There is something that has been getting at me lately, and that is how some progressives choose to attack the health care reform bill. One of those principal routes is by attacking the mandate as "forcing people to buy insurance they don't want". Here's the first reason on Jane Hamsher's 10 reasons to kill the Senate bill:
Top 10 Reasons to Kill Senate Health Care Bill
1. Forces you to pay up to 8% of your income to private insurance corporations - whether you want to or not.
PCCC/DFA has a poll out asking "Would you favor or oppose requiring all Americans to buy health insurance -- the so-called mandate -- even if they find insurance too expensive or do not want it?" with the results of 51% oppose, 38% favor.
Now, I have enormous respect and appreciation for the work Jane, FDL, PCCC and DFA have done on health care reform, and respect arguments on the basis of affordability, which is one part of this poll question. But this business about "whether you want it or not" is one step too far.
The House released a final version of the health reform bill. It has a public option all right, but not the robust version progressives were hoping for. The public plan would only cover 2% of Americans and premiums will cost more than anticipated.
Meanwhile, Sen. Joe Lieberman (I-CT) continued to threaten to join a Republican filibuster of a health care bill with a public option. A lot of people still think he's bluffing. Realistically, the public option probably faces more serious threats from inside the Democratic caucus. It's been whittled down at an alarming rate.
Nick Baumann of Mother Jones asks "What now for the public option?"
The Congressional Budget Office has estimated that public option premiums will actually be higher than the premiums for private plans on the health insurance exchanges. That doesn't mean it's going to cost the government more money-the public option is paid for by premiums, not taxes; it actually cuts the deficit. But it will be more expensive than some private plans. Wasn't part of the point of the public option to prove that a government-run program could compete successfully with privately-run plans? Well, yes, but here's the problem: that was all based on the idea that the public option would pay health care providers at Medicare rates.
Baumann predicts that insurers will do everything they can to drive the sick people off private insurance onto the public plan, a phenomenon known as "adverse selection." Hopefully some of the proposed insurance reforms will curb their worst excesses, like kicking people off the rolls for misspelling their preexisting conditions on their application forms.
Mike Lillis of the Washington Independent reports that the House health care bill would eliminate the popular and cost-effective Child Health Insurance Program (CHIP) and shift its low-income beneficiaries onto private health insurance exchanges.
This looks like a stealthy preemptive strike on the prospect of single-payer health care. CHIP is a single-payer program that progressive health policy types envisioned as a prototype for a future single-payer system for all kids, or even eventually for everyone.
As Lillis points out, abolishing CHIP is also a gimme to insurance companies. Generally speaking, kids are cheap to insure because they're healthy. Private insurers would love to stock their risk pools with kids on federal subsidies. It's like getting paid to stock your pond with delicious trout. We worry about adverse selection making the public plan more expensive. Well, CHIP is the reverse of that because this public program is keeping the good risks for itself.
Suzy Khimm argues at TAPPED that killing CHIP could be a good thing, provided the kids continue to enjoy the same legal protections that they get under the public plan. Khimm suggests that moving low-risk kids into insurance exchanges could help keep costs down for everyone by making the risk pool healthier on average:
That being said, if CHIP's dismantling ended up moving more folks into the health-insurance exchange, it wouldn't simply be a boon for "the insurance lobby and moderate Democrats." It could strengthen one of the most fundamental parts of the Democratic reform package -- a robust insurance exchange with a pool of participants that's large enough to drive down costs precisely because insurance companies have an incentive to jump in and compete for customers. Moreover, folding CHIP into the exchange would add a younger, healthier pool of participants to the exchange, offsetting its potential of becoming a dumping ground for the sick and elderly. Finally, CHIP has always suffered from under enrollment -- about 6 million children aren't insured in the program who should be -- and by bringing whole families in under the same plan, more children will be covered.
That's a nice idea, but it seems foolish to scrap one a popular and successful social program in favor of an untested insurance exchange system.
The frustrating thing about so-called health care reform is that legislators don't really want to change the system. They want to make the system work better while catering to all the established interests that made it suck in the first place.
Politicians aren't the only ones to balk at fundamental change. The Real News Network interviews Sam Gindin (video below), a former assistant to the Canadian Auto Workers Union, now a professor at York University. Gindin says that, over the years, labor conceded too much on health care and thereby failed to reestablish itself as a leading force for progressive change in the United States. Helping elect Barack Obama was a step in the right direction for labor, he maintains, but it's not nearly enough.
As John Nichols of the Nation put it, when the House finally wrote the bill, the compromise was even more compromised than expected.
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There are so many naive assumptions in this post by Jacob Heilbrunn I don't even know where to start, but the real thing that has me thinking is his assertion that a compromise bill (assumedly without a public option) will pass, and that Obama and Congressional Democrats will ride a tidal wave of public love for the bill into success in next year's midterms.
It seems foregone that if some kind of legislation does pass, it will include a bunch of good provisions on which there seems to be broad support in Congress: banning insurance discrimination against individuals with pre-existing conditions, for example. Or banning an annual cap on insurance coverage payouts. These are real and tangible things that a member of Congress can campaign on, that means something to voters. But the problem is that providing competition in the form of a strong public option seems to be the keystone to a system that will, in combination with those other reforms that have broad support, actually improve things. Without it, things could actually get worse. Consider:
If you ban discrimination for customers who have pre-existing conditions, but don't place any caps on deductibles or do any type of rate regulation, all you get is a lot of companies who are forced to offer insurance to sick people, but no one is buying it. You still have 49-year-old diabetics who want to purchase individual insurance, but face deductibles and premiums that are unaffordable, so not much changes.
Premiums for everyone else could go up. Forcing companies which seek to make as enormous profits as possible to pay beyond a level at which they would have previously stopped paying (e.g., enforcing a ban on annual or lifetime caps), or forcing them to accept new patients they would have previously denied that will consume a lot of care, will reduce profits. Since health insurance companies, as Anthony Weiner put it, operate to make profits by giving away as little as possible and collecting as much as possible, I would not be surprised if premiums for everyone go up in the absence of a public option providing competition to keep that from happening.
Adverse selection causes things to get worse for the healthiest among us. Following the last point, if premiums go up for the healthiest (imagine a 25-year-old male with no bad family medical history who doesn't see himself getting sick), they will drop their coverage. This leaves a higher risk pool, e.g. the sickest, for insurance companies to cover, meaning higher costs and higher premiums for those staying in the market. So they raise premiums again and force people out of the market, etc. This is what my boyfriend Perry, who teaches health economics at Syracuse University, calls "the insurance death spiral". It causes things to unravel for everyone else.So things for people like me (who is indeed a 25-year-old male and so far happy with his insurance) could get bad really quickly.
It will not make insurance any more affordable. For those who can't afford insurance now- be they healthy, sick or likely to become sick- one of the points of providing a competitive public option is to provide competition to the insurance industry, forcing down rates, etc. Without it, there will still be a lot of people who can't purchase an individual plan, a lot of businesses who are suffering under high costs of providing insurance, and so forth.
Looking at the political effects, it will be difficult for someone like me, who has insurance I am so far happy with, to find anything useful to me in the bill aside from feeling good that some provisions have been passed. It will be difficult for someone who has had to fight with insurance companies over tens of thousands of dollars in bills to find anything good in the bill either, because it offers no alternative to doing anything other than fighting with them again down the road, rather than switching to a public plan. So it's hard to imagine people who already have insurance they are happy with (so far) to be find anything good about the bill.
My point here is that while many Congressional Democrats and President Obama think that if they pass some bill, any bill, it will bring them lots of love in the punditry for coming to the table, and that the public will send their approval ratings soarings and award them in the 2010 midterms. That may be the conventional wisdom way of looking at it, but it ignores the policy effects, and it's completely wrong. You can't just agree on lots of smaller provisions that ostensibly do some good on paper, but don't cause any real positive change in voters' lives- and in fact, could make things worse absent competition. Without real competition, things could unravel even faster than they are now. A strong public option is the linchpin that makes all these things work together.
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