Parsing the Public Option

Cartoon by Daryl Cagle reprinted by permission. In his August 30 blog post, "How to Draw an Ugly Health Plan and Make it Pretty," Cagle (a supporter of single player--be it public or private) writes he came up with the cartoon to "comment on the speculation that the Democrats would use sentiment about Teddy Kennedy’s death to push health care legislation, possibly by attaching Kennedy’s name.

Thanks, Daryl for the permission. Everybody, check out http://blog.cagle.com (If you have trouble with these links, they aren't permanently broken; Daryl tells me his blog will be back on line, soon.)


I sure wish Teddy Kennedy were alive and well and fighting. Obama's proposal delivered to Congress on September 9 identified some of the problems in the healthcare system, but offered little about implementation of solutions--and all in terms so vague as to constitute a Rorschach test. Nate Silver, my favorite poll analyst, thinks that's part of why public opinion is hard to test.

September 14, he took on the WaPo's poll and the odd interpretation written by Jon Cohen and Dan Balz: "Reform Opposition Is High but Easing: More Support if Public Option Dropped." Like me, he questions the WaPo analysis that the public option should be taken off the table, despite a poll in which a majority support it. In "When You Assume, You Make a Mess Out of Your Poll" published in FiveThirtyEight.com, Silver writes,
One problem is that both the poll and the article assume that the public assumes that the public option is the default condition of the health care reform plan. But as anyone who is following the health care debate knows, this is hardly a safe assumption. Some versions of the "proposed changes to the health care system being developed by Congress and the Obama administration" -- like the one which was passed by the House tri-committee -- include a public option. Other versions -- like the draft prepared by Max Baucus's Senate Finance Committee -- do not. And the President himself is on the fence. As a matter of semantics at the very least, it is not really proper to state that "If [the public option] were removed, opposition to the overall package drops by six percentage points," because it is not clear that the public option is in the package in the first place...

When you're specifying that the plan does not include a public option, you're really doing two things. Number one, you're taking the public option off the table. But number two, you're providing specificity. And what the health care polling has consistently shown over the past few months is that the more specificity you provide, the more support for the package rises....The respondents may be reacting to the specificity more than anything having to do with the public option itself.
Another poll of doctors finds even more support for the public option: the New England Journal of Medicine's "Doctors on Coverage — Physicians’ Views on a New Public Insurance Option and Medicare Expansion," featured by NPR. The summary there:
Among all the players in the health care debate, doctors may be the least understood about where they stand on some of the key issues around changing the health care system. Now, a new survey finds some surprising results: A large majority of doctors say there should be a public option.
When polled, "nearly three-quarters of physicians supported some form of a public option, either alone or in combination with private insurance options," says Dr. Salomeh Keyhani. She and Dr. Alex Federman, both internists and researchers at Mount Sinai School of Medicine in New York, conducted a random survey, by mail and by phone, of 2,130 doctors. They surveyed them from June right up to early September.

What we DO know about Obama's preferred plan after reading his speech to Congress
Nothing in his plan requires a change to another insurer. Insurance companies will not be allowed to:
  • deny coverage because of preexisting condition
  • drop coverage or reduce coverage for illness
  • cap coverage during the year or lifetime
  • charge more than a set limit for out-of-pocket expenses
  • exclude or charge extra for coverage for routine checkups and preventive care
Four years from passage his plan will create an "insurance exchange" to hold down costs for small businesses and individuals, including tax credits. Until then there will be "low cost coverage" for those who cannot get insurance. Individuals and companies will be required to provide insurance except for
hardship waiver for those individuals who still can't afford coverage, and 95 percent of all small businesses, because of their size and narrow profit margin, would be exempt from these requirements.
He talks about the public option as only being for those who don't have insurance and that the CBO only predicts that 5% of Americans will enroll. Does that mean that I'll be forced to continue with my current policy? He also says no federal money for abortions and that the "conscience" exception will remain in effect. So unless a poor woman can get a private source of funding, I guess abortions are restricted to those who can afford them?

Additionally he talks about how premiums will have to cover the public option, but at the same time compares them to public universities. But, last time I checked tax dollars support these universities, although to a decreasing degree.

And he calls triggers and co-ops "constructive" alternatives, although there has been substantial criticism that both are problematic.

I've already written about the criticism of coops.. As for triggers, Tim Foley wrote about Robert Pear's description of the plan on May 30. (see also Pear's description of the trigger on September 9).
“the public plan would be created only if private insurance companies had not made meaningful, affordable coverage available to all Americans within several years.” All of these terms – “meaningful,” “affordable” and “several years” – are as vague as can be. The trigger may be set up so, in effect, it never happens, similar to the Medicare Part D trigger that would have created a public prescription drug plan – but never did. The threshold would be low enough that it could be easily, and superficially, met. Throughout those “several years,” the insurance plans would receive all of the uninsured who enroll through a National Health Exchange, pocketing what we can hope are generous government subsidies, with very few changes to their behavior. And even if the trigger is met and a public plan created years down the road, private insurance would have serious “status quo bias” on its side. ... So let me get this straight: for the sake of having a big, feel-good compromise in the Senate Finance Committee, we’d be willing to take the word of an insurance industry that has made record-breaking profits on the basis of cherry-picking, denying care, and setting up tilted, monopolized playing fields such that 94% of the health insurance markets in this country are deemed “non-competitive” that they can clean up a mess that currently makes them rich without a competitor to, in the words of the president, “keep them honest”?

Most of us know the health system is broken

Okay, some say we have the finest health system (what an oxymoron) in the world. But for those of you don't trust the World Health Organization's numbers, how about our own CIA?

The average life expectancy estimate for 2009 for the US, according to the CIA World Fact Book, rates 50th. And for infant morality, there are 44 countries that do better than the US.

We know a large number of folks lack health insurance. Others such as myself pay a high proportion of our income and still contend w. high deductibles. And we cannot shop for a better policy because we have pre-existing conditions. In my case, although I had insurance, the company (Blue Cross, now Anthem) delayed my treatment for months while my doctor argued for the proper tests. By the time this was approved, I needed surgery, radiation and chemo.

62 percent of all bankruptcies filed in 2007 were linked to medical expenses. Of those who filed for bankruptcy, nearly 80 percent had health insurance, according to (Himmelstein, D, E., et al, writing in “Medical Bankruptcy in the United States, 2007: Results of a National Study, American Journal of Medicine, May 2009. And according to Price Waterhouse, at least a quarter of all health insurance $ in the U.S. are spent on administrative costs. (I can send you the report.)

All the forgoing explains, perhaps why we spend a higher proportion of our gross national product and a higher cost per person on health care and still do not have as good outcomes as other countries in the developed world.

The question: are we going to have any real improvement?
I see little evidence that politicians opposing healthcare reform are ready to dial back their rhetoric. Or that a sufficient number supporting reform will come up with sufficient changes.
Rolling Stone
's Matt Taibbi agrees. In the September 3, 2009 issue, he outlines the legislative process to date in "Sick and Wrong: How Washington is screwing up health care reform – and why it may take a revolt to fix it." He writes

All that's left of health care reform is a collection of piece-of-shit, weakling proposals that are preposterously expensive and contain almost nothing meaningful — and that set of proposals, meanwhile, is being negotiated down even further by the endlessly negating Group of Six. It is a fight to the finish now between Really Bad and Even Worse. And it's virtually guaranteed to sour the public on reform efforts for years to come.
In his speech September 9, President Obama protested that
I am not the first President to take up this cause, but I am determined to be the last.
Let's hope that's not because the insurance and pharmaceutical companies and lobbyists and their allies achieve a permanent victory.