This is Part II of a response to Ezra Klein on the relative importance of the Public Option (PO) (Part I) and the "exchange" through which individuals would gain access to the PO. Part I is here.
Now about the exchange(s). I agree that exchanges can be useful; I’m fine that the concept is in the bill. But to single out the exchange(s) (there could one in each state) as critically important relative to the Public Option seems to confuse their respective roles.
If you read what Ezra says about them, their principal value arises from the fact you might have better choices within the exchange. But that’s only likely if there is a viable PO competitor pushing prices down and serving as an alternative model you could choose if the private insurers didn’t provide products you wanted (or continued to abuse their customers).
Klein’s discussion confuses the benefits of an exchange — the place (or website) you go to to choose a plan — with the competing plans themselves. We could have some competition without a formal exchange — just as different insurers compete today in offering plans to employers. And if we had a strong PO available to employers, we could have some very interesting competition, still with no exchange.
But if we don’t have a viable PO, then whatever competition occurs in the exchange is limited to the highly concentrated private insurers whose "competition" among themselves has already proved to be inadequate and a long ways from any economic model for competitive markets.
As currently envisioned, the exchange is simply a place, or more likely, a web site/office staffed by state and/or federal employees (or contractors), where you can get information about competing plans. Reducing the costs of information is usually good for markets.
To be sure, the eligible competitors listed with the exchange must meet certain requirements and regulations — but those come from the government regulator. The exchange is just the place or entity that checks to see that if an insurer lists on the exchange, it meets the regulator’s rules and so qualifies as plan that can be listed (and in the bills, becomes eligible for federal subsidies). Regulators could do this without the exchange, or with it, but that hardly makes the exchange the central feature of reform.
There are also benefits to pooling risks (and risk sharing). An exchange can facilitate that. But the ability to pool risk is a function of access/eligibility for the plans being offered, as well as other rules. It’s not the result of exchange functions per se.
Since the bills make access to the Public Option dependent on the access rules for the exchange, it makes it seem as though the exchange is key. But what this really says is that the access rules are critical, not the exchange itself. Those access rules are set by Congress or in later years, by the Secretary of HHS, not by the exchange administrators. For example, Congress could specify 100 percent open access to the PO even if there were no Exchange.
So the important question is: if you have to go through an exchange, what can you choose in an exchange? If there’s no PO, then you can choose between mega insurers A and B who dominate the market. Don’t expect that "competition" to do much, and having it occur within an exchange isn’t a game changer. If there is a viable PO, however, then you can choose between mega insurers A, B and the PO. The PO makes the critical difference.
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Hi Scarecrow. Nice work on Ezra’s ideas. What happens if we have a public option, but access to it is limited as in the current form of HR 3200?
Exchange and mandate without public option = bailout for the industry.
The House bill starts by limiting access to the exchange — and hence to the ability to choose the PO — to those who are uninusred, those who are self-insured, and to very small businesses/employees. That starts in 2013. The next year, 2014, the size of the businesses who become eligible to gain access is increased somewhat. In year 2015, the bill gives the Sec. of HHS the discretion to enlarge eligiblity to more businesses.
The early restrictions and the gradual phase in are designe to lower costs. Under the bill, anyone eligible to purchase insurance in the exchange (including the PO) is also entitle to federal subsidies, which are higher for very low income and less for middle income, phasing out at 400% of the federal poverty limit. As eligiblity for access to the exchange expands, so does the requirement for federal subsidies, as more and more people will become eligible for them.
The Blue Dogs proposed to reduce the level of subsidies even further, not by changing the access rules but by changing the thresholds of who is elibible for subsidies, thus forcing more people to pay more of the premiums with less help from the feds.
Thanks Scarecrow. But my question really was directed at the point that eligibility is limited in 2013 and 2014, and perhaps after that depending on what the Secretary of HHS does. Will the restricted PO of 2013 and 2014 really introduce competition into the market? Or will the huge insurance just eat the public option’s lunch? Also, what if the HHS Secretary doesn’t expand eligibility past the level in 2014? Why ought one believe that he or she will, considering the very heavy insurance company lobbying that will be opposed to such action? Also, does the bill allow the Sec’y to reduce the scope of eligibility after 2014 also, or only broaden eligibility? What I’m really asking for is your assessment of the chances that a bill like HR 3200 will actually bend the cost curve? Also, what happens from now until 2013. Premiums 40% higher than they are now?
I have mentioned this before but it is unclear how an exchange would differ from the confusing welter of plans offered under the drug benefit of Medicare Part D. In that, it was virtually impossible to really compare plans. In the few cases where someone found the right premium price, copay, and drugs covered they wanted, the plan could at the drop of a hat change what drugs it did cover, screwing up and over the enrollee.
I think given all the lack of serious reform in this debate this is exactly where we are heading with healthcare exchanges. Lots of plans, no way to compare, heads the insurance companies win, tails you lose.
If we’re talking about Sec. Sebelius, a strong supporter of the public option, I don’t see why she wouldn’t expand it.
Hi Hugh, I must admit I also think it will work out that way. I just heard a Blue Dog say that he agreed with the Democratic goal of universal coverage, and also with the goal of bending the cost curve. The difference, he thought, was that the “regular” Democrats wanted to provide universal coverage first, and bend the cost curve later, while he wanted to do it vice versa. The incompetent moderator of the Blue Dog Panel composed-panel, never followed up by asking just how the Blue Dog compromise plan was going to “bend the cost curve.” Undoubtedly the Blue Dog would have said that the health insurance exchange will do that. But its pretty clear that, as Jason partly indicates above, an exchange alone can’t do that because there isn’t a free market in health care. That’s just a health industry myth.
One of the big problems with the Democrats since Jimmy Carter is their complicity in getting people to accept the idea that a market is free as long as the Government isn’t in it. They never fought the spread of the myth that markets always work; and in the Clinton Administration they seemed even to buy that idea themselves, which is one of the things that led to the recent financial crisis. Well we’re past that time now, and its time for Democrats and progressives to emphasize the idea that markets often fail and that when they fail it’s only practical to do something else and not quit insisting on the religion that the market always knows best.
In a way, the whole public option plan is a hangover from pre-crash of 2008 days. When Hacker proposed public options, the free market ideology was still king. Now people are real skeptical about how well markets work. But neither the Administration nor the Blue Dogs nor many progressives have adjusted to this change in how we see reality. So, they still think that a “public option” plan that talks about the market and free choice is inherently more attractive to the American Public than “Medicare for All.” I really don’t believe that. I think we need to change the frame were using for health care reform, and fast.
OT: Not sure if this has been mentioned yet around here, but just saw this from Eric Cantor:
http://theplumline.whorunsgov……her-story/
Seems Mike Stark is creating quite a stir among the cocktail-weenie set. I say we need to fund those operations more and even step them up. Onward and upward!
these so-called “health insurance exchanges” already exist online…
http://www.ehealthinsurance.com/
I’d be very curious to know why E Klein thinks that his “exchanges” constitute significant reform above and beyond what is already available….
Do you like the competition that exists now? There has to be a mechanism to force the the insurance companies to competitively price healthcare. The fact that there is no competition now is exactly the crux of the problem. There is no reason to force those 7 Big insurance companies to lower prices. They are all bleeding America.
I don’t think we know who much costs can be reduced. The PO can affect pricing for insurance provided in the exchange, but can’t affect insurance outside the exchange, which is most of the market. I don’t expect much impact initially, which is where I agree with Klein.
If the House measures prevail, giving the Sec. of HHS discretion to expand eligibility, I expect there to be tremendous pressure on her from all directions — from those who want to expand access, those who want to shield insurers from competition, and those concerned about the unraveling of the emmployer-based insurance system. Where will unions come out? Dunno.
Again, my preference is to get the basic concept planted and prove it can work, then open it up on a defined, predictable schedule so everyone knows what they face. I’ve been through several industry transitions in different regions, and they’re very difficult periods — lots of requests for delays, exemptions, grandfather rights, etc. They key is to get everyone to agree on the schedule when everyone has to be in compliance and then be relentless in sticking to it. People will adapt when they think there’s certainty about what will happen.
The cost control stuff seems really hard. It’s not just the insurance inefficiency. A lot of the problem is with Doctors/hospitals, because people think they’re in a market when in fact we’re moving towards a regulated cost-of-service system, just like utilities. So we have most providers trying to set their own prices and figuring out how to manipulate the regulated systems, like Medicare. There’s a great story today on the debates about whether Doctors should be allowed to recommend MRI/scans when they own the equipment and earn on each usage. Is this good practice or a conflict of interest? And how would a cost regulator, like Medicare Administrators, looking at that judge how to price such tests? And how do we force doctors to abandon fee-for-service and move towards total care and salary and other performance-based systems?
It’s unrealistic to expect the PO vs private insurer resolution to solve the provider cost problems; they can influence it, encourage successful practices, etc, but it seems the big problem will be convincing Doctors/hospitals to change the way they practice medicine — and how do we do that? With a bill in Congress? I doubt it.
Scarecrow:
Speaker Pelosi has indicated that single payer will get a floor vote.
Should FDL whip in favor of single payer, or not?
Single payer. The only option to lower costs and provide universal coverage.
You’re right on what’s actually being discussed. Without a public option the insurance regulations meant to reign in the excesses of the drop-and-cash-in business model insurance companies currently follow wouldn’t work. People would get stuck on the exchange, and exchange which didn’t offer any plans, if regulations but no public option passes.
However, as a policy argument Ezra is right. If we totally redid our health care laws to make them all like the Dutch laws (which is basically what he’s trying to talk about without talking about it), then there could be meaningful competition, increased access, and reduced prices. But that would require Wall Street to accept Dutch ideas about acceptable profit growth. And that is never going to happen.
So while there is some shred of an underpinning to what Ezra is saying, it kind of falls flat on itself because the key aspects–changing people’s expectations about profits–can only be achieved in the American system through a public option. Maybe it shouldn’t be that way, but it is. Ezra seems to favor a parliamentary system. I think he’s spent too much time pondering that, and too little time pondering political realities of the American system re: policy.
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How do we convince the doctors and hospitals to change the way they practice medicine? Change their incentives. Under our fee-for-service health care system, the more waste and inefficiencies, the greater the revenue for the providers. Whoever holds the purse strings can change the method of payment. Private for-profit insurers have had no incentive to reduce medical costs, however, because they have been able to pass the increasing costs, together with their mark up, on to the consumer. The more the docs and hospitals charge, the more the insurance companies profit. Some providers paid on the fee-for-service basis attempted to reduce inefficiencies only until they found out it caused them to lose money. If the health care financial system is required by “a bill in Congress” to change its payment method to incentivize efficient (and at the same time better) services, medical costs will decrease. This is not a pipe dream; it is currently being done now in various parts of the country under several different models of care. One thing is for sure: the health care delivery system prevailing in most of the country will not reform itself.
Right lets let Canada compete as an exchange and see how their plan stacks up against anything America has.
I appreciate the incrementalist argument (i.e. the public option as constituted by current legislation isn’t exactly something to praise, but it creates and institution that can be built upon) but I’m not sold on it.
Arguing what might be the case in the future (i.e. in the future we can establish a public plan with no restrictions on access) is nonsensical. In the future we could fuckin vote for single payer… but that isn’t relevant to the debate we face. For now there are problems to deal with and we have the legislative and political constraints that have already been presented. And what’s been presented is a public option that doesn’t do a whole lot. So whether we get a co-op or the public option or neither doesn’t change much. As long as the exchange is kept, the real reform is in the building. But the public option as constituted isn’t anything substantial, just some shit to placate the village.
That’s not to say the public option should be on the chopping block. It’s a cheap way to cover people and congress is going to be hard pressed to achieve universal coverage for cheaper without something like the public option (unless they actually get tough on insurance companies, a la dutch system… HAH!). But it’s not a deal breaker for me. That said, I don’t expect nor desire Jane or anyone else to change their tune. The people with the megaphones shouldn’t back down from shit, no matter how little. It’s not our job to compromise. Leave that to our elected representatives.
Ezra Klein is supposed to be on our side? He’s a Blue Dog blogger imo. You need to stop letting the debate, even in the “liberal” blogosphere, being led by people who are in no sense progressives.
As for incrementalism, do people just not get that this is it? This is your reform. There won’t be a return to this in Obama’s presidency and probably not in the next guy’s. What on earth makes anyone think there will? Obama promised to reform health insurance. He’ll do that, pat himself on the back and consider that a job well done.
Is that the change you believed in? Hardly. Is that what Ezra weed his knickers over? Well, sadly, I think it is.
My thanks to Scarecrow for his erstwhile attempt to explain the Public Option or with more precision on my part, a Robust public option.
However, the ‘discussion’ for our Elected Officials should’ve started with a “Needs” Process in which each consumer has the responsibility to “define” the particular of self-interested Need as it applies to the family. Take, for example, should I Need coverage for a specific “delivered care” item of one child and not for another, the question rises to the level, “what am I getting for my monies, and what am I getting from the federal government, and when taken together, if possible, solves my Need?”
And if one keeps in mind that the “feds” spend 50 cents, the employer spends 40 cents, and the patient/family/consumer, spends 10 cents, how can I, the decision-maker, determine for myself, the various options that may or may not ‘match’ my Needs.
And since I am an advocate for expanding either Indian Health Services or the VA’s systemic, am I permitted to take my “Needs” Assessment over two these two medical institutions, and therefore, accept my “needs” and have them respond in a manner that I can understand as a “bid” for my medical care delivered.
In contrast, can such a systemic be established in which the “fee for service” schema is established in which the medical professional provides me with a “bid”? Not likely, since the doctor will become his or her own or inherent insurance company, and even a “pool” of doctors would not venture forth in establishing a responsive insurance company. And yet, perhaps, there is one way of doing this and “this” could be accomplished by establishing Community Development Corporations in which geographical allocations are fairly apportioned. And which means that doctors practicing within these geographical zones are required to participate, or otherwise, fend for themselves as to delivering their speciality to consumers sufficiently wealthy to pay this financial freight.
By way of background, Community Development Corporations were established during LBJ’s era of a “participatory” Democracy in which he used his Regimen of Law, reinforced with taxpayers’ dollars, and thus, set me free in a manner, that empowered me to engage and participate in our political discourse. Thus, CDS were at the outset, established to be innovative political vehicles that ‘expanded’ the economic development of a community/neighborhood, and hopefully for the betterment of all.
With this in mind, a CDC, working on behalf, as as a financial subset of a community-based organization, created a revenue stream of profits that could be pumped back into the CBO to continue and expand the delivery of services to the affected community/neighborhood. And as to the taxpayers’ dollars, the start-up capital was provided by the Feds. And today, where you see the CBO and the CDC, working in tandem, also operates on behalf of the City, County, State, and the Federal Government, and done in a manner in which each political subdivision has its ‘needs’ addressed and which corresponds to the funding source. Now, as to medical care, the CBO could effectively negotiate with the insurance providers, at perhaps, a fixed cost contract, that could conceivably cover the “Needs” Assessment of each particular resident of these affected communities/neighborhoods. And I think that is the “feature” or “bug” that is being advanced with co-ops, but they can’t be called CBO/CDC’s, since politically, it’s deemed ’socialistic’ in today’s toxicity of a congressional environment.
Consequently, Hacker and “Extra” Klein, are advocating a neo-liberal solution that still does not start from the bottom up and whence the “needs” assessment is of primary importance, but is irrelevant or cavalierly dismissed for achieving their (Hacker and Klein) anticipated result in advance of even considering the ‘needs’ of the person who will eventually pay this financial freight, such as myself, and done either out of my pocket, or with my taxpayer dollars, or even, the financial subsidies that have been put in place (embedded via the tax code) by my “agent” acting in my name, and to wit, my Elected and Appointed Officials.
Thus, some of my Passing Thoughts.
And since it’s early and I am working “European Hours”, I have to get back to earning my living.
Jaango
The way things are going, we may not be talking about Secretary Sebelius, but about a Republican Secretary trying to kill “Government-run Healthcare.” Putting this off until 2013 is really a dumb political view, in my view. Everyone’s going to see HR 3200 as kabuki, and that 2013 effective date for the public option will become one of John Stewart’s bitter jokes, and perhaps the subject of another Michael Moore movie. Oh well, perhaps it will serve to get people excited about the real reform we need. A Congress that is prohibited from taking anything else besides public funding. I know this last is idealistic and I’ve never been in favor of it before. But the shenanigans in the Energy and Commerce Committee and in Max Baucus’s Finance Committee have convinced me. After accepting four million dollars in contributions from the health industry he tells us that doesn’t affect his work in the slightest. Give me a break. Anyone who’d believe that, deserves to get sold a sub-prime mortgage, or a certain bridge in NYC.
Thanks Scarecrow. It’s a very good, honest, and deep answer, in my view. Now why should we support such a bill? Does the planting of this seed delay the time when there will be reform that makes a real difference in rising costs?
I don’t make the calls for what does or doesn’t get whips. However, those judgments seem to be based on what’s feasible, because they don’t want to ask people to make a lot of effort, when the likelihood of success is too small. People have to believe what they’re doing might actually have a positive outcome, even if they know the odds are long. I can offer an opinion.
The question is whether we should ask people to do something that has some likelihood of success, and if I thought there was some real value in getting people to make that effort, I’d do it. Judging conditions now, I don’t see the slightest chance for sp to be adopted in the House, let alone the Senate.
However, it’s conceivable that during the recess, the public demonstrated such a strong preference for sp that it somehow became a greater possibility. I suspect there’s a lot of support. There’s also tremendous opposition from the industry/Republicans about any “government takeoffer,” and all the phony horror stories about UK/Canadian rationing, interference between your and your doctor, etc. If there was a groundswell of sp advocacy, those opposition efforts would become even more outrageous. But as I said, if we came back from the summer recess and Congress had seen lots of demonstrations/events and new polls demanding, “why don’t we just go to sp?” then that would change the whole dynamic. I would be thrilled. But that assumes a radical change in the dynamics that I don’t see happening.
The fact that the House may allow a vote on sp does not, by itself, change this. At this point, I’d expect it to illustrate that are more or less than half of the House Democrats?? willing to support it. Is the point to have such an illustrative vote for its own sake? I’m not plugged into the politics, so maybe this is a good first step, maybe not.
A second argument might be that having a vote on sp would be helpul even if you expected to lose, because it would make it more likely the House/Senate would support the Bernie Sanders fall back point, “if you can’t do sp, then at the very least we should do a strong public option.” The idea is to illustrate that the PO is already a serious compromise, and weakening that compromise further is unreasonable and leaving it out is unconcionable.
I don’t know how to judge the value of that exercise, and I suspect that those who think anything but moving to sp is a waste of time would not be interested in this ploy, so it might keep us split.
We’re split now, which is unfortunate. I’ve tried to bridge that by explaining a possible path (that depends on a lot of ifs) that could go from A to PO to SP. But most reform advocates don’t trust any part of the system to follow that path. So we remain divided, and our inability to unite behind a common strategy weakens all efforts. I don’t know how to solve this.
I’d support a bill with the seeds of viable PO, knowing that’s just the first step. In other industry restructurings I’ve been in, even after the basic policy direction is set forth in statute, it takes years of persistent effort to keep things on track. You have to fight off the Dark Side at every stakeholder meeting, every regulation drafting session, every effort to write the manuals and operating procedures. then the software techies come and thry to adapt the reforms to match what their software can do, rather than demanding the software adapt to what the reforms requires. Years of effort.
I can’t map out a scenario that starts with a purpose to defeat such a bill in the hope that this will make it more likely that something better will be adopted sooner. It’s not that sp advocates haven’t thought about this; it’s that the country has become virtually ungovernable and seems to be getting worse. The “good” party is weak and corrupt; the “bad” party is completely nuts and their ideas are evil; the vested interests are extremely powerful and have a stranglehold on the process, and the media is mostly clueless or complicit.
We have a very narrow window to get something that, if we’re very lucky and work very hard, might actually do something worthwhile. It could also fail. So I’m committed to this window. I can’t see far enough to make out the next window, if there is one.
“I don’t know how to solve this.”
With this post, I am not “slamming” President Obama and his Team, but I realize that if Obama’s Legacy is for standing on the shoulders of FDR, Truman, and LBJ, he–Obama, has went about it the wrong way. And the leadership team in both the House and Senate, have not risen to the challenge of expecting Obama to stand on these ever-present and wide shoulders. Thus, Pelosi, and whom I much admire, and Reid, have not served Obama very well. They should have advised him that a successful approach to UHC, will become his ultimate Legacy. Otherwise, Obama will have adopted for himself, a second-rate leadership model. In contrast, Bush’s Legacy has been predicated on a third-rate leadership model in keeping with his tenure during America’s Era of Insanity inclusive of his War of Choice. In short, Pelosi and Reid should have grabbed Obama by the scruff of the neck, and explained the realities inherent in having a vast majority in terms of votes. And in this instance, history, has neither “informed” nor “taught” our leadership much.
And which brings me to “subsidiarity” and pontificated by the late William F. Buckley. Consequently, as a Chicano and a military vet (and I mention military vet, not for the purpose of wrapping myself in the flag, but to express myself as I have in a Diary on Equality and Honor.) In short, I am tired of being “racially profiled”. Now, here in the Sonoran Desert or Arizona, Republicans are intent on a legal three-step Waltz in which the votes of Chicanos, Native Americans and African Americans, will have absolutely no value due to this ‘third step’ being performed next year in the Republican-led legislature. And all this is a “stinky-nasty” that is causing Buckley to roll-over in dismay to what is being done as politically “unprincipled”. And “hypocrisy” is a gentle kindness for the purpose of an explanation for this egregious behavior.
Subsidiarity is just another fancy word for “can the local municipality” address effectively, “medical care delivered”? No one has asked any municipality; have not asked county leaderdship; and no one has asked state government. To wit, UHC has never been delivered, albeit, on the notional for subsidiarity and done with an actual response received.
For the casual observer, the Clinton’s White House dictated the terms, and failed. Now, Obama has willingly surrendered UHC in the vain hope and glory that Congress can or will establish his Legacy.
In closing, my post @20, I laid out an initial approach that can and will achieve local success for UHC, if adopted. And in a more symbiotic relationship, even a Council of Governments (regional) could do more for the body politic to implement UHC. And as Democratic activists, we ceded the “debate” to President Obama, and we all should know better than to do this, since ‘control’ of this debate has been effectively squandered. Our Democratic strength has been predicated on the backbone of municipal governance. Had municipal governments held “hearings” on UHC, a differing view would have occurred in which Congress and campaign donors could not have de-stabilized.
So, when I look at all the ‘experts’ and well-intentioned pundits, I cannot get angry, but I am frustrated relative to the ‘control’ of the debate.
As an aside, I am proud to see what has been accomplished here at the Lake, despite our disagreements. Perhaps, I should put into the Suggestion Box that the activists here at the Lake should be responding to our city council members and the respective mayors, seeking to hold “hearings” even at this late date. I think this would energize the “base” by bringing another aspect of attention to our national debate. And I mention this in passing, since the Cite of Santa Ana (California) has passed a resolution endorsing the Dream Act, and Congressman Joe Baca is having his ass chewed down to the last nub for his refusal to endorse, and thusly, introducted legislation that does nothing of any consequence. It’s gotten quite nasty, especially when Members of Congress don’t listen to City Councils.
Jaango
One last “passing thought” for today. :-)
Not many Democrats are enamored by Jimmy Carter, but I am. If you recall correctly, Carter introduced and passed the PURPA Act on his watch. This legislation required state ultility regulatory agencies to ‘revisit’ the economic schema for rate regulation since it was widely understood that the residential users were effectively subsidizing Corporate America. As such, Carter went the way of LBJ for a “participatory” Democracy. He created funding in which Community Action Agencies were provided the requisite monies to represent both seniors and the low-income. In Arizona, the ultimate outcome was the creation of the Residential Utility Board, and subsequently, put into law. Funding was accomplished through the State General Fund. To date, this RUB is active and continues to represent the residential ratepayers.
Jaango
I’d be very curious to know why E Klein thinks that his “exchanges” constitute significant reform above and beyond what is already available….
Well I don’t speak for Ezra, and I think he is off base on most of this to start with.
But the answer to your question is that each plan qualified to participate in the Exchange has to go through a review and qualification stage to become a QHBP. The current market does not have this kind of consistent regulatory framework and from what I see is subject to 50 different Insurance Commissioners or equivalent, many of which are exposed to the need to raise campaign contributions for re-election.
Under the current system there seems to be little to no vetting of insurance plans to make sure that they are not slipping unfair provisions into the fine print. Under the proposed system there will be such checks. Now certainly this will make our libertarian friends jump up and down in rage, but I say ’screw-em’, some things are too important to be left to uncontrolled free enterprise.
The 2013 date is not just an attempt to limit costs. It is a recognition that you can’t just set up something like this overnight. (And yes you could get Single Payer going quicker, that doesn’t change the realities).
Under HR3200 we have a time-table starting with the date of enactment. People wanting to speed up that timetable need to point out where they would shorten the process.
The only date certain in the bill is Day One of Year 1 which is to say Jan 1, 2013. If we were optimistic and suggest the bill will be signed into law this year and go into effect on Jan 1, 2010 we have the following timetable:
2010: nomination and confirmation of the Health Choices Commissioner, staffing and setup of the Exchange and the Health Choices Administration subject to normal Civil Service hiring rules and GSA building and equipment leasing procedures
2010: day 60-deadline for appointment of the Health Benefits Advisory Committee
2011: day 1-deadline for recommendations of the HBAC to be submitted to the Secretary
2011: day 45-deadline for Secretary to recommend or remand benefits package
2011: day 180-deadline for benefits package to be through the statutory publication process
The bill allows a year and a half for this total process, which doesn’t seem excessive to me.
2011 day 181 to 2012 day 365: contract negotiations and plan set up between the Health Choices Commission and the Insurers including all administrative procedures, forms, etc on both sides.
Another year and a half. If there is someone out there with experience in setting up a large scale administrative operation that can suggest significant places to slice away time without sacrificing the quality of the final product then please chime in. But please not that even this timetable assumes a rapid enactment, the designers of the plan had to take into account the real possibility of legislative delay. In an ideal world I could see squeezing a year out of the time table and so get a Jan 1, 2012 start, but people who think you can just wave a wand and set up an entirely new administrative and staff structure overnight are living in a fantasy world, the real world of leasing, and hiring, and getting permits for food service and the like just doesn’t work that way.
I asked this question is Part I, excuses if it was already answered there.
In what sense is access to the Exchange really limited? Given the goal? From my perspective the main goal is to extend health care coverage to the 50 million who don’t have it plus to get relief to people who for a variety of reasons are paying exorbitant out of pocket costs to pay for individual insurance. People in these categories are likely to be either self-employed or work in businesses too small to even offer access to a plan, still less to pay for it.
From what I see almost everyone in this totally vulnerable population are Exchange eligible from Day 1, individuals and employers in ’smallest employers’ can enroll right away. Moreover so too can uninsured or underinsured individuals who work for ’smaller employers’ or ‘large employers’. This may not add up to ‘most’ Americans but Ezra’s claims that it is just a small pool seems odd to me. For example if we took a look at the CBO score of HR3200 from July 14
http://3.bp.blogspot.com/_fjW7…..h+pg.1.jpg
we see that by the end of 2013 11 million people are expected to be enrolled via the exchange, another 10 million newly covered by employee coverage enabled by the plan, and 6 million newly enrolled in medicaid/SCHIP or fully half of the otherwise projected 52 million uninsured. Two years later the Exchange is projected to cover 27 million all on its own with overall coverage of the legal non-elderly population at 97%. How exactly is this in any real world sense ‘limited’?
I understand that Ezra is young, I have t-shirts literally older than him, but come on 97% coverage by 2015 is pretty damn impressive.
Sacrecrow, I agree that we have a unity problem.
If we all united behind Medicare For All and created a real stink, there’d be a lot greater chance of getting a public option comparable to Jacob Hacker’s original proposal out of the opposition. I’m one Medicare for All, advocate who’d be willing to settle for a good public option, if if that were all we could get after fighting the good fight, as it were.
But having been cut off at the knees, before the fact, by folks who evidently made the abstract and intuitive judgment that Medicare for All couldn’t be sold, even though they agreed that it was the best alternative solution, and then presented the rest of us with a public option as a fait accompli for the progressive movement to support, I’m now angry and resentful at the premature compromise that a public option represents. I think many other Medicare for All supporters feel the same way.
Progressives could be re-united if public option supporters joined us in one great effort to get Medicare for All. If that failed to mobilize the popular support to get it through, then I think we’d be ready to mobilize in back of a good public option; but not HR 3200, which makes it very hard to see a pathway even to Hacker’s original public option, not even to mention a pathway to Medicare for All.
That Bill needs to be amended to implement the exchange and the public option by next fall, and that public option has to use Medicare rates, and has to be able to use Medicare’s provider network. And if we do agree to the limited eligibility in HR 3200, we need the Secretary of HHS to be able to extend eligibility by 2011, not 2015. Progressives in Congress should not agree to anything less and should also insist on the Kucinich Amendment.
Good luck.
But one thing you have to realize. No matter how much Medicare for All makes sense from a national perspective, no matter how much it would actually save this country over both the medium and long term it will score very, very crappy under CBO scoring methods. Like trillions of dollars crappy. CBO simply refuses to include third party savings say to employers and individuals.
I want to get to Single Payer but under current political realities and the current blinkered way in which CBO scores such things you run right up against various Pay-Go limitations that Congress has bound itself with.
Yes this is a frustrating and mostly artificial limitation. But there it is.
Right So why have we already compromised by pushing the public option? Why not just back Medicare for All and leave the compromise to the politicians. It’s their job to judge what’s politically feasible, at their peril. Iyr problem is that we’ve been letting them tell us what’s on the table, rather than our telling them what’s on it.
Thanks for the good wishes, Bruce. Good luck to you in getting HR 3200 to work.
I understand the problems with Medicare for All you’re citing, but problems like these have a way of disappearing when political demands become overwhelming. The scenario I’ve been defending is one in which we develop a mass movement around Medicare for All; one strong enough that politicians will be afraid to vote against it; afraid to interpose “pay-go,” afraid to talk about “current political realities.
Why? Because those political realities will have changed. And in the new ones, Congress can ask CBO to score savings to third parties and individuals, and to the economy at large and can change the meaning of “pay-go” to something far more rational.
Bruce, the need to get this into operation is urgent. All your time periods and deadlines are arbitrary and out of thin air. In context they are unreasonable, because people need that public option to start working, and the Government needs to find a way to het it done. One year from the date of passage of the bill, given current computer resources is plenty of time. Get Howard Dean to do it. A year will be plenty of time for him.