advance the debate.

This is actually an interesting question to ask, and I don't know if it has been.

Has anybody ever looked at H$3200 from an actuarial standpoint. Suppose, say, that the 30 million who (allegedly) were getting insurance didn't need care, and suppose that the remaining 17 million unterbussen who didn't get insurance did need care.

Surely the calculus of purity and reality would change in that case? I should do some research on this. (I think this turns into the argument that the insurance companies will make sure that those likely to get sick are thrown on the public plan).

I am in earnest -- I will not equivocate -- I will not excuse -- I will not retreat a single inch -- AND I WILL BE HEARD.  

[ Parent ]
Finally a meeting of the minds (0.00 / 0)
Yes you should do some research. Maybe starting with reading the primary sources.
[ Parent ]
About half of the remaining uninsured (4.00 / 1)
are not legal residents. Per CBO HR3200 will cover 97% of legal non-elderly American residents but only 94% of all residents. CBOs methods are less than transparent but I suspect a good part of the rest are in that segment of society that have no settled address and bounce between the drug world, jail and the cash economy and could never document themselves in a way tha qualified them for coverage. I know a lot of people in this category.  
[ Parent ]
Bad Faith (4.00 / 2)
Both sides are assuming the other side is operating in bad faith.  The public option folks assume the single payer folks just want to be pure rather than saving lives, the single payer that the public option folks are just sell outs shilling for a bad bill.

I actually think you are wrong.  As heated as the arguments have gotten, I don't get the impression many people are arguing in bad faith at all, nor that many assume others are.  We actually disagree.

Yep (4.00 / 1)
I don't think there is an awful lot of anger in these discussions here.  We just don't agree.
[ Parent ]
but I really don't see (4.00 / 2)
how a reasonable public option could pass through Congress.

Look, the insurance industry isn't stupid. They understand that a successful public option would end up putting them out of business. Therefore they will fight a serious public option just as hard as they would single-payer.

It's a confused approach--the idea that the insurance companies won't let single-payer go through, but that we can somehow sneak through legislation that will eventually lead to single-payer. Because the people who run those companies are stupid, or asleep, or something.

I'm also hearing the usual right-wing canards about how switching to single-payer will put tons of insurance workers out of work. Leaving aside the fact that many of those workers will still be needed under a single-payer system, Physicians for National Health Program estimates it should take about $20 billion to retrain and find jobs for those workers who are displaced--very little in comparison with the savings that will be realized by the switch. So let us dispense with that talking point.

Exactly my point (4.00 / 1)
If a robust public option can't pass Congress and I also made the point that the fight to pass a robust public option is the same fight you'd need to win single payer, same enemies, same balance of forces, same everything, then might we not be better off WITHOUT the 98 lb weakling version that calls itself public option but isn't?

Isn't the future battle for single payer better off not having to defend the dishwater public option?

That's why I'm thanking Bruce Webb for actually pointing out what's actually in the bill.

My order of preference:
1. Single Payer

2. A Robust Public Option as Hacker originally defined it.

3. A collection of ameliorative measures that do some good but don't solve the problem of the inherent contradiction in for-profit health insurance and leave many problems for the next round of this battle.

4. A collection of ameliorative measures that do some good but don't solve the problem of the inherent contradiction in for-profit health insurance carrying a useless appendage called "public option" that is nothing but a dumping ground for the cases nobody else wants and is perpetually strapped for cash.


sTiVo's rule: Just because YOU "wouldn't put it past 'em" doesn't prove that THEY did it.

[ Parent ]
Funny health care video (4.00 / 2)
A funny video about why health care reform is important to everyone, even the already insured.

http://www.youtube.com/watch?v...

I say, Doctor, is there something I can take?

sp

nice! (0.00 / 0)

[ Parent ]
A decent public option will lead to single payer (4.00 / 1)
... or at least we'll see private health insurance relegated to a niche, like in France, with public insurance dominating.

It will start with individual health insurance: there's no way private insurance companies will be able to compete. Small businesses will follow, and we'll see private health insurance only for large companies.  At that point, the bigger companies will be looking for a way out.

The only way to stop this is for the insurance company lobbyists to weaken the public option to the point where it's no option at all.  But at least for individual insurance this will be hard to do.

Finding Common Ground Between Public Option Advocates and Single Payer Advocates | 112 comments
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