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The Public Option: Dead By Pen Strokes In Congressional Committees

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The so-called public option has emerged as the single most divisive point in the health care reform proposals being shaped in various committees in Congress. Republicans have risen up to demonize it as a government takeover of health care on the slippery slope toward socialism. Within the powerful Senate Finance Committee, it is being called a deal-breaker for any bipartisan bill.

The public option refers to a new public plan that would compete with private health insurers in an effort "to keep them honest". It is a concept trumpeted by Jacob Hacker, now a professor of political science at the University of California, Berkeley. His original idea, as first envisioned in the 1990s, was that a large public program, operated along the lines of Medicare, could cover as much as one-half of the non-elderly population by shifting all or most of the uninsured, as well as all Medicaid and SCHIP enrollees, into the plan from the start. Because of its size and efficiency, such a large plan would be able to keep its premiums much lower than private plans, thereby increasing its attractiveness to enrollees. In addition, all non-elderly Americans, whether privately insured or not, would be eligible to participate. Government subsidies would be extended to those unable to afford the plan. Private insurers would be required to offer the same minimum benefits as the public plan.

So the initial idea was premised on the thought that a public plan could bring needed competition into the financing of health care. Forget that dream. Although the current House and Senate bills both include a "public option," it is in name only. What might have roared like a lion is becoming, at most, a mouse that barely squeaks. The details change every day, but already these kinds of changes from Hacker's original concept make it a policy non-starter:

  • Many people with private insurance who want to change will not be able to select the public option
  • The public plan may not kick in until 2013 or until such time as private plans have been demonstrated not to save money (a so-called "trigger")
  • Whatever new regulations that are imposed by the reform bill will only apply to new private plans; existing plans will be grandfathered in as is
  • Private insurers worry that a public plan would crowd them out by undercutting their premium levels, so they lobby to keep the public program small
  • The current proposals in Congress do not impose caps on private insurance premiums; nor do they allow the public option to significantly lower its premium rates below private plans
  • The public plan will not be "pre-populated" with all Medicaid and SCHIP enrollees from the start, thereby keeping the plan small
  • Instead of initial coverage estimates in the range of 120 million enrollees by public plan advocates, the Congressional Budget Office (CBO) estimates that only 10 million would be enrolled because of the fine-print restrictions now being placed on the plan within Congressional committees. These restrictions are being heavily lobbied by the private insurance industry to ensure that they won't have any real competition.

The transformation of the public option from a potentially useful policy to its present irrelevance is well described in the recent brilliant analysis by Kip Sullivan, attorney and member of the Minnesota chapter of Physicians for a National Health Program. (PNHP web site at www.pnhp.org) This transformation is no accident. Opponent of a public plan have so far successfully and deceptively argued that it would be a "government takeover". The Lewin Group, a supposedly non-partisan health services consulting group now owned by UnitedHealth, the second largest private insurer in the country, serves its new masters in two ways -- by making projections for a public plan in the range of 120 million (a scare tactic), and keeping its silence during Congressional testimony on the cost-saving advantages of single-payer financing (as it has demonstrated in many state studies in recent years).

The fight against real competition is a do-or-die battle for the private insurance industry. Over many years, it has demonstrated its inability to control health care costs, is in business to make money for its shareholders by covering healthier people and avoiding sick people, and has already failed to compete against Medicare in efficiency, reliability or value. The currency of the realm in this industry is the medical-loss ratio (MLR), or how much is paid out for actual medical care, its "losses." Between 1993 and 2008, industry-average MLR's dropped from about 95 percent to 80 percent, diverting more money away medical care to administration, profits and shareholder returns.

We are now being told by the Obama administration and many legislators that the public plan will bring competition into the system and will help to cut costs and make insurance more affordable. At the same time, they are trying to reassure the insurance industry that the public plan will not put them out of business. This is double-talk and snake oil of the worst kind.

As just another plan available to a small segment of the population, the public plan if ever enacted will further fragment the system, increase bureaucracy, and still not result in either cost containment or open choice of coverage. The playing field would remain tilted in favor of private insurers, and the public plan would likely become a dumping ground for poorer and sicker patients through adverse selection.

Though many may not yet realize that the public option is dead on arrival if it ever gets to a floor vote in Congress, it is high time to move the debate on to consider real policy alternatives in our quest for cost containment, universal access, and improved quality of care. Let's check the closet. Where is that H. R. 676 when we need it?

John Geyman, M.D. is the author of The Cancer Generation and Do Not Resuscitate: Why the Health Insurance Industry is Dying, and How We Must Replace It, 2008 by John Geyman. With permission of the publisher, Common Courage Press.

Buy John Geyman's Books at: http://www.commoncouragepress.com

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