Supporters of adopting a public plan, a national insurance program anyone could opt into, argue that it’s an indispensable component of the Democrats’ soon-to-be-unveiled health care overhaul proposals, providing an affordable option to patients and keeping private insurers honest through increased competition. But critics contend that a federal plan is the first step to a single-payer system, tipping the scales unfairly with government subsidies and threatening the very existence of the private insurance market.
Aside from aligning Democrats against Republicans, the young debate is also threatening to put liberal Democrats at odds with moderates, incite another intra-party rift between Democratic leaders in the House and Senate, and leave President Barack Obama — who wants to pass reforms supported by all parties — struggling to find some middle ground.
The episode highlights the difficulties facing Democrats in Congress and the White House as they try this year to make good on one of their very highest legislative priorities: revamping the nation’s health care delivery system in an effort to cover the 46 million uninsured Americans and slow the skyrocketing growth in medical costs. The debate will be a test of the political skill and will of party leaders, who are trumpeting the urgency of health reforms at the same time they’re urging caution in enacting them; who are hoping to trim the fat in the health care system at the same time they don’t want to eliminate jobs in the middle of a recession; and who are proposing enormously expensive reforms at a time of record deficits.
Lawmakers will also have to contend with the powerful insurance industry, which opposes the adoption of a public plan — and is lobbying furiously to keep it out of the Democrats’ proposal.
On Friday, the debate over public plans was launched in full after news leaked that Sen. Edward Kennedy (D-Mass.), chairman of the Senate health committee, intends to include the government-sponsored option as part of his sweeping reform proposal, expected to be unveiled next week. The leak inspired thoughts that Kennedy’s bill would be much more liberal than that being drafted by Senate Finance Committee Chairman Max Baucus (D-Mont.), who works closely with Sen. Charles Grassley (R-Iowa), a fierce opponent of the public option.
Kennedy and Baucus insist they remain on the same page, issuing a rare Saturday statement vowing to craft “complementary legislation that can be quickly merged into one bill for consideration on the Senate floor before the August recess.”
Joseph Antos, a health-policy analyst at the conservative American Enterprise Institute, said the leak — probably intentional — was likely intended to send a message to liberal Democrats that Kennedy’s on their side. It might also have been a message to Baucus that he’d better be prepared to nudge his proposal left — a situation that puts the Senate Finance Committee chairman in a squeeze between an allegiance to party and the promise to find bipartisan consensus on health care reform.
“He wants to be left of the 50-yard line, but he doesn’t want to be too far left of the 50-yard line,” Antos said of Baucus. “It’s the sort of thing we’ve seen often out of the Finance Committee … There’s a lot of game-playing going on here.”
The same dilemma faces Obama, who appears torn between his support for a public plan and a desire to have a bipartisan bill. The White House did not return requests for comment Wednesday.
Supporters of the public plan option argue that it’s vital if Democrats hope to slow the growth of health care spending, which is skyrocketing at a rate well above that of the rest of the economy. A government-sponsored plan, they say, could provide cheaper coverage because it wouldn’t have to pay the marketing and outreach costs that burden private insurers; it would cater to more people, lowering costs for reasons of sheer volume, and it wouldn’t be bound to produce profits for shareholders.
There are other advantages to the public option. Ron Pollack, executive director of Families USA, a consumer health care group, pointed out that private insurers operating under Medicare have been known to alter the terms of coverage, leaving patients without necessary treatments. A public plan, Pollack argued, “provides some stability” to patients. The government option would also create an enormous database of health coverage information that could inform future policy decisions, Pollack said — information private insurers often won’t disclose for proprietary reasons.
Conservatives and the insurance industry have other thoughts. Summing up the criticisms of the public plan option, Senate Minority Leader Mitch McConnell (R-Ky.) on Tuesday argued that a federally subsidized plan could offer “artificially lower prices” that would quickly attract interest from individuals and businesses alike. The result, McConnell contended, would be the death of the private insurance market.
“The very concept of a government ‘option’ is itself misleading,” McConnell said on the Senate floor. “What starts out as an option could quickly become the only option.”
Sen. Judd Gregg (R-N.H.), who floated his own health reform proposal this week, said the public option would eventually lead to “delays and rationing” for patients.
“The first rule of health care is, do no harm,” Gregg told MSNBC Tuesday. “Well, one thing which would do serious harm would be if the federal government came in and stood between you and your doctor or created a system which led to delays and rationing, which is what a public plan would.”
Several proposals floated on Capitol Hill in recent weeks seek to satisfy both supporters and critics of the public plan option. Under one measure, sponsored by Sen. Charles Schumer (D-N.Y.), the government would administer, but not be permitted to subsidize, the public plan. Instead the plan would have to rely on premiums and co-payments to cover claims, like any other insurer. The Schumer plan would also force the public plan to pay health care providers at rates higher than Medicare pays.
Another proposal would offer private plans the opportunity to expand coverage and reduce rates on their own, with the public option kicking in only in regions of the country where the private market failed to meet certain minimum thresholds of coverage and cost. Opponents of that strategy, including Schumer, argue that the nation’s 46 million uninsured residents are evidence enough that those thresholds have already been met.
Antos, of AEI, said one of those compromises could work, but first the language surrounding the debate would have to change so that the Republicans who’ve so adamantly opposed the public option wouldn’t be seen going back on their word.
“You’ve got to find a face-saving way,” Antos said. “So the first thing you do, you don’t call it a public plan.”
Douglas Holtz-Eakin, former head of the Congressional Budget Office, said that, without any details, it’s still too early to speculate about the fate of public plans in the coming debate. “There are many different flavors of a public option,” said Holtz-Eakin, the chief economist for the 2008 presidential campaign of Sen. John McCain (R-Ariz.). “We’ve got to see a specific proposal.”
Robert Blendon, a professor of health policy at Harvard University, pointed out that, even if the Senate isn’t able to pass the public plan provision, House Democrats will almost certainly include that option in their version of the bill, which is currently being drafted by Reps. Henry Waxman (D-Calif.), Charles Rangel (D-N.Y.) and George Miller (D-Calif.). For all the controversy swirling around public plans, Blendon added, there’s a larger barrier to the Democrats’ push for health care reform this year.
“This is very contentious, but not as contentious as how they plan to pay for it,” said Blendon, an expert on the Clinton administration’s failed attempt to pass comprehensive health care reform in 1993. “If they can find savings someplace, they would not stop the train for this issue. They would find some Sen. Schumer-like compromise and push the thing on through.”
David Cutler, a health economist at Harvard University who’s advised the Obama administration, downplayed the significance of the partisan griping over public plans, arguing on Tuesday that overall support for health care reform this year remains as strong as ever.
“You see these sorts of splinters,” Cutler said, “but you don’t see anyone walking out yet … We are in so much better shape than 16 years ago.”