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Public Option Compromises

Sen. Tom Carper is floating a compromise that would allow states to individually decide whether to offer a public option, a co-op or another form of insurance competitor. Call it the federalist option:

In a one-page document he began circulating last week, Carper suggests giving states the option of creating a competitor to private insurers, which could include a government plan, a network of co-ops or a large purchasing pool modeled after the revered Federal Employees Health Benefits Plan.

This has some real promise, at least when compared to alternatives like a trigger. I'm trying to find out more.

By Ezra Klein  |  September 30, 2009; 12:20 PM ET
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This sounds promising. This is more about states rights which is what Republicans stands for. Thus if California wants to have a public option they can. If Nebraska doesn't want a public option then they don't have to have one.

Posted by: maritza1 | September 30, 2009 12:25 PM | Report abuse

Do the short form. The wheels have fallen off the wagon. If congressional Dems can't put the wheels back on the wagon, it's time to stop pulling the wagon.

Posted by: serialcatowner | September 30, 2009 12:27 PM | Report abuse

Ezra: wouldn't this depend on whether the state-mandated public options could join together to get the requisite bargaining power to be effective? If West Virginia opts for a public option, but it's barred from joining forces with larger states, its public option isn't exactly going to be a formidable rival to the insurance companies doing business in WV.

Posted by: rt42 | September 30, 2009 12:30 PM | Report abuse

Couldn't a state put together a public option today if they wanted to? Why would this need an act of congress?

Posted by: spotatl | September 30, 2009 12:33 PM | Report abuse

My dear spotatl, I think the reasoning is this: the Exchange (which nobody has a problem with) WILL be federally mandated (though composed almost entirely of private insurers), and this compromise would put in a "public option" run by the federal government that states could choose to opt into or opt out of. If a state thinks it would be too expensive, or whatever, then they could avoid it and go the way of co-ops (which don't work; see But if a state wanted, then said state could opt in.

Posted by: Bertilak | September 30, 2009 12:41 PM | Report abuse

So from reading the article he's hoping to allow the states to form co-ops that could include a public/non-profit option if they want?

Posted by: JWHamner | September 30, 2009 12:45 PM | Report abuse

If all companies were allowed to buy into a state level public option, it could be a good deal. Otherwise, if it were limited in the way that the public option is currently proposed to be, (only individuals whose business does not offer insurance or small businesses) I can't see a state level plan getting big enough to have any leverage except in the largest states (Surprised Carper is pushing this - s state level plan in Delaware certainly wouldn't be worth much.)

Posted by: exgovgirl | September 30, 2009 12:54 PM | Report abuse

Ezra, can you a get of that one page public option alternative paper, circulating by Sen. Carper, please?

Posted by: makensei | September 30, 2009 12:57 PM | Report abuse

bertilak- but right now today any state could put together a public insurnace plan. Any group of states could bind together to form a larger pool and form a larger risk pool. Nothing I have seen in the exchange legislation would prevent a state run plan from entering the exchange as long as they covered all the mandatory stuff. I don't at all see why this would need to be a provision of the healthcare bill unless you are trying to require providers to give the state run public plans medicare rates.

To me this is just paying lip service to the democrats who think there HAS to be a public plan. This is something that could be done right now today but would be taken as a victory by people who don't really pay attention to the details.

A public plan that pools together with medicare could certainly lower costs. A state run public plan is just another non-profit insurer that won't do anything except to make people feel warm and fuzzy by calling it a public plan.

Posted by: spotatl | September 30, 2009 1:01 PM | Report abuse

spotatl-hi! I agree with you that this compromise totally a sop to Democrats who wanted a public option. And I'll add that it is a total shame you seem to remember...THE PUBLIC OPTION WAS THE COMPROMISE IN THE BEGINNING between people who did and didn't want something like single-payer. Sigh.

But I wonder if states really could band together to form a public option group of their own, as you've supposed, given the strictures (which I support: see for why) against buying insurance "across state lines." And anyway, isn't the idea that all the states have different standards for what insurance to offer--so how could they possibly agree on how to form this sort of group? I'd think the Federal gov't would have to lay down the rules, to which the states could sign on or not as they choose.

To your last point, I was going to say something similar in my previous comment. I think that there wouldn't be enough bargaining power in the just-a-few-states options we've imagined, state-coordinated or Fed-run. I suppose that if a lot of states signed on to a Federal plan it could be worth it, though. And any "compromise" is still better than killing all hope of any public option outright. If there is a public option even available to a few people in a few states (as opposed to Obama's idea of just a few people in all the states), and it seems to be working, then that could help press the case for even further reform.

Posted by: Bertilak | September 30, 2009 1:20 PM | Report abuse

Ezra, can you a get of that one page public option alternative paper, circulating by Sen. Carper, please? Polisci student at UF, whose favorite issue is health care, i would like to have the document in my healthcare pdf files. + carper is one of my favorite senators.

Posted by: makensei | September 30, 2009 1:22 PM | Report abuse

Yet another proposal that is disguised as something it is not, just to get 60 votes.


Posted by: RandomWalk1 | September 30, 2009 1:34 PM | Report abuse


Wouldn't this create some risk pooling problems? Ostensibly, we're talking mostly about Southern Red States that would opt out, which might lead to those who can't afford more expensive private insurance or simply those who are more ill to move to states where the public option is offered?

Posted by: jonrepartay | September 30, 2009 1:54 PM | Report abuse

This just propagates that fantasy that anything other than a single payer system can work for this country. We are too diverse, there are too many insurered, and our health costs are too out of control for anything else to save us from financial meltdown.

Posted by: bmull | September 30, 2009 2:02 PM | Report abuse

As someone mentioned, why do states need an act of congress to do what they want to do? Unless what this actually means is allowing states to choose whether a federal public option can operate on their exchange. That makes some sense. Or perhaps allow states to band together and create multi-state public options, which as "interstae commerce" would I'm guessing require at least tacit congressional approval.

However, I'm not sure I prefer this to a trigger. Right now, we have massive progressive attention focused on the health care bill, along with what I believe is an honest negotiator in Olympia Snowe. I trust this arrangement to produce more favorable results than leaving it up to notoriously corruptible, easily bribed state governments to concoct their own public plans long after the public has lost interest. Then again, it would perhaps allow some progressive states to create strong public plans.

Posted by: CarlosXL | September 30, 2009 2:10 PM | Report abuse

This is HORRIBLE idea. To me, it's akin to passing a civil rights act and allowing states to opt-out.

If this idea passes, those of us in the South, where we have higher portions of impoverished and uninsured, will be forever suffering (has anybody noticed where all those free clinics take places with thousands lined up to get in?).

Posted by: cjo30080 | September 30, 2009 2:44 PM | Report abuse

Forget it this needs to be a National Deal. If it's handed over to the States, the Insurance companies will set up shop in those States that favor their Corporate Status. Who is this guy kidding? Doesn't he know know that this is a Federal issue? Health Care is a right for All Americans, not just the right of those Americans who win the lottery by living in a State that favors them. Obama addressed this very issue in the National Presidential debates. My suggestion: Go back to Politics 101 and watch the Presidential Debates again.

Posted by: lamptech | September 30, 2009 3:07 PM | Report abuse

The public option was the compromise.

Benedict Carper's plan lacks any detail--and all similar plans have been discredited--so I don't see how you could say it has "real promise."

Experts agree it takes 20 million people of average health to create a viable competitor a private monopoly. No state or region could not put that together on its own.

Posted by: bmull | September 30, 2009 3:09 PM | Report abuse

An awful awful horrible horrible idea. Medicaid (not Medicare) has led to 50 different plans that are the favorite Lucy footballs of the states' legislatures.

"One Nation, Indivisible" doesn't mean much anymore, I guess.

I'd rather have no public option and deal with the consequences than 50 over-manipulated state plans that exclude or mandate wingnut medical care at their whim. Mandatory castration for gays? Sure, why not. Hysterectomies for pregant unwed mothers of the wrong race/class? Of course! Illegal aliens caught doing robbery: cut off their hand in the ER, and then to jail!

A far better fallback is allow any person under 65 to buy into Medicare Part A, B and D, paying the full cost, or some tax credit/income deduction scaled to income. That could be done by reconciliation.

Posted by: JimPortlandOR | September 30, 2009 3:12 PM | Report abuse

Can we please get a REAL health care columnist? Because you'd have to be a poseur to think that Carper's plan has any merit at all.

What makes you think that under Carper's plan a doctor in Massachusetts would accept the same reimbursement rate as a doctor in Idaho?

"a large purchasing pool modeled after the revered Federal Employees Health Benefits Plan." That is the now-proposed Health Insurance Exchange. It's not the public option nor is it any better.

We know Conrad's co-op idea is worthless.

And state-based plans won't work unless all states are involved.

Posted by: cab91 | September 30, 2009 3:21 PM | Report abuse

this could work if the mandate was state-centric as well. the proponents of mandates keep telling us it's just like car insurance, well car insurance mandates are done at the state level so why not health care? pare down the bills completely so they only set up a health exchange (and a few natl rules regarding preexisting etc) and leave everything to the states.

Posted by: PindarPushkin | October 1, 2009 11:59 AM | Report abuse

To those talking about state-level plans - if I'm reading this right (and not having seen the actual proposal), it sounds like he's talking about one federal-level public plan that states can choose to offer or not. So the comments that a state-level plan wouldn't be big enough, or that states can create such a plan on their own, wouldn't apply.

*IF* the plan Carper's proposing would be nation wide, just not available in all states, that in itself is complicated enough to make me lean against it, too. Just not for the same reasons those who believe it's a state-level plan are against it.

Posted by: KarenJG | October 1, 2009 12:03 PM | Report abuse

My mistake... having read more on the proposal, it looks like the "state-level" people are right. As Emily Lutilla would say, nevermind...

Posted by: KarenJG | October 1, 2009 1:02 PM | Report abuse

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