September 19, 2007
Clinton's Plan Is Not the Slippery Slope to Single-Payer
Maggie Mahar, author of the excellent "Money Driven Medicine" who is now with the Century Foundation, has a posting over at TPM Cafe on Sen. Hillary Clinton's health care plan that suggests the Medicare-like default option in the proposal will put the government in head-to-head competition with the private sector, and that the public sector's efficiency and lack of profit motive will win the day.
She writes:
The Clinton plan emphasizes choices: Americans can a) keep the insurance they have now, b) buy a new plan from a for-profit insurer, c) pick a plan from the same menu of quality private insurance options that their Members of Congress receive through a new Health Choices Menu (FEHBP), OR d) choose a public plan option similar to Medicare.This is the exciting news: under Clinton's plan Medicare would be competing with for-profit insurers.
Sorry Maggie. Where's the evidence that people will opt for the government plan? If the uninsured are adequately subsidized to go into insurance-company provided FEHBP-type plans, why would they opt for the default Medicare-like plan? It will probably be limited to the core benefits that every insurer will have to provide.
In theory, people would opt for the government plan if it was cheaper, which it no doubt will be. But the price mechanism only goes so far in health care. Medicare or the "plan similar to Medicare" that Sen. Clinton mentions won't market itself to patients. Physicians won't be whispering in their patients' ear: Psst, why don't you join the default plan? And while some employers may encourage their workers to choose one of the public alternatives (and go to the "pay" side of "pay or play in the plan), why wouldn't their employees choose Kaiser Permanente (one of the FEHBP alternatives) instead of an expanded Medicare, even if it costs a little more? Public sector programs, sad to say, have an image problem in this country.
I just don't see Clinton plan as a slippery slope to single-payer. Nor, it should be pointed out, does she. "We looked at every permutation of how you get to universal health care," she told the Wall Street Journal yesterday. "There's great attachment to the employer-based system, even though it is eroding."
By contrast, the plan offered by Yale political economist Jacob Hacker had just one insurer -- the government -- for the uninsured and for employers who wanted to buy their way out of employer-based coverage. That single government-run plan would provide the mano-a-mano competition that private insurers need.
Medicare consistently scores the highest satisfaction ratings among beneficiaries. There's no reason to think that a government-run plan for the uninsured wouldn't rack up similar high ratings, while providing lower cost and more efficient coverage.
That said, the liberal in me likes Sen. Clinton's plan a lot. Getting everyone insured in the end is about the politics of neutralizing the special interests who run this country, and run the health care system with a vengeance. Her plan has been carefully crafted to neutralize as many of those special interests as possible. A Hacker-type plan would bring back Harry and Loise.
I'm starting to buy her "I have the arrows in my back to prove it" argument that she's the one who can get the job done. Maggie, you and I will be be arguing about the quality of care and its inordinate cost until they lower us into our graves. Better we should be having those arguments with everyone insured.
Posted by gooznews at September 19, 2007 01:59 AMDear Gooz--two questions come to my mind:
1. What is the difference between "neutralizing" the opposition and catering to them? Hillary seems to be doing the latter.
2. "Getting everyone insured" does not really mean that much; it means everyone pays for a health plan, but it doesn't say anything about the coverage. Isn't it also important to scrutinize exactly what sort of system Hillary et al are proposing?
-MTMS
Posted by: mtms at September 21, 2007 10:23 PM Hillary's plan says that all of the choices on the menu must offer coverage equal to what Congressmen have now. So I assume that the "medicare-like" plan will not be a bare-bones plan, offering limited coverage--it will offer rich, comprehensive coverage.
Meanwhile private insurers will have to offer equally comprehensive coverage--and they won't be able to cherry-pick by turning down people who are sick, or charging them more.
This seems to me to put private insurers on a level playing field with Medicare--which has lower administrative costs and no need to make profits--which should allow it to offer more coverage for less.
Merill,you suggest that even if the "medicare-like" plan is less expensive, people won't opt for it because "Public sector programs, sad to say, have an image problem in this country."
You are right that many public sector programs--including Medicaid--have an image problem. But Medicare does not. No one thinks Medicare is perfect, but most middle-class and upper-middle-class people in this country are happy when they finally turn 65 and are safely on Medicare.
Moreover, many doctors prefer Medicare to private plans. In many cases Medicare pays somewhat less but it pays on time (private insurers play games, playing the float with reimbursement money for 90 days), and it pays without requiring the doctor to make three phone calls to convince someone that it's okay to hosptialize the patient.
The doctor knows what Medicare covers--the rules are clear. Finally, the forms that he needs to submit in order to get paid are clear. Private insurers, by contrast, all use different forms thatare filled with little twists and turns that encourage mjistakes. Make a mistake and you're not reimbursed--you have to resubmit the claim. This is why physicains have to hire somebody just to learn all the twists and turns, submit them, then re-submit them. The cost of providing that person with a salary and benfits easily wipes out the advantage of being paid a little more, per service, by the private insurer.
So if I were a doctor, and a patient asked my advice, I would urge him or her to choose the "medicare-like" option.
There may be something I'm not understanding about Hillary's plan, but if I have it right, it really is opening a back door to single-payer. And the beauty of it is that rather than decreeing a single-payer system, it lets people
choose a single-payer system. . .
.