Debating the Public Option

Paul Starr, Robert B. Reich and Robert Kuttner
The American Prospect
June 29, 2009
In “The Perils of the Public Plan,” Paul Starr warns that a public-insurance option could turn into exactly the opposite of what progressives want. Here he discusses the problems with the Prospect’s two other co-founders, Robert Kuttner and Robert Reich.
Paul Starr:
The public plan will likely end up as a dumping ground for high-cost, mostly low-income people if the exchanges are open only to the individual and small-group market and have inadequate power to risk-adjust premiums or to regulate private insurers’ marketing and benefit design.
In other words, we could get a public plan that instead of “disciplining” private insurers, as the president said last week, actually buttresses their dominance of the system. Watch what you wish for.
Robert Kuttner:
The public option, as it is evolving, is even more dubious than Paul Starr’s apt critique suggests. Under the House leadership bill, people who have coverage through their employers are ineligible. So the proposed, head-to-head competition between the public plan and private competitors is left to employers, not individuals.
Politically, protecting the public option from industry mischief is no less a heavy lift than single-payer. It’s a pity that all the progressive energy that’s gone into defending the public option hasn’t gone to advocate national health insurance.
Robert Reich:
I’d prefer a single-payer, but it’s got no skin in the game. The only practical hope we have for expanding coverage and taming health-care costs lies with the public option. That’s why it’s the epicenter of the current fight. The House is supportive, but the Senate is backing off because Republicans and Blue Dog Democrats have been told it’s a Trojan horse for single-payer. And the medical-industrial lobbies are hard at work convincing the public that the public option will lead to a wholesale government takeover of the health-care system.
Yesterday the president said he might sign a health-care bill that did not include a public option. That’s exactly the wrong message. If progressives fail to work hard for a public option because it’s not a single-payer, or we allow the other side to demagogue a public option, we miss the moment.
Paul Starr:
The public option has gotten all the political attention, but the real “crux” of reform is the system of rules that govern all competing plans. If the Democrats can’t get a strong public plan through the Senate but can get a strong design of the exchanges by trading off a weak public plan, they should take that deal and pass the bill.
Robert Kuttner:
It’s interesting and significant that the three co-founders of the Prospect are reprising the three major strands of progressive views on health reform. Robert Reich is arguing that the Obama plan, with the public option, is the best practical brand of reform available. Paul Starr, holding out for something that looks a lot like the Clinton plan, argues (convincingly in my view) that the most likely form of the public option will backfire. And I continue to be the single-payer guy. We’ve been having different versions of this friendly argument for two decades, as has the progressive community.
Reich says that single-player has “no skin in the game.” Well, let’s put some there, rather than being apologists for a threadbare cloak of a public option.
Where Starr and I disagree is on both his diagnosis of Medicare for All, and on his optimism that “exchanges” could be designed in a way that would meet his hopes (the exchanges sound a lot like the purchasing pools of the Bill Clinton plan that Paul Starr helped devise).
Although Starr and Reich seem to disagree, they have one thing in common. They are both somewhat wishful about what it would take politically to legislate the crucial details of either the Obama public option (Reich) or the exchanges (Starr) necessary to achieve meaningful reforms. In order for the fine print in either approach to do the job, progressives would need first to crush the industry influence in Congress that is very likely to hobble either strategy. And both Reich and Starr are right that a weakened version of the Obama plan could well be worse than nothing.
The political reality is that Medicare for All is no harder politically than a version of the Obama plan that would meet all the tests that Reich and Starr apply. And it would be far simpler and more cost effective.
The regulatory and political nightmare of doing everything that Starr insists is necessary to get a system of insurance exchanges to work efficiently is actually far more of a daunting challenge than having a single system under direct public control. And the odds are that the Obama administration, by the time it is done reassuring Max Baucus, the health insurance industry, the drug companies, and the Blue Dogs, will settle for far less than Starr’s formula.
Reich may say that if we just work hard enough, we can prevent that fate and still get a good program. But Obama began with less than what we need, and he has not painted this as a battle of the people against the interests. The bill gets weaker with each succeeding round. I suspect that by the time there is finally legislation for him to sign, Reich and Starr will both feel that it falls way short. It is high time for progressives to stop settling for badly flawed second bests and to throw their energy into a first best that could rally popular support and produce a system that serves everyone.
To read the full article:
http://prospect.org/cs/articles?article=debating_the_public_option

To rephrase the very important point that Paul Starr brings to this debate, it is not the design of the public option that is crucial to successful reform under the model being advanced in Congress, but rather it is that the design of the insurance exchanges must be absolutely compliant with the rules of social insurance. If the exchanges are poorly designed, the public option would become a Medicaid-like dumping ground for low-income people with high-cost problems, and would suffer from a lack of willing providers because of chronic underfunding. And poorly designed exchanges could never meet the test of social insurance.
Robert Reich would have us design an empowered public option that could shape up the private insurers by exerting full competitive pressure within the exchanges. That’s a nice wish, but all Republicans and an insurmountable number of Democrats in Congress have already made an irrevocable decision that an empowered public option will never survive the legislative process. It is possible that the “public option” label might survive, but only if applied to a private market-type plan, public in name only.
So can the insurance exchanges function as a bona fide social insurance program? Look at some of the decisions that have already been made.
Social insurance programs based on private plans require an individual mandate for everyone to purchase the plans, except those whose incomes are too low and therefore qualify for public programs. Congress and the state governors are very concerned about the costs of the Medicaid program and want it to be limited to the poor, especially since Medicaid is crippling many state budgets. Medicaid will not be expanded to include average-income individuals.
Adequate health insurance plans are no longer affordable for average-income individuals and families. Some form of tax subsidies will be required to assist with the mandated purchase of these plans. The amount of tax funds that would be required for everyone to be able to purchase coverage has proven to be far more than members of Congress are willing to budget. Consequently, it has been decided that hardship waivers must be a part of any reform legislation, effectively providing tens of millions of individuals with a government permission slip to remain uninsured.
Just to try to pull a few more in, the government will require insurers to provide multiple tiers of coverage. The lowest tier will be designed to be affordable, even though affordable plans, by design, are underinsurance products that fail to protect those who need health care.
Then the government would regulate the insurance exchanges, but look at the results in the most highly regulated states. No state has escaped the problems that are driving our current efforts at reform. No matter how many regulations are passed, the private insurers have always introduced innovations that relieved them of any real responsibility to address the severe deficiencies in our dysfunctional health care system.
Paul Starr may want well designed insurance exchanges, but this Congress has already rejected them. Robert Reich may want an empowered public plan, but this Congress has already rejected that.
As Robert Kuttner states, “progressives would need first to crush the industry influence in Congress that is very likely to hobble either strategy.”
But then, “It is high time for progressives to stop settling for badly flawed second bests and to throw their energy into a first best that could rally popular support and produce a system that serves everyone.”
And, “The political reality is that Medicare for All is no harder politically than a version of the Obama plan that would meet all the tests that Reich and Starr apply. And it would be far simpler and more cost effective.”

Paul Starr, Robert B. Reich and Robert Kuttner
The American Prospect
June 29, 2009

In “The Perils of the Public Plan,” Paul Starr warns that a public-insurance option could turn into exactly the opposite of what progressives want. Here he discusses the problems with the Prospect’s two other co-founders, Robert Kuttner and Robert Reich.

Paul Starr:

The public plan will likely end up as a dumping ground for high-cost, mostly low-income people if the exchanges are open only to the individual and small-group market and have inadequate power to risk-adjust premiums or to regulate private insurers’ marketing and benefit design.

In other words, we could get a public plan that instead of “disciplining” private insurers, as the president said last week, actually buttresses their dominance of the system. Watch what you wish for.

Robert Kuttner:

The public option, as it is evolving, is even more dubious than Paul Starr’s apt critique suggests. Under the House leadership bill, people who have coverage through their employers are ineligible. So the proposed, head-to-head competition between the public plan and private competitors is left to employers, not individuals.

Politically, protecting the public option from industry mischief is no less a heavy lift than single-payer. It’s a pity that all the progressive energy that’s gone into defending the public option hasn’t gone to advocate national health insurance.

Robert Reich:

I’d prefer a single-payer, but it’s got no skin in the game. The only practical hope we have for expanding coverage and taming health-care costs lies with the public option. That’s why it’s the epicenter of the current fight. The House is supportive, but the Senate is backing off because Republicans and Blue Dog Democrats have been told it’s a Trojan horse for single-payer. And the medical-industrial lobbies are hard at work convincing the public that the public option will lead to a wholesale government takeover of the health-care system.

Yesterday the president said he might sign a health-care bill that did not include a public option. That’s exactly the wrong message. If progressives fail to work hard for a public option because it’s not a single-payer, or we allow the other side to demagogue a public option, we miss the moment.

Paul Starr:

The public option has gotten all the political attention, but the real “crux” of reform is the system of rules that govern all competing plans. If the Democrats can’t get a strong public plan through the Senate but can get a strong design of the exchanges by trading off a weak public plan, they should take that deal and pass the bill.

Robert Kuttner:

It’s interesting and significant that the three co-founders of the Prospect are reprising the three major strands of progressive views on health reform. Robert Reich is arguing that the Obama plan, with the public option, is the best practical brand of reform available. Paul Starr, holding out for something that looks a lot like the Clinton plan, argues (convincingly in my view) that the most likely form of the public option will backfire. And I continue to be the single-payer guy. We’ve been having different versions of this friendly argument for two decades, as has the progressive community.

Reich says that single-player has “no skin in the game.” Well, let’s put some there, rather than being apologists for a threadbare cloak of a public option.

Where Starr and I disagree is on both his diagnosis of Medicare for All, and on his optimism that “exchanges” could be designed in a way that would meet his hopes (the exchanges sound a lot like the purchasing pools of the Bill Clinton plan that Paul Starr helped devise).

Although Starr and Reich seem to disagree, they have one thing in common. They are both somewhat wishful about what it would take politically to legislate the crucial details of either the Obama public option (Reich) or the exchanges (Starr) necessary to achieve meaningful reforms. In order for the fine print in either approach to do the job, progressives would need first to crush the industry influence in Congress that is very likely to hobble either strategy. And both Reich and Starr are right that a weakened version of the Obama plan could well be worse than nothing.

The political reality is that Medicare for All is no harder politically than a version of the Obama plan that would meet all the tests that Reich and Starr apply. And it would be far simpler and more cost effective.

The regulatory and political nightmare of doing everything that Starr insists is necessary to get a system of insurance exchanges to work efficiently is actually far more of a daunting challenge than having a single system under direct public control. And the odds are that the Obama administration, by the time it is done reassuring Max Baucus, the health insurance industry, the drug companies, and the Blue Dogs, will settle for far less than Starr’s formula.

Reich may say that if we just work hard enough, we can prevent that fate and still get a good program. But Obama began with less than what we need, and he has not painted this as a battle of the people against the interests. The bill gets weaker with each succeeding round. I suspect that by the time there is finally legislation for him to sign, Reich and Starr will both feel that it falls way short. It is high time for progressives to stop settling for badly flawed second bests and to throw their energy into a first best that could rally popular support and produce a system that serves everyone.

To read the full article:
http://prospect.org/cs/articles?article=debating_the_public_option

Comment:

By Don McCanne, MD

To rephrase the very important point that Paul Starr brings to this debate, it is not the design of the public option that is crucial to successful reform under the model being advanced in Congress, but rather it is that the design of the insurance exchanges must be absolutely compliant with the rules of social insurance. If the exchanges are poorly designed, the public option would become a Medicaid-like dumping ground for low-income people with high-cost problems, and would suffer from a lack of willing providers because of chronic underfunding. And poorly designed exchanges could never meet the test of social insurance.

Robert Reich would have us design an empowered public option that could shape up the private insurers by exerting full competitive pressure within the exchanges. That’s a nice wish, but all Republicans and an insurmountable number of Democrats in Congress have already made an irrevocable decision that an empowered public option will never survive the legislative process. It is possible that the “public option” label might survive, but only if applied to a private market-type plan, public in name only.

So can the insurance exchanges function as a bona fide social insurance program? Look at some of the decisions that have already been made.

Social insurance programs based on private plans require an individual mandate for everyone to purchase the plans, except those whose incomes are too low and therefore qualify for public programs. Congress and the state governors are very concerned about the costs of the Medicaid program and want it to be limited to the poor, especially since Medicaid is crippling many state budgets. Medicaid will not be expanded to include average-income individuals.

Adequate health insurance plans are no longer affordable for average-income individuals and families. Some form of tax subsidies will be required to assist with the mandated purchase of these plans. The amount of tax funds that would be required for everyone to be able to purchase coverage has proven to be far more than members of Congress are willing to budget. Consequently, it has been decided that hardship waivers must be a part of any reform legislation, effectively providing tens of millions of individuals with a government permission slip to remain uninsured.

Just to try to pull a few more in, the government will require insurers to provide multiple tiers of coverage. The lowest tier will be designed to be affordable, even though affordable plans, by design, are underinsurance products that fail to protect those who need health care.

Then the government would regulate the insurance exchanges, but look at the results in the most highly regulated states. No state has escaped the problems that are driving our current efforts at reform. No matter how many regulations are passed, the private insurers have always introduced innovations that relieved them of any real responsibility to address the severe deficiencies in our dysfunctional health care system.

Paul Starr may want well designed insurance exchanges, but this Congress has already rejected them. Robert Reich may want an empowered public plan, but this Congress has already rejected that.

As Robert Kuttner states, “progressives would need first to crush the industry influence in Congress that is very likely to hobble either strategy.”

But then, “It is high time for progressives to stop settling for badly flawed second bests and to throw their energy into a first best that could rally popular support and produce a system that serves everyone.”

And, “The political reality is that Medicare for All is no harder politically than a version of the Obama plan that would meet all the tests that Reich and Starr apply. And it would be far simpler and more cost effective.”

Wealth, Income, And The Affordability Of Health Insurance

By Didem M. Bernard, Jessica S. Banthin and William E. Encinosa
Health Affairs
May/June 2009
There have been debates over how many uninsured people can afford insurance but refuse to purchase it.
The difference in purchasing power between the insured and the uninsured is not fully revealed by income comparisons. Median income of the privately insured was 2.9 times the median income of the uninsured in 2002-03 ($53,130 versus $18,404). However, median net wealth among those with private insurance was 23.2 times that of the uninsured ($78,472 versus $3,384). This discrepancy is even larger when we focus on families in the individual market. Median net wealth among those with nongroup insurance was 34.6 times that of the uninsured without access to employer coverage ($105,819 versus $3,057). Our results suggest that assets are an important determinant of effective affordability, undermining the notion that many people are uninsured by choice.
http://content.healthaffairs.org/cgi/content/abstract/28/3/887

By now you must be annoyed by those on the right who repeatedly claim that we do not have a problem with uninsured individuals. They say that the actual problem is that we are not counting them properly. Most of the uninsured would be insured, if only they showed a little more personal responsibility.
Many of the uninsured have incomes that are low enough to establish their eligibility for public programs. But those denying the problem would exclude these individuals from the count because they are “technically insured,” but merely too lazy to enroll. This ignores the multiple logistical barriers that make it impossible to enroll everyone who is eligible.
Many others without insurance are “illegals” who do not have their immigration papers in order. As long as we continue with national policies that include these individuals in our workforce, regardless of immigration status, then we have to accept the fact that they are part of our intrinsic economy and will access our health care system. Excluding them from the count would understate the issues we face when trying to figure out how to finance the care of uninsured individuals.
Although these undercounters dismiss most of the uninsured as failures of personal responsibility, they do remain conflicted on higher-income individuals who elect not to purchase insurance. Some consider these to be individuals who are exercising their right to freedom of choice – the freedom to self-insure instead of purchasing an insurance plan. Others consider these to be free riders who transfer the risk of catastrophic costs to the rest of us who are already paying our share.
But are these really individuals who are simply declining to purchase coverage they can afford? With health care costs now averaging $16,700 for an employed worker with a family of four, that takes quite a bit out of a typical income of $60,000. Many of theses families have little in the way of assets, living paycheck to paycheck, and really don’t have enough money to purchase a reasonable health plan.
This Health Affairs study demonstrates that not only income but also net wealth are important determinants of whether or not health insurance is affordable. Expanding net wealth requires both a higher level of discretionary income and a longer interval to accumulate assets. Thus both income margins and time are variables that influence the affordability of health insurance.
Since current proposals for reform would use tax subsidies to help individuals and families purchase private health plans, does this mean that we need to establish an eligibility grid that includes both income and net assets as variables? If we did, we might see an epidemic of personal failure based on the inability of so many to master the logistical requirements of the eligibility grid. (Have you tired calculating your precise net wealth recently?)
Why do we keep playing these games with all of the variables that go into determining our insurance status? Why don’t we simply make it automatic for everyone? If you exist, you’re covered.

By Didem M. Bernard, Jessica S. Banthin and William E. Encinosa
Health Affairs
May/June 2009

There have been debates over how many uninsured people can afford insurance but refuse to purchase it.

The difference in purchasing power between the insured and the uninsured is not fully revealed by income comparisons. Median income of the privately insured was 2.9 times the median income of the uninsured in 2002-03 ($53,130 versus $18,404). However, median net wealth among those with private insurance was 23.2 times that of the uninsured ($78,472 versus $3,384). This discrepancy is even larger when we focus on families in the individual market. Median net wealth among those with nongroup insurance was 34.6 times that of the uninsured without access to employer coverage ($105,819 versus $3,057). Our results suggest that assets are an important determinant of effective affordability, undermining the notion that many people are uninsured by choice.

http://content.healthaffairs.org/cgi/content/abstract/28/3/887

Comment:

By Don McCanne, MD

By now you must be annoyed by those on the right who repeatedly claim that we do not have a problem with uninsured individuals. They say that the actual problem is that we are not counting them properly. Most of the uninsured would be insured, if only they showed a little more personal responsibility.

Many of the uninsured have incomes that are low enough to establish their eligibility for public programs. But those denying the problem would exclude these individuals from the count because they are “technically insured,” but merely too lazy to enroll. This ignores the multiple logistical barriers that make it impossible to enroll everyone who is eligible.

Many others without insurance are “illegals” who do not have their immigration papers in order. As long as we continue with national policies that include these individuals in our workforce, regardless of immigration status, then we have to accept the fact that they are part of our intrinsic economy and will access our health care system. Excluding them from the count would understate the issues we face when trying to figure out how to finance the care of uninsured individuals.

Although these undercounters dismiss most of the uninsured as failures of personal responsibility, they do remain conflicted on higher-income individuals who elect not to purchase insurance. Some consider these to be individuals who are exercising their right to freedom of choice – the freedom to self-insure instead of purchasing an insurance plan. Others consider these to be free riders who transfer the risk of catastrophic costs to the rest of us who are already paying our share.

But are these really individuals who are simply declining to purchase coverage they can afford? With health care costs now averaging $16,700 for an employed worker with a family of four, that takes quite a bit out of a typical income of $60,000. Many of theses families have little in the way of assets, living paycheck to paycheck, and really don’t have enough money to purchase a reasonable health plan.

This Health Affairs study demonstrates that not only income but also net wealth are important determinants of whether or not health insurance is affordable. Expanding net wealth requires both a higher level of discretionary income and a longer interval to accumulate assets. Thus both income margins and time are variables that influence the affordability of health insurance.

Since current proposals for reform would use tax subsidies to help individuals and families purchase private health plans, does this mean that we need to establish an eligibility grid that includes both income and net assets as variables? If we did, we might see an epidemic of personal failure based on the inability of so many to master the logistical requirements of the eligibility grid. (Have you tired calculating your precise net wealth recently?)

Why do we keep playing these games with all of the variables that go into determining our insurance status? Why don’t we simply make it automatic for everyone? If you exist, you’re covered.