Getting Health Reform Right: A Q&A With Jacob Hacker

Wanted: a framework for comprehensive health reform that provides near-universal coverage, reduces costs, and fosters continued improvement in medical care. Oh - and the plan must be politically achievable. Jacob Hacker thinks he's designed a plan that fits this bill, and after a Q&A with him I've come to think he could be right.

Health reform hasn't received this much attention since 1994. Obama's approach has been to lay out overall goals and let Congress work out the details, a strategy that insiders say makes reform more likely. But Republicans are going to be cautious about handing Obama any policy victories, as we've seen from the House stimulus vote, and they'll probably stick to the free-market line when it comes to health reform. Initiatives are likely to be criticized from the left, too, if they don't dramatically reduce the number of uninsured. But the assessment has already been made in Washington that single-payer ("Medicare-For-All") coverage isn't politically achievable.

That's where Jacob Hacker comes in. Hacker is a Professor of Political Science at UC Berkeley. He's a leading health policy theorist and political commentator whose book The Great Risk Shift: The New Economic Insecurity and the Decline of the American Dream is the best overview yet on the decline of the post-World War II social contract between workers and employers.

Professor Hacker's proposal, Health Care for America, is based on two simple principles: First, that both the employer-based private system and publicly-funded Medicare are essentially working for their members. Second, that every uninsured American (or legal resident) should be able to buy into a Medicare-like public program at affordable rates, with need-based subsidies. In theory, the Hacker plan increases coverage while lowering costs in several ways: by bringing more people into a system whose costs are rising more slowly; by helping the government increase the scope and effectiveness of its design changes; by encouraging private plans to keep costs low: and by increasing the public system's leverage and reach.

The plan has been well-received across the center/left spectrum, even receiving a friendly review from Don McCanne, MD, a Senior Fellow with single-payer advocacy group Physicians for a National Health Program (PHNP). But I had a number of questions, so Prof. Hacker was kind enough to agree to an email Q&A. He was able to address many of my concerns - including economic fairness (some other plans place unreasonable burdens on uninsured working families) and the risk of dislocation within the health economy.

Health Care for America's public/private mix is an attractive option for several reasons:

• It minimizes the risk of creating more problems gaining access to doctors who will accept the public plan (although the this problem has sometimes been over-stated).
• It emphasizes employer mandates rather than placing the burdens on individuals first - and it limits out-of-pocket costs.
• It leaves private plan options in place, which minimizes the backlash that would result if people lost freedom of choice. (As Prof. Hacker noted, "some people buy cars that Consumer Reports says are less reliable .. because they like how they look and drive ... and more seriously, the private plans will be able to do things like selectively contract with small numbers of providers ... some people will value these innovations.")
• It emphasizes "medical homes" - the idea that people should have a doctor somewhere who knows them and understands their overall health needs.
• It gives private insurers the chance to compete with the public system. If they control costs more effectively - or provide more attractive benefits - they can still win people away from the public plan.

That last point remains a subject of continued controversy. Newt Gingrich once predicted that Medicare would "wither on the vine" when private-sector alternatives became available. (Prof. Hacker caught my offhanded reference to this quote in our Q&A - although I've always suspected Gingrich's line was a subtle parody of Engels and "the withering away of the state.") But, pace Gingrich, we've now seen that private Medicare Advantage plans are significantly more expensive than the government program. Not a lot of withering going on there. But, interestingly, the Hacker plan provides the same sort of competition Gingrich envisioned - but for all age brackets, not just the one already receiving publicly-funded care.

Free-market health advocates still insist that the private sector can do a better job. It's true that private Medicare plans had no incentive to innovate, since they were heavily subsidized by the last administration. So, shouldn't conservatives support this plan? If the private sector really is a source of greater innovation than government, what better way to prove it than in direct competition? (Or, as Prof. Hacker rather drily observes, "Perhaps they will discover inner wellsprings of cost-consciousness we didn't know they had.")

Health Care for America is designed as a framework for more detailed discussion. There are issues to explore and details to flesh out. But Congress and the President need a global outline around which to frame the ongoing policy debate. The Hacker plan fills that need. And, as PHNP fellow and single-payer advocate Don McCanne observed, "It is just possible that (Hacker) may have crossed the threshold of political feasibility."

If that's true - and I suspect it is - then Health Care for America should become the framework for genuine reform.

(The complete Q&A with Jacob Hacker is available here)

The Sentinel Effect: Health Policy Blog

Comments

[cqyates]

Hey that was my idea!!!

[larmarch5]

There is a better argument. Look at your local taxes that are being spent to provide indigent care and cover care for people who do not have insurance. This care takes place in the most expensive place: the ER. How many care providers are harmed by delayed payments by insurance companies. How does it make sense to add a layer of costs by profit oriented, not care oriented, businesses. The insurance bureaucracy is a sinkhole that conservative voters just don't get and conservative politicians most certainly get.

[ThomH]

"But the assessment has already been made in Washington that single-payer ("Medicare­-For-All") coverage isn't politically achievable"

This is the saddest possible comment on the state of our political system. How can something favored by clear majorities of both ciitzens and physicians not be politically achievable?

Because it is opposed by the insurance companies, who have bought or cowed the politicians with some of the $950 billion per year they receive from premium payers. In short, citizens are paying the money used by the healthcare lobby to subvert their will and perpetuate the totally crazy non-system we have for health care.

When asked why he did not favor single payer, Joe Biden said :"Because I'm not crazy--I don't want to be eaten alive by Harry and Louise" . Think about what that means: he has publicly acknowledged that he has allowed his position on one of the most important issues of the day be determined by a self interested lobby group in opposition to the desires and best interests of his constituents. Out of fear. .A true Profile in Cowardice.

[dmccanne]

Over at Daily Kos, DrSteveB discussed this post, including my polite response to Jacob Hacker's proposal. This is an edited version of my response as posted on DrSteveB's blog:

DrSteveB is right. I was being polite. Jacob Hacker is a highly respected political scientist who supports social justice. I have greatly admired his work.

In his proposal he was looking for a political solution to satisfy those with good employer-sponsored plans who are uncomfortable with trading them in for a public plan that has not yet been precisely defined (since any proposed public plan must clear the hurdles in Congress). In so doing he compromised on policy, trading away many of the advantages of the single payer model.

Since I wrote the comments above, the public option described by Hacker has come under intensive attack by Enzi and his fellow Republicans, by AHIP, and by the U.S. Chamber of Commerce. It has been singled out as the most important feature that the Democrats will have to trade away if they expect the Republican support and industry support that they will need.

Health care costs are now so high that only an administratively efficient, equitably funded universal risk pool will work properly. It would automatically include everyone, with financing based on ability to pay. As a single payer, the program would be a single purchaser (monopsony), finally providing us with a mechanism that would ensure value in our health care purchasing.

Don McCanne

[Montanagramma]

My honest opinion is that with the influence of insurance companies and pharmaceutical companies lobbies, we will probably not see anything that is truly "affordable", to a lot of our population. The big corporation influence money "talks" to the politicians. Somehow the lawmakers seem to believe that people have much more money to spend on these things than is anywhere near reality. Every day more people are without any health coverage, yet the premiums continue to rise. The companies are not competitve. I really expect that anything approaching real help for many of us will be blocked, and termed "socialism" by the repubs. We need single payer coverage. But that won't happen in my lifetime. Maybe someday, but not now. Yep! I'm very pessimistic on this subject.

[OkieMon]

solving the health care crisis is easy...those who can afford it go on medicare and those who can't go on medicaid...and let the insurance companies go back to insuring houses and cars....

[BarryS]

Brilliant. That is the most succinct explanation of the solution I have read to date. I will say this to everyone who asks [and those who don't] Finally an intelligent slogan

[zaz33]

Brilliant - medicare is not free but it's afforable.

Trumping special interests is the problem.

Whenever a politician says there's "no political support" they're talking about special interests.

[OkieMon]

why not? especially when you consider most working americans have been contributing to medicare their entire working lives....why should we wait until 65?

[Dap]

Dear Brother RJ,

You're Da-Man! Thanks... but I'm not happy to have to read all the information you've provided, now I have to educate myself, I knew you would drag me into the issue, lots to learn. From your post I am getting good vibes of hope for our health care system, we can do this. Thanks again. Agape, dap

[Succatash]

I'm glad you mentioned continued improvements in medical care. But, you can't have a health care discussion on Huffington Post without many complaints about Western medicine. Will this new plan cover methods shown to be effective through evidence based research or will every Quack promoting heavy metal detoxification, magnets, and herbal douches come out of the woodwork to "get some". Will I bet able to get a Panchakarma treatment at the Ayurvedic center? Paid for by my boss or even better by Uncle Sam?

[JackLove26]

Please explain "near-universal coverage." Does it mean some person will be left out? President Clinton held up a pen and announced thqt he would veto any health care plan that was not "universal." He was ignored by Congress and the "Harry and Louise" people.

[RJ Eskow - Huffpost Blogger]

The phrase "near-universal" is my own. It's intended to avoid political hyperbole and acknowledge that there are likely to be a few scattered people who are temporarily overlooked in any insurance system, if only because of administrative snafus. I also say "near-universal" to recognize the fact that not all conditions are covered by any program, even Medicare - and that many other proposals which describe themselves as "universal" are anything but.

That said, for all intents and purposes coverage under this plan would be very close to universal. If properly designed, it would be far more universal than the Massachusetts program touted by some Democratic candidates (e.g. Edwards, Clinton) in the 2008 election. And it would certainly match the results projected for the 1994 Clinton plan.

Hope that provides some reassurance. Not sure I understand the reference to President Clinton, though. He wasn't "ignored" by the people you mention - he was actively "opposed" by them. That's something we can hopefully prevent from happening again.