Boats: If you have something to say about the public option and health care, spit it out. Otherwise you're just being an ass.

"Senator Merkley also stated that one way the public option might work is to allow states who are willing to experiment with the plan to do so."

so we can re-invent the Oregon Health Plan as our state's experiment in the public option? wasn't that more or less what Kitz had in mind in the first place? this could be a very good thing for Oregon.

T.A., the Healthy Americans Act, of which Jeff is a cosponsor, has a provision written at the specific request of John Kitzhaber, which would allow states to pursue a public option, single payer, or some other bold plan. A state would need to demonstrate to the Secretary of HHS that its plan would meet the baseline requirements (care equivalent to what Congress gets), and as with the Oregon Health Plan, obtain a waiver to begin the program.

So the answer to your question is yes, Oregon could expand the Oregon Health Plan under what Jeff talked about and under the bill he has cosponsored. That also happens to be exactly what the Oregon Health Fund Board called for in its final recommendations, and the President of Oregon AFL-CIO, Tom Chamberlain played a big role in that effort.

Of course, a national public option remains on the table, as well.

"The Public Option won't get done ..." Which public option?

What Jeff is advocating here puts him firmly on the "fake" side of the public option choices between "real" or "robust" and "fake" that Howard Dean described in Portland on June 6.

He addresses "level playing field" only from the point of view of restricting the ways that a public plan could be more competitive, thus limiting its notional and partial potential to moderate price inflation.

He does not say that private plans must be required to accept applicants on the same basis as the public plan. Apparently that playing field won't be level. This means that the private insurers will dump riskier & more expensive people onto the public plan while cherry picking more profitable lower risk people (who they will continue to gouge). If this further is combined with an individual mandate, it means an expansion of a captive market and insurers' profits.

What he is saying is that a public plan must look as much like a private plan as possible. How then will it solve the problems with the private plans? It won't. It will just replicate them.

Josh Kardon, like nearly everyone in Washington who invokes "what Congress gets," is being disingenuous. Because what Congress gets is the highest tier of a multi-tiered "plan" set of choices, fully paid for by the government. Neither Ron Wyden's Healthy Americans Act nor any of the public plan options being discussed contemplate everyone getting top tier benefits fully paid for by the government.

Instead, people will face the same choices that insured people today face: spectacularly rising premiums that force them into high-to-huge deductible & high co=pay "affordable" plans, which effectively mean that the insured are paying premiums but won't be covered for most costs short of catastrophic ones, will continue to avoid seeking early stage consultation or treatment for emergent or possibly emergent illness, waiting until unavoidable, higher cost, poorer results interventions are required.

The other sleight of hand with this kind of "has to look like a private plan" type of public plan is that most people who have private insurance have a very large portion of the full nominal premium paid by an employer as a benefit. Where is the employer counterpart for this Merkley/Schumer type public plan? With all the phony politics around denominating the costs over ten years (which brings us into trillions) the level at which public subsidies will cut out will be not very far up the lower middle class part of the income distribution.

If this combines with an individual mandate, it means either people being forced to buy lemon insurance, or being punished for refusing to enter the captive market. So some of the "options" discussed allow "hardship waivers."

I.e. you can get permission to be uninsured. Whoopee!! Yay!! We can have universal opportunity to be "covered" if we can afford it.

Oh. Wait. We have that. It's the system we're supposed to be fixing.

The CBO, in providing cost estimates based on these kinds of assumptions, estimates that to keep the subsidy costs under the phony "not more than a trillion dollars in ten years" ceiling, as many as 37 million people will opt out under hardship waivers.

(That figure is phony because it ought to be costed by year. $1.2 trillion over ten years is "too high." $100 vs. $120 billion in one year? Different debate. Compared to the cost of empire in Iraq and Afghanistan? Less.)

Assuming that with rising unemployment and employer benefit cuts we are probably at about 50 million uninsured, that would be a gain of 13 million "covered." That might not seem like a number to be sneezed at, but the poor quality of the mostly "affordable" lemon plans likely involved at least gives one the sniffles.

So: to return to President Obama's criteria for healthcare reform

1) Universal -- baaaah!!! (buzzer sounds) (-tens of millions)

2) Choice (of plans, NOT providers since plans restrict providers) -- baaaah!!! (buzzer sounds again) (a) see 1; b) choice restricted by income)

3) Controls costs -- baaaah!!! (buzzer sounds again) (See CBO estimates, also note no controls placed on private plans raising rates, public plan not allowed to use full benefit of potential gov't price negotiating power.)

Bonus anti-criteria

4) Strong punitive individual mandate to raise "coverage" numbers for show on criterion 1, forcing expansion of captive market for non-price-controlled private insurers & raising their profits -- ding ding ding ding ding ding!!!

5) Lack of control over dumping costly people into the public plan used in rightwing propaganda to discredit public financing of health care -- ding ding ding ding ding ding!!!

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Jeff calling for grassroots pressure for "the Public Option" is meaningless unless he sides with Howard Dean, to help the public understand that a "strong" public plan means one that changes the dynamics of the market and the system to provide people with greater health promotion, maintenance and security.

Instead he fails to do that but backs as Schumer like approach -- change the dynamics as little as possible, as long as it can remotely plausibly be called "public."

Bad enough that Jeff won't back up his "I'll vote for single payer if it comes to the floor" with the very minimal step of co-sponsoring Bernie Sanders' S 703 (if he's really for a public plan option but can endorse Ron Wyden's bill too, why not Sanderss'?)

Now he's backing a lousy approach to "public option" and even fobbing off potential failure of that onto "the grassroots."

What a disappointment.

"Oregon could expand the Oregon Health Plan under what Jeff talked about and under the bill he has cosponsored."

1) What Jeff is talking about is a day one NATIONAL public option--not a potential state by state opportunity. Wyden's plan does NOT create the public option Merkley is talking about.

2) It's disingenuous to talk about "the bill he cosponsored" as if that means he favors the bill over options that actually include a full and robust public option. What Merkley is talking about, "the bill he cosponsored" does not offer.

Kurt, do you think it's a good thing because he's running from his R label, meaning the pressure is on to get out of ideological anti-government lockstep? The Gordon Smith of the Midwest? Or because you think it reflects less partisanship on his part?

If the latter, his con is working on you. As far as health care reform goes he is a disciplined Republican knee-jerk, and if he's trying to hide the fact of his partisanship, it's not a good thing.

TJ, You're right that Jeff M.'s support for Ron Wyden's HAPI plans appears to be token or a courtesy to the senior senator.

But if Carla's report is accurate, which I have no reason to doubt, Senator Merkley is not at present for a robust public option, but for a weak, Schumer style-one.

Why do you think he is for a robust or strong one?

I guess the grassroots pressure needs to begin with him:

<hr/>

HEY JEFF! Really, I want you to support a single payer system straight out, since the strongest of public options won't solve the cost inflation issues to the economy or the affordability issues for families and individuals.

But it seems you are going to focus on a public insurance plan approach, choosing a self-fulfilling view of political realism over health realism and economic realism.

If so, for heaven's sake at least work for a plan potentially might change the dynamics of the collapsing system, and with them the definitions of political realism!

Handicapping the advantages of public purchasing power and rational public funding to protect the non-competitiveness of private insurance that is failing to protect people or promote health is a phony public plan. It is the wrong answer even by the lowered standards of "public option."

<hr/>

With leadership such as Jeff is offering, and President Obama, nothing can emerge this summer that will change the dynamics of system failure.

Best then to continue advocating for a tax-funded guaranteed national health system, to identify clearly what would make a strong or robust public plan, and to insist that phony "pubic options" that merely mimic the failing and extortionate private insurance system are snake oily, phony as the year is long.

That's phony public options.

Steve:

It's not that tough, I'm sure you can catch on.

It means that there would not be an additional government subsidy to lure people to a public option, should it become law. It will be a plan that will compete directly with private plans, with no extra subsidy incentives.

"Senator Merkley also stated that one way the public option might work is to allow states who are willing to experiment with the plan to do so."

Ugh. Let me also reply to Chris Lowe with this. The comments he has made, eg in the KGW interview, have given me reason to believe he favors a full and robust public option (FRPO), and while the HELP version is not as good as HR676, it's way better than co-ops or HAA.

But the idea that individual states can take up a public plan experimentally, and that somehow this will achieve what a national FRPO would, is a bad one.

The HCAN definition of the "right" option is:

1) National/available everywhere 2) Day One 3) Publically accountable 4) Able to bargain/compete

I hear Merkley affirmatively on 1, 2 and 4, (1&2 from his being a signatory to the HELP bill, 4 from the KGW interview). The statement above is a backtrack on #1.

TJ:

The problem is that what you're saying may not be politically viable. In order to negate the powerful argument that this is a one-size fits all solution, those working on a public option are trying to find a way. Merkley's suggestion was one way it MIGHT look.

I don't see how allowing different states to try different things (for example, an evidence based plan) somehow blows up the idea of it being available nationally.

And to address Chris..honestly, we're not going to get single payer. Obama never allowed it to come to the table.

"The problem is that what you're saying may not be politically viable."

Yeah, right. Just not possible, so let's forget it. Forget the overwhelming majorities, forget that it's the preferable public policy, forget that there should be an automatic cloture vote on any filibusters...just not possible. Oh well.

Why is "one size fits all solution" even a relevant argument, much less one to negate? Why is a national option bad, specifically?

Different states trying different things means some states doing nothing, other states basically capitulating to the one or perhaps two private providers throttling their state's insured, and the same problems that Merkley talks about with variable payouts. The upshot is that it fails on two of the four principles: not national, not given the power to bargain. Individual states cannot create enough scale to bring down costs.

Merkley (and all Democrats) needs to heed Bernie Sanders and the Coalition of the Unwilling: there cannot be a bill that does not provide a proper, full and robust public option. There's no political reason not to, there's no policy reason not to--there's only a financial reason not to: doing so might make some Senators feel awkward when it's time to meet the literally HUNDREDS of lobbyists prowling the corridoors for private health and pharma.

Yeah, right. Just not possible, so let's forget it. Forget the overwhelming majorities, forget that it's the preferable public policy, forget that there should be an automatic cloture vote on any filibusters...just not possible. Oh well.

Yeah..you could run right to the extreme of the conversation instead of having a discussion about it with me...

Whether it's "possible" or not remains to be seen. As it stands right now, the politics of it are pretty difficult. Like it or not, Democrats aren't exactly sprinting to the left on this issue (and others). Obama has made single payer a nonstarter.

One-size fits all doesn't work for a lot of stuff. Certainly not for schools or other entities where lots of people from diverse sets participate. I suspect that's what makes the argument persuasive when it comes to healthcare.

Will some states do nothing? Not likely. Given that the money will be there for them to enact a public plan, there's no reason for them not to do it other than Sanford-esque stupidity, and we see where that got Gov. Mark.

A full and robust option can very much include a state-to-state implementation based on the needs of those from that state. Frankly, I'd rather have that than the feds dictating exactly how it's going to go.

This idea that it all has to be Sanders way or the highway isn't flying with me. I think Bernie is fantastic, but he's not the only one whose got a lot to contribute to this discussion. Just because Sanders hasn't articulated the idea of state laboratories for the public option doesn't mean it shouldn't be done.

Carla,

A full and robust option can very much include a state-to-state implementation based on the needs of those from that state. Frankly, I'd rather have that than the feds dictating exactly how it's going to go.

Any minimum standards? E.g. should states be allowed to make anyone who can get insurance through an employer ineligible for the public plan, even if they'd prefer the public one? Allowed to prevent employers from offering partial coverage of public plan premiums as their insurance benefit or one part of it?

I have no idea what you mean by "full and robust" at this point, because you say it would be stupid to opt out, which implies you think it should be possible to opt out, at which "fullness" is taking on a Cheshire Cat quality. Not even a minimum requirement to participate.

I would be genuinely interested in how you define fullness and robustness.

A national public plan would have some potential competitive (i.e. cost lowering) advantages that would be lost by breaking it into pieces. E.g. portabiity. E.g. large risk pool. E.g. uniform bureaucratic billing practices. E.g. ability to contribute to creating national scale electronic records standards.

State-by-state would put the public plans on a different and lower footing than insurance companies that can operate nationally.

The language of "the feds dictating" and "one size fits all" covers up a basic problem of equity in the system: That in some cases "local conditions" means state level power holders saying "We think people who don't have insurance (poorer people) are that way because they're lazy and shiftless and that this public plan idea is just a form of welfare and we're against welfare so we're going to do the minimum possible with this and not allow it to be an incentive to be lazy and shiftless." I.e. not local conditions legitimately related to differences in the timely and effective ways to take action that best promote individual health and population health.

In Medicaid state variation (within not very robust minimum standards) is tied to an expectation of state budgetary contributions. Should "the public plan" work that way too?

Could a state "public plan" be expanded Medicaid?

You say we're not going to get single payer. I continue to advocate it because whatever we do get is not going to really get at the current crisis, which means the debate isn't going to end this summer. Your willingness to buy into this further degeneration is another straw in the wind for me that we are going to get very little at all.

You are right about President Obama's lack of leadership, not only on single payer, but even within the terms and criteria he has set out for reform including a public plan.

<iany minimum="" standards?="" e.g.="" should="" states="" be="" allowed="" to="" make="" anyone="" who="" can="" get="" insurance="" through="" an="" employer="" ineligible="" for="" the="" public="" plan,="" even="" if="" they'd="" prefer="" the="" public="" one?="" allowed="" to="" prevent="" employers="" from="" offering="" partial="" coverage="" of="" public="" plan="" premiums="" as="" their="" insurance="" benefit="" or="" one="" part="" of="" it?<="" i="">

I suspect there would be minimum standards, and there should be. I don't know how those should/would look at this point. Certainly making the public option viable vs private insurance in the region would be one such standard. Merkley essentially articulated as such when talking about the need for the public option to be competitive.

I have no idea what you mean by "full and robust" at this point, because you say it would be stupid to opt out, which implies you think it should be possible to opt out, at which "fullness" is taking on a Cheshire Cat quality. Not even a minimum requirement to participate.

Chris..seriously..I think you need to take a deep breath here. I was responding to TJ who was making the assertion that some states might opt out. You're so ready to pounce that I don't think you're reading this stuff in context.

I think "full and robust" means that a public option must be, at the very least, fully competitive with the private insurance offerings. It must be open and accessible to every American. Beyond that, I'm still waiting to see what the actual proposals are--along with their price tags. I'm concerned about the cost (more for PR purposes than writing the checks).

The language of "the feds dictating" and "one size fits all" covers up a basic problem of equity in the system: That in some cases "local conditions" means state level power holders saying "We think people who don't have insurance (poorer people) are that way because they're lazy and shiftless and that this public plan idea is just a form of welfare and we're against welfare so we're going to do the minimum possible with this and not allow it to be an incentive to be lazy and shiftless." I.e. not local conditions legitimately related to differences in the timely and effective ways to take action that best promote individual health and population health.

Perhaps..anything is possible. But I suspect that given the popular support for the public option and the serious need for alternatives, I find it highly doubtful that this will the case. As I mentioned upthread to TJ, there are going to be Sanford-esque ideologues who won't want to participate or will try and lowball the outcomes--and they'll get hardcore pushback. The same arguments happened with stimulus money and the outcry from the state level was too much for these Governors and others to overcome.

In Medicaid state variation (within not very robust minimum standards) is tied to an expectation of state budgetary contributions. Should "the public plan" work that way too?

I don't know for sure, but at first blush I say no. The reimbursement structure is just too difficult for smaller states and a fundamental lack of equity ensues. It creates an unfair hierarchy/caste system and in that regard is not much better than private plans.

You say we're not going to get single payer. I continue to advocate it because whatever we do get is not going to really get at the current crisis, which means the debate isn't going to end this summer. Your willingness to buy into this further degeneration is another straw in the wind for me that we are going to get very little at all.

I pick the windmills to which I'll tilt very carefully, Chris. It's one of the ways I choose not to burn out on activism.

One of the problems for some on the left is an expectation that if we don't move from one end of a policy spectrum to another...IMMEDIATELY..then it's just an abject failure. I'm not one of those of people. Change that sticks often (not always) comes incrementally. I think this is one of those cases.

I'm not saying that you should stop being an advocate for single payer and I agree that the conversation and work continues after this current round of health care reform. But it should come with an understanding that moving the ball way forward (which a public option could and should do) is a big leap from where we were just a year or two ago. And that it's a success if it happens.

I'm not especially concerned about some big, bipartisan plan either. I think the Republicans are in it to block good policy and then point fingers at the Dems and call "failure" (much the way they've done with the stimulus plan). But there ought to be a way to do this without having to beat the shit out of Democrats who are generally with us and can be brought along. Some (like Ben Nelson) need to be bludgeoned sometimes to get their attention. But others (like Merkley) are already on board for the most part. I don't see how it does a service to a positive outcome, frankly.

Thanks Carla,

Sorry I missed that you were responding to a TJ hypothetical.

As I've said in a different context to T. A. Barnhart, there are times when compromises are an incremental step forward, and times when they can be roadblocks.

To me a robust public option implemented the right way could shake up the dynamics of some health care system dysfunctions and perhaps politics, maybe make it easier to get to a rational and coherent national health system. But a weak public option can become another roadblock I think.

Part of the problem I have had with the whole HCAN approach to including a public plan in whatever reform happens has been that there was very little content to it or recognition of distinctions among public plans. When Howard Dean sent out a letter to MoveOn members, following the national org's undemocratically reached decision to join HCAN and back their approach, it did not say "there are real pubic options and fake ones" as he said in Portland in June.

If he had said that then, and if HCAN were using stronger, clearer criteria, it would make working out a more cooperative approach to handling differences and identifying common ground among the broadly progressive reform forces.

My approach to avoiding burnout varies with issue. In this case, my approach is taking the long view. At the present moment I am working on making single payer unavoidable in the next go-round. I'm not sure we'll get it then either, but if it's fully in the debate as it should be it will make the debate better & clarify the basic issues better than the current opportunistic horse-trading does. I am sure that nothing currently on offer really is going to resolve the crisis.

If there were a clearer strategy and a clearer set of criteria I would give more serious thought than I do to the idea that I should throw my energies behind a well-designed public plan with well organized support at this moment. But since there aren't, and as far as I can tell the game-players and machers in Washington pay nearly as little attention to the HCAN forces as to the s.p. forces, and in neither case are dealing with really analyzing what it wrong from a health standpoint and what could fix it, only to "what can pass," I don't think whether I did that or not would make a difference.

At bottom none of the currently "politically realistic" proposals are health realistic or economically realistic, and eventually the political barriers are going to have to give way.

Oops. that is "it would make easier working out"

Tyler,

Would that be "Fight Club" as in fighting to move the DP left? I'm guessing not. So what, then?

This is a completely serious question. I have never looked upon Barack Obama as my "Dear Leader."