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Lots of activity on the health care policy front recently. For detailed analysis of the Schwarzennegger plan you should turn to Jonathan Cohn and Ezra Klein. What I'll say is that insofar as universal health care plans that I'm not enthusiastic about go, this is the kind of plan you're looking for -- one proposed by Republicans. I think there's a big difference between the sort of measures it might be reasonable to accept as part of a compromise the other side proposes and the sort of concessions that it makes sense for progressives to concede in advance. For more the kind of thing I'd like to see the good guys fighting for, check out this plan from EPI and public policy golden boy Jacob Hacker:

What Health Care for America would do is simple: every legal resident of the United States who lacks access to Medicare or good workplace coverage would be able to buy into the "Health Care for America Plan," a new public insurance pool modeled after Medicare. This new program would team up with Medicare to bargain for lower prices and upgrade the quality of care so that every enrollee would have access to either an affordable Medicare-like plan with free choice of providers or to a selection of comprehensive private plans.
At the same time, employers would be asked to either provide coverage as good as this new plan or, failing that, make a relatively modest payroll-based contribution to the Health Care for America Plan to help finance coverage for their workers. At a stroke, then, no one with a direct or family tie to the workforce would remain uninsured. The self-employed could buy into the plan by paying the same payroll-based contribution; those without workplace ties would be able to buy into Health Care for America by paying an income-related premium. The states would be given powerful incentives to enroll any remaining uninsured.

This, to me, is good. It compromises away from the ideal end-state, but does so in a smart way. The idea is less to appease the insurance companies (nice to achieve, but probably impossible) than it is to simply appease people who are happy with their current health insurance situation. Now, as it happens, it seems to me that if this plan were implemented and succeeded on any level it would, in fact, speed up the already rapid unraveling of the employer-based system and can expect to be opposed tooth and nail by insurance companies, but from where I sit, that's inevitable -- the forces of progress are fated to an arduous generational struggle against the health care industry and there's not much to be done about it.

1/11/07 9:16AM del.icio.us this incoming links

Comments

My feeling is that yes, some employers will opt for the 4 to 7 percent fee and decline to get involved with health insurance. A set fee will at least cap their costs and free up administrative resources. Medium and large sized companies that already have plans or are self-insured may prefer to keep their plans for now (depending on current costs and contracts), but I can't see new or small companies wanting to deal with health insurance. You're also correct that any new plan needs to assure people who are content with their current coverage that they will be able to keep that coverage. Workers will resist any plan that may jeopardize their current coverage - the average American is not a risk taker. First, do no harm.

Posted by: Marvyt on January 11, 2007 10:02 AM

Small quibble with that last sentence. It's a struggle against the health INSURANCE industry not the health CARE industry.

Posted by: Ron on January 11, 2007 11:39 AM

I love that war on terror comparison. We need some way to split moderate "Harry and Louise" street from the radical insurance company jihadists.

Posted by: Consumatopia on January 11, 2007 11:59 AM

It seems to me that in many countries that allow the private sector to compete alongside the government program the private program eventually cripples the government program. There's a variety of reasons for why that could be happening, but why do you think the government program would eventually drive out the employee-based coverage?

Posted by: Paul on January 11, 2007 07:17 PM

The problem is that the private insurance companies have every incentive to cherry pick. So in the long run the sick people end up on the public funded plan, and the healthy pay into the profitable private funds. It doesn't matter how well you negotiate your prices if you've got lots of sick people to support.

Posted by: Lee on January 11, 2007 09:23 PM

A "Medicare for All" plan would do even better at appeasing people who already have their own insurance, and are generally happy with it (Leave aside the probability that, if they're happy with it, that problably means that they just pay premiums and haven't tried to collect benefits lately. Current medical insurance is very efficient at collecting its premiums, but strangely inefficient at paying out claims.), and would appease them with much greater transparency than these hybrid plans that try to retain some elements of the wholly parasitic private insurance industry. You just need to explain the dynamics of the flow of premiums into the insurance entity, and its outflow in claims for medical services.

Right now, working people who have private insurance are actually paying for two sets of coverage. They pay a relatively small payroll deduction for Medicare, and a much larger premium for their private insurance. What they pay into Medicare will cover their medical claims for that part of their life, after age 65, when they will have the bulk of their lifelong needs for medical services. The much larger sum they pay to their private insurer will cover them against the unlikely event that they will need any medical services at all, greater than the co-pays and deductibles, before they reach 65 (Again, if they're satisfied with their private plan, they are much more likely to be part of the group not putting in claims.) What they will get with "Medicare for All" is to trade in the obligation to pay that fat premium to their private insurer for the obligation to pay a much smaller amount in payroll tax, added to the current Medicare payroll deduction, but smaller in size, because the liability for the young that "Medicare for All" will add will be smaller than the liability for the old that Medicare already carries.

Posted by: Glen Tomkins on January 12, 2007 12:31 AM

The idea that only a plan that includes private insurance has a hope of passage is obviously false - in California at least. As I understand it, Schwarzenegger vetoed a single-payer plan that had been approved by the legislature last year. (See Paul Krugman in today's NYT.) If the California legislature has already passed a single-payer plan, what possible argument can be made that a single-payer plan would never make it through the legislature? Maybe a single-payer plan would never make it through Arnold Schwarzenegger, but in that case he is the problem here, not the problem solver.

Posted by: brooksfoe on January 12, 2007 03:06 AM

Re: Now, as it happens, it seems to me that if this plan were implemented and succeeded on any level it would, in fact, speed up the already rapid unraveling of the employer-based system and can expect to be opposed tooth and nail by insurance companies

A smart insurance company would imemdiately offer its expert services in administering the plan. The government is going to need people to do that, and in many states private companies are hired under contract to do all the back office and customer service work for Medicaid and CHIPs programs, and this has proven to be a profitable business.

Re: There's a variety of reasons for why that could be happening, but why do you think the government program would eventually drive out the employee-based coverage?

Because the government plan would be cheaper for the average employer and the average employee. 7% is a heckuva a lot cheaper than what most companies pay these days. Plus it's unlikley to increase by leaps and bounds as premiums do now.

Re: The problem is that the private insurance companies have every incentive to cherry pick. So in the long run the sick people end up on the public funded plan, and the healthy pay into the profitable private funds.

The Schwartzeneggar proposal in CA specifically forbids cherry-picking and requires community rating across the board. This does indeed need to be part of any proposal like this so everyone is competing on level ground. Moreover, cherry-picking is to some extent hampered by HIPAA already; in employer group settings it rarely happens now.

Re: Current medical insurance is very efficient at collecting its premiums, but strangely inefficient at paying out claims

This is mostly a hassle for prvoiders, not patients. Outright denials of benefits are rare (despite a few high-profile outrages). The usual strategy is to foot-drag on payment*, and to whittle the payment amount down by a death of 1000 cuts. Since in most cases the provider (assuming s/he is in network) has signed an agreement to acept whatever the insurance company offers the patient is not even aware of what is going on here.

* To be fair even to insurance companies a surprising number of providers are slow aout putting in claims and some are very incredibly slow about cashing their checks once they get them. Doctors are not businessmen and altogether too many practices are run very inefficiently.

Posted by: JonF on January 12, 2007 08:52 AM

"The states would be given powerful incentives to enroll any remaining uninsured."

As plans for the millions of people who are long-term unemployed, or self-employed at too poverty-stricken a level to pay for any insurance, go: this is a tad sketchy.

It's unfortunately close to "my plan is to have a plan."

Posted by: Gary Farber on January 13, 2007 11:53 PM

Re: As plans for the millions of people who are long-term unemployed, or self-employed at too poverty-stricken a level to pay for any insurance, go: this is a tad sketchy.

The long term unemployed are probably eligible for Medicaid already (assuming they do not have significant non-work income). The self-employed should be able to buy into the plan at the same rates that businesses are charged.

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