Liberal Values Defending Liberty and Enlightened Thought

The question in reforming health care increasingly appears to be not whether to get the government involved but deciding on which plan to adopt. Jacob Hacker has written a proposal based upon expanding Medicare. The plan would allow all Americans to buy into Medicare and require employers to either provide coverage of equal quality or pay into a fund which would be used to cover the employees. I have posted a portion of the information on his plan below the fold.

Hacker is realistic in admitting that “Health Care for America is not single payer—a vision that, for both political and budgetary reasons, is unlikely to be achieved in the near future.”

Ezra Klein calls this “Medicare for Many” as opposed to Kennedy’s “Medicare for All.” He finds some virtues in the proposal:

You’ll notice that, unlike the other plans, Hacker’s took four sentences to explain. It’s a simple, elegant mechanism for coverage, requiring none of the complex market restructuring and odd coverage schemes of the plans that seek to preserve the private insurance market as a protected whole. Its secondary virtue is that it offers an easy, potential path to effective single-payer, allowing the government insurer to compete with private insurers, and possibly outcompete them as well.

Other liberal bloggers are not as happy. GoozNews fears the plan does not do enough for cost containment. MyDD calls this half a loaf and isn’t satisfied with anything short of single payer universal coverage:

Opposition to single-payer health care and muddled plans like this one or the Wyden one will be the same in intensity. And this one is weird and complicated, like every other plan that isn’t single-payer. This is an issue for the voters. We will have to go to the voters and basically ask them to vote to end the health insurance industry. Barring that, and you’re just not serious about universal health care.

This illustrates why, with all their problems, Republicans win so many elections. Regardless of the faults of any industry, Americans who have grown up under free enterprise are not going to go along with the idea of voting “to end the health insurance industry.” The reason is simple. Voters will substitute their industry for “health insurance” in this phrase and realize that any vote to end an industry has dangers.

The question is whether the goal is to solve problems or achieve ideological purity. Hillary Clinton convinced Bill to agree to veto any health care proposal that Congress passed which was not 100% universal coverage. This was a foolish use of the veto, which should be reserved to stop bad laws and not to prevent laws which simply they do not believe goes far enough. The consequence is that we got nothing, and this will be the result of continuing to demand 100% ideological purity in any proposed plans.

Before the 2004 election John Kerry proposed a plan that preserved choice while providing care for most Americans which The National Journal ranked as best health care proposal among the candidates. For a while I answered questions on health care in the campaign’s official forum. Obviously some who objected were conservatives who would not agree to any new government program, but many people were interested but had concerns. One of the most common questions people asked is whether they would be able to keep their current insurance or would be forced to join a new government program.

Opposition to new government health plans isn’t limited to those who might be harmed financially, but includes a large number of voters. Perhaps they would be better off in a single payer program that would be more cost-effective, but that is not what they currently desire. Ezra is on the right track when he sees such plans as an “easy, potential path to effective single-payer.” Allow people to buy into Medicare (and perhaps the programs now insuring Congress as Kerry proposed), and include ways to make it easier for individuals and small companies to pay for the coverage when necessary. If Medicare can really provide care more economically than the private plans it will evolve into something close to a single payer plan without forcing people to decide. Instead of being eliminated by law, insurance companies will only be eliminated if they cannot compete.

Update: More discussion at The Reality-Based Community

Following is a portion of Hacker’s description of the plan:

Health Care for America embodies this strategy. It would extend insurance to all non-elderly Americans through a new Medicare-like program and workplace health insurance, while creating an effective framework for controlling medical costs and improving health outcomes to guarantee affordable, quality care to all. It is at once comprehensive, realistic, consistent with American values and beliefs, and grounded in the best elements of the present system. It combines employer and personal responsibility with a strong public commitment to ensuring that American workers and their families and American employers can afford coverage. It promises better care, lower costs, more choice, healthier citizens, and immensely stronger guarantees for workers and their families. And it promises real savings for employers and state governments—without un-raveling existing sources of health security, without forcing workers to obtain coverage on their own, and without pressuring patients into Health Savings Accounts or tightly managed health maintenance organizations (HMOs).

What Health Care for America would do is simple: every legal resident of the United States who lacks access to Medicare or good workplace coverage would be able to buy into the “Health Care for America Plan,” a new public insurance pool modeled after Medicare. This new program would team up with Medicare to bargain for lower prices and upgrade the quality of care so that every enrollee would have access to either an affordable Medicare-like plan with free choice of providers or to a selection of comprehensive private plans.

At the same time, employers would be asked to either provide coverage as good as this new plan or, failing that, make a relatively modest payroll-based contribution to the Health Care for America Plan to help finance coverage for their workers. At a stroke, then, no one with a direct or family tie to the workforce would remain uninsured. The self-employed could buy into the plan by paying the same payroll-based contribution; those without workplace ties would be able to buy into Health Care for America by paying an income-related premium. The states would be given powerful incentives to enroll any remaining uninsured.

Equally important is what Health Care for America would not do. It would not eliminate private employment-based insurance. It would not allow employers to retreat from the financing of a reasonable share of the cost of health insurance. It would not leave Americans coping with ever-higher private insurance premiums with an inadequate voucher, or pressure them to enroll in HMOs that do not cover care from the doctors they know and trust. It would not break up the large insurance groups in the public and private sectors that are best capable of pooling risks today. And it certainly would not encourage individualized Health Savings Accounts that threaten to further fragment the insurance market and leave Americans even less protected against medical costs. Instead, Health Care for America would preserve what works in American health financing and replace what does not—through a simple yet comprehensive strategy that holds out the best promise of controlling costs, improving quality, and guaranteeing health security.