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Dissecting the Republican Health Care Plan (Part 1)

The word of the day is "convergence." That -- and that alone -- is the definitive message of the conservative health reform alternative developed by Sens. Tom Coburn (Okla.) and Richard Burr (N.C.), as well as Rep. Paul Ryan (Wisc.). For now, some of the key provisions are about as clear as mud. The plan's changes to the tax code, in particular, are impossible to discern. So I'll do another post when I can get some clarity on those issues. The politics, however, are perfectly straightforward.

A superficial read of the Patients' Choice Act -- which I've uploaded here -- would make you think you're digging into a liberal bill. A fair chunk of the rhetoric is lifted straight from Sen. Ted Kennedy's office. "It is time to publicly admit that the health care system in America is broken," begins the document. "Health care is not a commodity in the traditional sense," it continues. "States should provide direct oversight of health insurers to make sure they are playing by fair rules," it demands. The way we pay private insurers in Medicare "wastes taxpayer dollars and lines the pockets of insurance executives," it says. Elsewhere, it praises solutions that have worked in several European countries."

And though it's still too early to say how the policy fits together, it's clear that many traditionally Democratic concepts have been embraced. To put it simply, the plan wants to encourage a version of the Massachusetts reforms -- which it calls a "well-known, bi-partisan achievement of universal health care" -- in every state. There are some differences, of course. The plan doesn't have an individual mandate. It doesn't have an obvious tax on employers. But it strongly endorses State Health Insurance Exchanges. And that, for Republicans, is a radical change in policy.

This idea -- present in every Democratic proposal but absent in Arizona Sen.John McCain's plan -- would empower states to create heavily regulated marketplaces of insurers. The plans offered would have to "meet the same statutory standard used for the health benefits given to Members of Congress." Cherrypicking would be discouraged through risk adjustment, which the PCA calls "a model that works in several European countries." The government would automatically enroll individuals in plans whenever they interacted with a government agency and states would be able to join into regional cooperatives to increase the size of their risk pool.

In essence, Coburn, Burr, and Ryan are abandoning the individual market entirely. Like Democrats, they're arguing that individuals cannot successfully navigate the insurance market, and they need the protection of government regulation and the bargaining power that comes from a large risk pool. This is literally the opposite approach from McCain, who attempted to unwind the employer-based insurance and encourage families to purchase health coverage on the individual market. The core elements of this plan, in other words, make it the same type of plan Democrats are offering. A plan that enlarges consumer buying pools rather than shrinks them. It's pretty much exactly what I'd expect a Blue Dog Democrat to propose. And it's further evidence that the argument over health reform is narrowing, rather than widening. And it's narrowing in a direction that favors the Democrats.

By Ezra Klein  |  May 20, 2009; 12:06 PM ET
Categories:  Health Reform  
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I have not read the attachment so I am responding solely to your post. This does seem to indicate that the discussion is narrowing in the correct direction. Even more notable is the fact that Coburn is behind this...although he is a physician, he certainly is extremely conservative.

Posted by: scott1959 | May 20, 2009 12:13 PM | Report abuse

There's no individual mandate, right? So what if the insurance companies just raise their premiums through the roof? They still abide by community rating and guaranteed issue, but the only people who can afford it will the upper-middle class and above.

Does the PCA address this point anywhere?

(p.s. like many physicians, I support a public option. check out

Posted by: cpage1 | May 20, 2009 1:27 PM | Report abuse

A few things are conveniently skipped over in this article:
1/ The republican's Patient's Choice Act keeps insurance in the private sector and avoids a gov't sponsored public plan which would suffocate all the private plans and would ultimately lead to a universal health plan w/ rationing, hugh expenses, increasing taxes etc.
2/ It allows for employee Health spending accts which are tax deductible --right now only the business/employer gets this tax break
3/ It allows patients to keep their insurance plans even when changing/losing a job
4/ It is a cost neutral proposal unlike the democrats/Obama's plan which will put the deficit over $11 trillion in 10 years....
These are all very important points which Mr. Klein has ignored, and make the republicans' plan very different than the democrats. BTW, where is the discussion re: tort reform and the ever escalating rates of malpractice insurance??? I guess Mr. Klein, being partial to the democrats and the trial lawyers, found that an easy point to ignore as well --but he's in good company as the democrats and Obama ignore it as well.

Posted by: roespan | May 20, 2009 5:53 PM | Report abuse

For those who think national health insurance and private providers = no choice, rationing,etc...I suggest you try it.

My experience in Germany was just like my experience in the states with 2 exceptions.

I was cared for by our family MD, with an office conveniently around the corner. The only two differences were- no co-pay and MUCH LESS PAPERWORK.

Check it out!

Posted by: massmarba | May 20, 2009 7:10 PM | Report abuse

You must have not been really sick - I bet your experience wouldn't be as happy-go-lucky if you needed an MRI pronto and a complicated surgery to follow (I certainly do not wish anything bad on anyone). Most people confuse availability of trivial medical care with serious stuff, when it really matters.

"For those who think national health insurance and private providers = no choice, rationing,etc...I suggest you try it.

My experience in Germany was just like my experience in the states with 2 exceptions.

I was cared for by our family MD, with an office conveniently around the corner. The only two differences were- no co-pay and MUCH LESS PAPERWORK.

Check it out!"

Posted by: catofan | May 20, 2009 7:55 PM | Report abuse

Catofan, I live in Germany and have only positive experiences of the healthcare here. Thankfully my personal experiences are limited to primary care of "trivial" conditions like flu and ear infection. However, two different friends have called upon the German state-regulated system for serious injuries sustained in a car accident and a climbing accident. Both received an MRI scan within 2 hours of arriving in hospital. The Government-regulated cover also covered residential physical therapy for both of them whilst they recovered from their injuries. The Conservative demonizing of European healthcare is just plain wrong!

Posted by: FlacidCasual | May 20, 2009 10:03 PM | Report abuse

If you would, please, disect the Democrate Health Care plan as well.

If you can do this, I would like you to provide a link to the bill.

But, you cannot because it does not exist. It will, probably, be unveiled in the wee hours of the evening and brought to a vote in a hurry.

Having worked in Healthcare, as the computer guy who had to program the system to deal wit it, it will be, most probably, a real mess, full of government bean counters acting as the gateway to the approved proceedures and payments.

Been there, done that, back in the 80s as part if the UB82 and DRG complience standards. They did not work and neither will Pres. Obama's plan.

The government clowns cannot be trusted to run AmTrack, Welfare or the other big tickets items. And you want them to control your health care options?

Good luck on that.

Nuff Said!

Posted by: wjd1 | May 20, 2009 10:07 PM | Report abuse

FlacidCasual, seems like your friend, have not had terribly bad problems either. I know that in Canada it takes weeks and weeks to to get a CT scan and my numerous friends in Germany, including a practicing physician, told me that complicated testing and care, especially surgery, are not at the same level as in US. And those are instances that truly really matter. This is, however, hearsay and anecdotal evidence: there is well documented statistics that proves better survival rates the US for the most serious medical conditions – life and death situations. I am not a conservative and I don't demonize European health care - just stating that when the s*** hits the fan, our system is still better. If government reallyy knew how to run things efficiently, we would have nationalized everything, including health care, a long time ago.

Posted by: catofan | May 20, 2009 11:02 PM | Report abuse

catofan -
Do you have any idea how much more we pay to achieve those marginally better outcomes? By any standards, the American health care system is insanely expensive and wasteful due to high administrative costs, inefficiencies, unnecessary treatments, waste and fraud. Do you know that we spend more money per capita on health care than ANY other country, and yet we still have a life expectancy only marginally higher than Cuba's? Whatever you might say about Canada, they spend less than half what we do, per capita (and have a higher life expectancy/lower infant mortality rate to boot). A quarter of our health care dollars go to administrative costs. Could government run health care really be less efficient than THAT? Honestly, if the government can substantially reduce the cost of our health care, I don't give a damn if that means I have to wait two weeks for a CT in a non-emergency situation.

Posted by: csl35 | May 20, 2009 11:40 PM | Report abuse

csl35, please read "Don't Doc American Health Care" in a recent Forbes (available online) for the facts.

Also, "we" sounds collectivist to me -- I wish everybody all the nest but as a consumer I want the best options for me and my loved once when it comes to the situations where the best care really matters.

Finally, the reason the costs are so high, is because government, beginning with WWII and then the "Great Society" got us into this insane middleman payer system, where the power of the purse is taken away from the consumer and given to the employer insurance and Medicare. I'd like to go back to free market, where the consumer votes with her/his feet and money.

Posted by: catofan | May 21, 2009 6:31 AM | Report abuse


There was a good Frontline piece about health care in other countries called "Sick Around The World" (you can find it online). The doctor/correspondent went to Germany and found that people generally don't have to wait to see a specialist or get a procedure, or at least don't have to wait any longer than in the US. And Europeans get just about the same overall health outcomes as we do in the US at slightly more than half the per capita cost.

As for the "free market," I think it's pretty clear that it doesn't put the right incentives in place for good health outcomes. For instance, it gives insurance companies the incentive to go after only healthy people and deny coverage whenever possible. I have yet to see a market system where sick people can get insurance at a reasonable price, because who would want that person in their system?

I'm generally a free market person, but I'm not going to ignore evidence that shows it's not necessarily the solution to every problem.

Posted by: dasimon | May 21, 2009 3:51 PM | Report abuse


I am a big fan of NPR and give them a lot of money on a monthly basis, but this particular piece was completely skewed. I listened to every part of it and read transcripts - this is not evidence but one man's opinion and very biased at that. If you want, we can go point-by-point on this.

As for the free market, I have no idea how you can make a claim that "it doesn't put the right incentives in place for good health outcomes" First of, we haven't had free market in health care for reasons of government interference that I mentioned before. Second, when you are buying a TV or replacing a roof, does free market "put the right incentives in place for good outcomes?" - this is not how free market functions...

Posted by: catofan | May 21, 2009 8:45 PM | Report abuse


You say that the Frontline piece was biased, but I can't evaluate your claim without specifics. He reported what doctors and other participants in the other systems told him. Do you think they were unreliable?

As for incentives, you don't respond to my example regarding the private insurance industry: that all providers have the incentive to insure only healthy people and deny coverage whenever possible. That doesn't seem to be a good prescription for good health outcomes. And our system is closer to a free market than European ones, yet we get no better outcomes at almost twice the cost. I suppose it's possible that going to a completely unregulated system might do better, but I don't see why that would be the case.

Why the resistance to evidence that European systems work better than ours?

And yes, when you're buying a TV, manufacturers have the incentive to offer better products at lower cost. Competition seems to work. But competition on health care doesn't. Rewarding procedures means too many procedures. The health insurance issues have been cited above: who will insure those with health problems?

To insist that the market is the solution to every problem isn't reality as much as it is ideology. And the real world won't fit itself to ideology, wherever on the political spectrum that ideology comes from.

Posted by: dasimon | May 23, 2009 11:57 PM | Report abuse

Let's set aside statistics. Everyone here knows you can make statistics say whatever you want it to say. The plan should stand or fall on whether or not it provides the best and most affordable health care for everyone.

Ask yourself a couple of questions, will I or my family get the best care available under this plan? Will it be the most affordable health care plan for what I need?

What do you consider as good care? Have you ever felt helpless because there was no leverage you could use to get someone to do what you thought was right? I know I've been in that situation before. Have you been to the hospital to see over a seriously sick family member? What kind of care did they receive? Did you have the leverage you needed in correcting problems you saw in the care that was received?

I have had family members in critical care at hospitals and the care has been mediocre at best. My sister-in-law had incurable cancer and her lungs filled up with fluid because she was too weak to cough the fluid out. Well, the nurses had a 20 minute schedule to come in and remove the fluid buildup. Rarely did they keep to that schedule. She lived for two weeks barely able to breath. Essentially she suffocated to death over a two week period. Horrible.

How much leverage do you think you will have if you are not paying for your health care, that it is being paid through the government? How can we best incentivize the hospitals to provide the best care possible?

We are all going to be in the health care system at some point or another. It's critical that the politicians get it right.

Posted by: enoughalready3 | May 25, 2009 4:21 PM | Report abuse

With respect to NPR, it's a long story so I'll just give a couple examples on France. First, the reporter mentioned that the woman with cancer announced that they now allowed a second opinion (a new practice in France, apparently). Would we find out that no second opinions were allowed had it not been changed? - I doubt it.

Also, no hard questions were asked about hospital conditions, procedure availability, survival statistics, etc. And what about sustainability? Apparently there is a huge unfunded liability in France: government, for instance, wanted to limit benefits for immigrants (there was a revolt among Brits retiring to France according to NYT). Why, even Cuba looks good to Michael Moore as told by patients and doctors...

"Twice the cost for the same results" is not accurate -- see my references to Forbes ad Cato.

Resistance to European system is due to its worse outcomes for serious illness, collectivism, limiting choices and sustainability issues - it is becoming more and more unaffordable with public sector running it and more rationing to come.

It is absolutely correct that a TV manufacturer has an incentive to offer a better product at lower cost. What incentive does government have? In terms of pushing procedures, it is precisely because of our middleman system forced by government - as a consumer I would not pay for a procedure that didn't make sense any more than fro a bad TV.

Posted by: catofan | May 25, 2009 5:57 PM | Report abuse

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