Posted by: Jeff | December 21, 2009

Still A Believer

Of course the week in which I go incommunicado to visit friends over Christmas turns out to be the week when health care reform’s fate was more or less decided. The big news, certainly for progressives and others of us on the left, was the necessity of killing the public option in order to corral 60 votes in the Senate.

Long time listeners will recognize the name Jacob Hacker from our two-part podcast on the public option. He was the man who essentially came up with the policy, and he deserves a good deal of credit for pushing it into the mainstream of the American political discourse. So it’s worth pointing out that, in spite of the death of his brain child, Hacker remains convinced the Senate bill is worth passing.

The public option was always a means to an end: real competition for insurers, an alternative for consumers to existing private plans that does not deny needed care or shift risks onto the vulnerable, the ability to provide affordable coverage over time. I thought it was the best means within our political grasp. It lay just beyond that grasp. Yet its demise–in this round–does not diminish the immediate necessity of those larger aims. And even without the public option, the bill that Congress passes and the President signs could move us substantially toward those goals.

As weak as it is in numerous areas, the Senate bill contains three vital reforms.  First, it creates a new framework, the “exchange,” through which people who lack secure workplace coverage can obtain the same kind of group health insurance that workers in large companies take for granted.  Second, it makes available hundreds of billions in federal help to allow people to buy coverage through the exchanges and through an expanded Medicaid program. Third, it places new regulations on private insurers that, if properly enforced, will reduce insurers’ ability to discriminate against the sick and to undermine the health security of Americans.

As Hacker goes on to argue, with the public option now behind us, the portion of health care reform most critical to left/progressive goals are the insurance exchanges. (Arguably, they were the most critical part even when the public option was still alive.)

The exchanges have the potential to meet the same ends for which the public option was meant. If enough Americans are able to access them, and if they operate over a great enough regional area, then the exchanges will provide an economy of scale, and an influx of competition, that should bring costs down in the same manner as the public option would have. (It’s also worth mentioning that there were many forms of the public option, and the forms most likely to provide robust competition were eliminated from the realm of the politically possible long before we reached this point.)

Currently, the Senate bill’s exchanges operate mainly on a state-by-state basis, while the exchanges in the House bill operate on the national level. The latter is obviously much better, so which iteration triumphs in the merger between the two bills will be of critical importance. How many Americans will be able to access the exchanges also remains up in the air. These are two points I hope to post about more after the holidays.

And, of course, since the House bill also contains a public option, the final conference between the two houses of the legislature may yet resurrect that policy as well. But the Senate is the choke point here, so I wouldn’t hold my breath.

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