The Five Most Important Pieces of Health-Care Reform That Aren't the Public Plan
There is an emergent argument in the liberal grassroots that if health-care reform doesn't have a strong public plan, it's not worth doing. Atrios wrote that without a public plan, “there really isn’t much point to any of this. The public plan is the point.” TPM's Brian Beutler articulated the same sentiment in a different way when he tweeted, "If the public option fails, then I propose anti-individual mandate tea parties."
But we need to distinguish between different types of public plan. There's the public plan which is actually a version of Medicare-for-All. Everyone can buy in, the plan can partner with Medicare to become the largest bargainer in the system, and the expectation is that it will eventually take over the insurance market. I could understand making that the definition of health-care reform, as it is a fundamental transformation of the health-care system. But if you don't think we can pass Medicare-for-All, there's not much reason to think we can pass that.
And then there is the public plan that Sen. Chuck Schumer and others are actually trying to insert into the process. The public plan that the HELP Committee built into their bill. This public plan is simply another insurer run by the government. It would be good for competition and transparency and experimentation. It might have some small price advantage due to lower administrative costs. It might end up a dumping ground for the sick and the ill. I could imagine a world in which this public plan does a lot of good and a world in which it barely causes a ripple. Either way, it is not the point of health-care reform. It's more a perk of health-care reform.
But it has captured the process. Its existence, or lack thereof, is how the left and right are both benchmarking their success. The only problem is that it's not necessarily a very good benchmark. The left may win a political victory by including it in the policy but find that it hasn't won a particularly large substantive victory at all. The right could give up a lot to block the public plan only to find their concessions worth more than their triumph.
So -- and I say this as a strong supporter of a public insurance option -- here are five issues that I think are arguably more important than the public plan and, at the least, deserve a lot more specific attention than they're receiving:
1) The Health Insurance Exchange: I know. I'm a broken record on this point. But if the fundamental fact driving health-care reform is that our system is broken, then the central question is whether we're building something to replace it. If the Health Insurance Exchange is strong enough, it can serve as that something. If it is weak, and it is limited to the unemployed and the self-employed and small businesses, then it isn't likely to emerge as a viable alternative. And if you're still not convinced that you should care about the Exchange, then consider this: The Exchange is the body that offers the public plan. You could have the strongest public plan in the world, but if the Exchange is only open to 20 percent of the country, then only 20 percent of the country will be able to purchase public insurance coverage.
2) Medicaid: I have my doubts about expanding the Medicaid program. I would prefer a universal system in which low-income Americans were given access to the same coverage that the median American enjoys. But insofar as we're keeping Medicaid as the first line of coverage for the poorest of the poor, then the way we expand it matters enormously. In particular, the question of whether eligibility moves to 133 percent or 150 percent of the poverty line is of huge importance.
3) Subsidies: This is pretty intuitive. Are we helping families up to 300 percent of the poverty line? Or 400 percent of the poverty line? How much help are we giving them? What's the out-of-pocket cap? This all becomes particularly important if we have an individual mandate. You can't demand that people purchase something that they can't afford and that you're not willing to help them afford.
4) The Minimum Benefit Package: This isn't getting a lot of attention -- including from me -- but it's actually central to the whole enterprise. The individual mandate is going to demand that people have something called "insurance." The employer mandate is going to push employers to give their workers something called "insurance." The subsidies will exist to help people buy something called "insurance." But "insurance" can mean a lot of different things. Congress is going to set a definition for the lowest level of acceptable coverage. If that level is too low, we may end up in a situation where almost everyone is "insured" but those people aren't really protected.
5) Can You Choose Not To Keep What You Have? In some ways, this relates to the question of the Health Insurance Exchange. But as a principle, it deserves to be broken out on its own. It is core to the current health-care reform discussion that if you like what you have, you can keep it. But what if you don't like what you have? Can you change it? If the Exchange seems like a better deal, is there a way to cash out of your employer's offerings and choose from the Exchange's plans? If you think you'll be changing jobs a lot in the next few years but don't want to be tossed into a new health-care network every time, can you buy into a plan outside the employer-based market?
It wouldn't be terribly hard to pick another three or four policies that should be added to this list. But people like the number five. And, at the least, these are four specific policies that could literally make-or-break health-care reform. If you don't have enough subsidies you can't have an individual mandate. If you don't have a sufficient benefit package then you're losing sight of the reason you want people to have insurance. If you don't do a good enough job expanding Medicaid, you're left with a patchwork system for the neediest Americans. If the Health Insurance Exchange isn't strong enough to grow into a better and more efficient health-care system, we won't have fixed anything at all.
The public plan is important, but it's not the most important piece of health-care reform.
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