Saturday, October 24, 2009

Why we will never have universal health care, Part Five

Nearly two months ago, I gave four reasons "Why we will never have universal health care." They were, in brief,

1. Too many advocates, both in and out of government, subscribe to the bonehead notion that it is "smart politics" to propose what you think might pass and negotiate back from there rather than to propose what you want and negotiate from there - which in practice means you'll invariably wind up with less than what might have passed and never with what you want.

2. It is always the left, never the right, that should do the compromising.

3. The Democrats, apparently possessing less backbone than a stalk of wheat, are being steamrollered by the exact same arguments the health industry has used literally for more than 60 years.

4. Industry money is more important than the public good to too many legislators.

Well, now comes a fifth reason: Even when the chances of some actual improvement, albeit short of the ultimate goal, appear to be within reach, a combination of personal self-interest and ignorance of the reality will screw it up.

The Washington Post reported yesterday on the seeming "dramatic shift" in momentum on the idea of a public option as part of a health care "reform" bill. "Prospects," it said, "have gone in a few short weeks from bleak to bright." House Majority Whip James Clyburn recalled that earlier this month, such an option was supposedly "off the table."
Clyburn said the debate is no longer whether to include a public option, but "whether or not we will get this form of a public option or that form of a public option."
Um, okay - but that's exactly the problem. The meaning of the term "public option," which originally referred to the idea of a government-run, government-provided, insurance plan similar to Medicare which would compete with private health insurance plans and offer subsidized coverage to those who could not afford it otherwise, has been so watered-down and spread out that it's no longer clear what anyone means when they refer to it. What it has unhappily come to mean to too many is laid out by the Post:
Any public plan is likely to have a relatively narrow scope, as it would be offered only to people who don't have access to coverage through an employer.

The public option would effectively be just another insurance plan offered on the open market. It would likely be administered by a private insurance provider, charging premiums and copayments like any other policy. In an early estimate of the House bill, the Congressional Budget Office forecast that fewer than 12 million people would buy insurance through the government plan.
So first, if you can get insurance through work, you're stuck with it. No "option" for you. Even if the plan sucks, even if it's with a crap outfit like Cigna or UnitedHealth or Wellpoint - in other words, most plans - even if the deductibles and co-pays are beyond your reach, even if your portion of the premium is more than you can afford so you can't take advantage of it anyway, tough. You're SOL.

Second, it is avowedly "just another insurance plan," one administered by a private company; it's no longer even a government-run plan. I admit this could be a bit of soft-sell, of trying to increase support (or, more likely if this is the case, soften opposition) by emphasizing just how small a change it is. But that of course is part of the problem: Minimizing the impact of a public option also minimizes the whole point of it, which is (or, rather, was) to change the landscape.

One of the ways it was supposed to do that was by competing directly with private plans, thus forcing them to moderate costs and premiums. But if the population that can go for this option is limited to those who do not have insurance through an employer (which is how the vast majority of people who have insurance other than through existing government programs - Medicare, Medicaid, the VA - get it), where is the competition? What is the population for which you're competing? Those who have no insurance, the very people in who the private insurance companies have already shown they have no interest? What are these people smoking?

What's more, one of the ways the option was supposed to contain costs was the fact that as a government program, it could be run on a nonprofit basis. Even if it was to never get additional funds from the government and had to cover its own costs, without investors to be sated and multi-million dollar CEOs at who to throw money, costs could be considerably lower. (It's worth recalling that in terms of cost efficiency, that is, in percentage of costs that go directly to patient care rather than overhead and so on, Medicare is about the best thing out there.) But if it's to be administered by a private company, what happens to that idea? That company will certainly want a profit on the deal, not to mention having a CEO to fatten.

And what's the result of all this? "Fewer than 12 million people would buy insurance through the government plan." Now, bluntly, I'm going to assume that this actually means 12 million people would obtain insurance through the plan rather than would "buy" it - the not insignificant difference being that in the latter case, which would mean 12 million policies would be issued, many more than 12 million people would be covered since those policies surely would include a lot of family coverage. And I can't imagine in that case the emphasizing word "fewer" would have been used.

That is, then, no more than about one-quarter of the nearly 50 million (and rising) uninsured will be able to benefit from what has become "the public option."

So "just another insurance plan" limited to people who have no insurance, three-quarters of who will see no benefit from it. The only landscape change I see here involves a lot of whitewash.

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