The Public Option Is Not Where You Draw the Line

It’s rare that people arguing about health care reform come at me from the left.  But more and more these days, that’s what’s happening.  Today I was on the phone with a friend who was threatening to be done with the Democrats once and for all if they didn’t pass a public option.  I told him he was over-reacting.

You heard me right.  At this point, I can live without a public option.

Lest you doubt my progressive credentials on health care reform, I’ve never hidden my belief that a single-payer solution is the most cost-effective way to achieve universal coverage. I haven’t wavered.  I still say that when asked, and I have no problem defending that position.

But too many, in politics and out, said that was never going to happen.  We wanted to tinker and tweak, not revamp and rebuild.  And now that we see the result, many are rallying around the public option like it’s a singular opportunity to save the world.  It’s not; it’s not even close.

Be real.  The House version of the bill contains perhaps the most robust version of a public option.  The CBO estimates that maybe a third of people in the exchange will choose it.  That’s fewer than 10 million people, maybe 3% of Americans.

The public option has never been about coverage.  It’s about cost.  No more people will obtain health insurance if we have a public option.  Nor will the quality of care go up.  Some very smart people think we also need it for political cover, but I don’t really care about providing politicians with extra protection right now.  The public option is meant to increase competition and lower the cost of insurance.

How much lower?  At best, maybe $110 billion over 10 years.  I’m not scoffing at that amount.  It’s real money.  But remember that’s an average of $11 billion a year in savings in a country that’s spending at least $2.4 trillion for health care.  I just can’t get worked up about a measure that might knock off less than one half of one percent of total costs.  For this you’d kill health care reform?  Are you kidding me?

Since we decided to “build on what works and fix what doesn't”, let’s be truthful about this.  All of the bills, even the Senate Finance Committee’s, accomplish the following:

1)     Increased Medicaid and CHIP coverage

2)     Subsidies to help lower income families buy coverage

3)     Universal guaranteed issue (no denials of coverage)

4)     Universal community ratings (no penalties for pre-existing conditions)

5)     Increased insurance company regulation (no recissions)

6)     An insurance exchange for those buying on the individual market

7)     Out-of-pocket caps (maximum amounts you can ever pay)

No one will be denied insurance because of pre-existing conditions, no one will be priced out of coverage because they are on the individual market, and no one will go bankrupt because of medical expenses.  There’s still a lot of good in there.

Don’t get me wrong.  I’d rather have a public option than not.  I’m in favor of lower costs.  I’m so enamored with lowering them I’m for a single-payer system.  In fact, as I’ve said before, I’d be in favor of almost any other comparable country’s system.  But we didn’t want that.  And I do realize this is an awesome deal for the insurance companies.  It's also an awesome deal for pharma, for hospitals, and for doctors.  Since we chose a path that buys off industry, let's be honest that this may work out well for them, too.

It’s fine to push for a public option.  It’s fine to push for even more.  It’s even fine to negotiate from a position of strength.  But, please, in your hearts, calm the rhetoric.  Those of you on the left, don’t overestimate the importance of the public option to the overall goals of health care reform.  If we don’t get it, yes, the cost of the bill will be higher.  But we’re already pretty used to high health care costs.  The public option isn’t a back door to a single-payer system either, so don’t make that mistake.

Those of you on the right, don’t go crazy either.  The public option isn’t the devil.  It’s not going to lead to a nationalized system or to the end of private insurance.  It’s just a means to increase competition and try to reduce the cost of reform.  There was a time when those craving fiscal sanity would have liked that.

So let’s have a debate.  Maybe we will get the public option.  Maybe we won’t. Either way, the reform we are going to get is not nearly enough.  We’ll still have a significant number of Americans without insurance, a system that lacks sufficient quality, and costs even higher than before.  We won’t be able to afford it for long, and we’ll need to do this again.  Throwing a tantrum and running home will mean your voice will not be heard next time.

So fight for your goals, fight for what you believe is best.  But don’t burn down the village over the public option.  It’s not worth it.

Read more about health care policy and get your questions answered at Rational Arguments.

Read more at: http://www.huffingtonpost.com/aaron-e-carroll/shuffling-the-deck-chairs_b_320265.html

 

 

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Comments

[kevinw]

As with many of the healthcare industry tools, the doctor here makes a primary mistake of confusing access to insurance as access to healthcare. The coverage proposed for the mandated insurance only controls premiums. There are no caps on deductibles or copays. There is also no definition on what the limitations are on coverage. These all add into the mix of whether the person is being forced to purchase healthcare or pating extra for being in the same situation they are in currently. With no public option, they will have to pay for these crummy useless catastrophic coverage plans. They might not have the money to standard visits and preventative care, since the first x number of thousands will be directly out of their pocket. Now, do you think the insurance company might use the fact that you were not following normal preventative care as a reason to deny coverage of problem that is expensive and will go over your deductible? You betcha. Having an individual mandate and no public option allows the insurance industry straight out profit on all government subsidized premiums up until the time that the deductible is reached. There are no real controls in the healthcare bill to keep them form denying coverage or restricting usage of expensive treatments once this threshold is reached. The doctor is looking at this from the medocal establishment side of getting paid. He obviously does not have to worry about adequate coverage for himself or his family.

[Aaron E. Carroll - Huffpost Blogger]

I really, really encourage you to read more of my work. I have stated, and will so again, that I favor a single payer system. I favor far more robust reform. I'd remake the entire system.

I think the public option doesn't do enough; it doesn't go far enough.

I think it's an incremental addition on an incremental bill. And it's not worth sacrificing everything else over it.

[Veronikaleblanc]

Aaron, it is so easy to be in favor of something that has no chance of happening. What does it have to do with your advocating a cave-in on the public option?

It's like saying 'I'm in favor of world peace, but if we can't have that, let's make wa.r.'

[Veronikaleblanc]

It's very easy to be in favor of something that has no chance of happening. What does your position on single payer have to do with your advocating a cave-in on the public option?

The two don't seem connected to me. We have to draw the line somewhere, why not the public option? It's closer to the position you say you are in favor of.

[wildedge]

Dr, Carroll fails to address the problem of mandating people to buy insurance, some form of which is, I believe, in all the bills. Without a public option, this mandate is simply unjust.

[austinraider]

The current bills without the public option will lead to skyrocketing insurance costs. There either needs to be a public option or very tight regulation, including regulating the maximum premiums that insurance companies can charge. If insurance companies are forced to take in people they would have rejected, either their profits will go down (not a chance) or the premiums will go up for everyone else. There are some provisions that would help to cover premiums, but these are mostly for people near or below the poverty line. I would rather have the existing system rather than see my premiums double or worse under this mess. The health insurance lobbyists will make sure that this bill only benefits the industry.

[Aaron E. Carroll - Huffpost Blogger]

What's your definition of skyrocketing costs? I'm concerned about the total costs of health care. As I say above, those are currently about $2.4 trillion. The CBO estimates (or did before) that the robust house option carries a savings of about $11 billion a year. Is that real protection? Are we really that afraid of $11 billion that we'd kill the bill over it?

There are lots of things to fight for, and I think we should fight for savings wherever we can get it. But don't overplay the hand. The public option is not what a lot of people think it is.

[theLeftPaw]

Most Americans don't realize that even in its very BEST current proposal, it would be made available after a couple years, and will only be a choice for a very small segment of the population. It's no real threat or effective competitor for private insurance, not at all!

And like you said, it doesn't really address the actual health care costs.

[mikecal]

The public option is a political concoction that is not worth fighting for in any form that will come out of the current Congress. Better to press for single-payer or extremely strong regulation of the insurance industry. The public option is be proposed as a mere stopgap and Dr. Carroll is right to emphasize that there are other better aspects of reform.

If you want public insurance fight for single payer.

[kevinw]

Who are you kidding. Single payer was rejected outright by the Obama administration and the Senate leadership right at the beginning of the debate. Remember the health care hearings where they actually asked all of the medical professionals supporting single payer to leave the room. So now you are saying don't support the public option, only support single payer. There is no bill that has single payer in it. There is absolutely no visible support by the Democratic leadership for single payer. They are only now supporting some form of the public option out of fear. If you will only support single payer, then you should at the very least fight the individual mandate.

[theLeftPaw]

There is indeed a way to have Single Payer with the current reform proposals, via the Kucinich amendment for states to enact their own.

[bigrich1]

Prof Carroll is a proponent of single payer and so am I. The disagreement comes on how to get there. It should be obvious that this push for health care reform is historic in its scope and timing. There is no guarantee when another such major health care bill will come forward after this. That is why the Dems must unite all their forces to get as much as possible at this time - public option, free choice, repeal of antitrust exemptions, expanded coverage, strengthened regulations. The stars are aligned, if they would but see them. The public is in support, if they would but heed them. And a true progressive victory on this issue will set the stage for all the victories still needed - financial sector reform, climate change legislation, repeal of don't ask don't tell. Now, above all, is not a time for half-measures. Now is the time for change we can believe in.

[GrahamInCanada]

There are two ways to approach a goal. The first way is an all out effort, a never say die effort, anything short of the goal is not acceptable effort...

When you approach a goal this way, and you go to an ally, and say, if we don't reach the goal this time, I am going to change this for the next effort: a declaration, like I am through with the political party, and that ally only tells you that you are overreacting, it seems clear to you that the ally is not listening.

The other way to approach a goal is by first getting yourself to the halfway line, and then go from there. Don't be so focused on the ultimate goal, just get halfway there. And then, when that's done, cut the distance in half again.

When you approach a goal this way, and an ally comes to you, and says, by golly, if we don't reach the goal this time, I'm going to quit the party, or whatever declaration, you think that your ally is overreacting in a way akin to cutting off his own nose to spite his face and you want to dissuade your ally.

The second way to approach the goal is called Zeno's dichotomy. The thing about Zeno's dichotomy, is that if you go halfway there, and then halfway there, and then halfway there, you will never ever get there.

[kevinw]

You may accept less than perfect solutions, however you do not place an individual mandate on everyone to buy insurance and then allow the only potential for decent coverage in the public option to be stripped from the bill. That is not getting to the 50 yard line. That is running back into your own end zone and fumbling the ball.

[theLeftPaw]

"The second way to approach the goal is called Zeno's dichotomy. The thing about Zeno's dichotomy, is that if you go halfway there, and then halfway there, and then halfway there, you will never ever get there."

This is surprising, especially coming from a Canadian. Are you seriously unaware of how Single Payer came to be in your own country? One province at a time, half way, half way, then completely national!

[Factonfact]

"The Public Option Is Not Where You Draw the Line"

Sure it is.

[janiceh]

Ditto.

[Veronikaleblanc]

A mandate for coverage without a public option is a giveaway to the insurance companies. A huge, huge giveaway. I have a problem with that. Aaron, your statement of 'the insurance companies would do well' or whatever is really not-smart. Sorry. Look at what these companies have done to people. They ruin lives every day for a profit. You would have the government hand them massive amounts of money and call that reform. I feel sick.

[Ant]

I disagree. If you mandate coverage without providing competition to the insurance companies then health care costs will sky rocket. And frankly, I've always believed that health care reform should have been "Medicare for all who want it" and that's it. Once that option is provided, we don't have to worry about the things you listed above because the health insurance companies would do it on their own.

[theLeftPaw]

Repealing the exemption from antitrust would do the same thing, but far more effectively; because it would END their ability to collude for price fixing.

The public option in its very best form to date won't even be available to the general public; it will only be an option for the unemployed and those employed by super small companies (I believe it's 20 employees or less) or those who are self-employed - and won't be an option at all for these select few for at lest a couple of years too. This is too small a pool of people and too small a segment of the population to actually be an effective competitor!

Now consider that class or wealth is the biggest indicator of health status in the US - meaning the poorer you are, the poor your health tends to be. This means the option would really only serve the least healthy amongst us, and is in itself a gift to insurers.

[janiceh]

If the public option isn't a big deal, then Congress should just give it to us. Why do the people have to be the ones to decide it's not worth fighting for. Since the "public option" is so insignificant, then Congress should be the one to decide (along with their insurance company contributtors) that it's not worth fighting over.

[billhodges]

The public option is just the first step toward National Health Care according to Obama and Barney Frank in their own words.

I want no part of the government controlling the health care system.

http://www.youtube.com/watch?v=Dn5-Vw9Do0g&feature=channel_page

[janiceh]

Why don't you want national health care?

[taikan]

First, it would help to recognize that the problem being addressed by all of the reform bills -- health insurance reform -- is distinct from the problem of providing adequate health care to all residents of the United States. Thus, no matter what is included in the final bill that gets passed, the fundamental problem of lack of adequate care for all will not be resolved.

[jmpurser]

Agreed. I've been for single payer since Obama got elected. When he "took it off the table" and instead started making empty promises about an undefined "public option" I knew I wouldn't be voting for him again.

With or without a "public option" these bills are nothing but massive corporate welfare bills. The only excuse not to fight against all of them is that under any of them perhaps a few less Americans will die needlessly.

Obama's "health care reform" is a disaster that we're just going to have to do over again once he's out of office.

[kevinw]

Who are you kidding? Clinton tried and failed in 93. It has taken until 2009 to get a second bite at the apple. If the bill coming out of the congress is another Medicare part D gift to insurance, the Democratic party may have a hard time holding onto the House and Senate majorities. They act like a timid minority party with 60 votes in the Senate. Do you think Reid is going to grow a pair with less. We may not even see another attempt at reform, again in my lifetime.

[jmpurser]

IF the bill is a gift to insurance companies????

ALL of them are MASSIVE corporate welfare for the insurance industry except the single payer bills that Obama and the congressional democrats as a whole are trying so hard to squash.

And the fact that we may not even try to fix this mess again in our lifetimes is one of the many reasons it's such a disaster.

[ValerieJK]

Another thoughtful post. I was starting to get angry, and then I realized that you're right. I thought deep down that the public option will deliver us to a single payer system. It won't. Why am I fighting so hard for something that isn't anywhere near as important as that?

[jmpurser]

Agreed. I thought the "public option" MIGHT not be a full blown disaster until I heard the promises Obama was making about it. Then I started reading the bills. The "public option" has no other purpose than to kill single payer and with it any hope of real health care reform.

[losingitbigtime]

Aaron, you make a good point. My concern about the public option is that when it passes, those inside the beltway will back slap each other and the public will sit back and wait for results. After a few years, there will be news stories about increases in costs and the number of uninsured and in a decade or so there will be momentum to do more.

Whatever passes must be viewed as only one in a series of battles that must be fought to win the war. At some point, americans will wake up to the fact that so many other countries produce better outcomes at half the cost. I guess a few more people need to die.

I support the public option as a first step, but I do not believe that even a strong public option will mean mission accomplished in 2009. There are cheap band aids, there are flexible fabric ones, there are even ones with anti-biotic ointment on them, but at the end of the day, a band aid is just a band aid.

[theLeftPaw]

Like losingitbigtime, I agree with the doctor. The longer this goes on the more limited the option becomes. I no longer have any doubts about whether it will be in there, just what it will be.

It looks like the option won't be available for a couple years; and then it will ONLY be assessable to the unemployed or employed by small companies. If that horrid trigger makes it in there, could be locked up out of reach indefinitely? I personally think hopes for a "robust" option at this point are futile.

I'm a STRONG supporter of Single Payer, it IS the "most cost-effective way to achieve universal coverage" - the most fiscally conservative plan, with better health results too.

My main targets have been the Kucinich amendment for states to enact Single Payer, & the amendment to repeal the antitrust exemption; these are vastly more important now. I'm thrilled the repeal is becoming a reality - it will go a LONG way in reducing costs. Most Americans don't realize that aside from legally being allowed to collude for price fixing, their exemption also allows them to practice the things we seek to reform (denial of claims & coverage, recision, etc...) - AKA redlining:

http://navybluewife.com/2009/08/17/big-insurances-competition-immunity/

Now, if we can get the Kucinich amendment passed, I'll be satisfied. I'll continue the fight I'd expected to have for another year or so, to get Single Payer (one state at a time).

[Wisconsin Dave]

The doctor bases all his figures on an assumption that the House
versions are the best possible Public Options being discussed. But surely,
more robust Public Options are now being pushed hard by liberals in Congress.

Comes now light to force such darkness to give way:

FALSE: “Public option... just a means to increase competition and try to
reduce the cost of reform.”

TRUE: A robust Public Option would be identical to Medicare, as the
government would eliminate all the corruption and excessive profit inherent
in a profit driven medical system, one where everyone makes a profit on the
suffering of others.

FALSE: “Public option... would cover... fewer than 10 million people, maybe 3%”

TRUE: A robust Public Option would attract at least 20% to start and within a
year would have at least 80% enrolled.

FALSE: “Public option... How much lower? At best, maybe $110 billion over 10 years.”

TRUE: Over $2.3 trillion is now consumed and destroyed by a capitalist
medical industry, as a robust Public Option would surely bring on Medicare for
all, as healthcare costs in the U.S. are double other nations, surely in ten years
the savings would be at least $1.5 trillion each a

[Wisconsin Dave]

END OF ABOVE: $1.5 trillion each and every year.