Ezra,
As far as the single-payer lite is concerned, I'd quote Tom Hanks from A League of Their Own, "There's no crying in Capitalism."

A better alternative would be to remove whatever artificial barriers are preventing private insurers from having the same bargaining power as Medicare. To the extent that universal health care is subsidized, you give consumers the choice to apply that subsidy towards a private plan. If they can do better, there's no reason that this wouldn't lead to insurance company consolidation that could compete with the public plan. Ideally, you'd do away with state-by-state regulations as well in favor of a uniform standard. Any idea as to how that'd increase efficiency?

So how will Obama's plan bring down costs if it settles for the level playing field public option? Will the comparative effectiveness board he has proposed and the lower overhead costs of the middle-ground public plan be sufficient?

Since they've made a decision to make rising costs the center-piece of their argument for reform, it seems to me they would be better off going with the option that would have the strongest impact, Single-Payer lite.

The liberals need to start hammering on the republicans for taking away choice. After all they don't want people to be able to choose a public option. Framed like this the pro public plan argument is straightforward and elegant whereas the anti public plan is complex and sounds bad. Sort of efca in reverse. It's a winning argument for the dems if they learn how to coordinate and hammer the message. I won't hold my breath.

What I wonder about the public plan is that two techniques private insurers use to hold down costs are to cherry-pick and to make life hell for anyone who files a claim, neither of which the public plan will do. That being the case, won't the public plan be more expensive than the private plan?

I guess you need some cost-control mechanism. Without cherry-picking, hell-life-making, or single-payer, what do you got?

In theory, my favorite cost-control mechanism is to compensate providers in a lumpish-sum for their fixed costs, and then make the marginal cost of health care cheap for consumers.

An example of this, I guess, is one aspect of the UK system. The UK system is notoriously cheap, yet people in the UK can visit their primary doctors as many times as they want. The number of visits remain manageable probably because going to the doctor is not a desirable thing to do, even if it's free.

In the realm of drugs/biotech, the high-fixed cost, low-marginal cost policy might be something like the Dean Baker's et al. prize proposals.

If you download the CAP Harbage/Davenport report, and scroll down to the section "Efficiency and service instead of risk-segmentation", they *discuss* the issue of risk segmentation, but they don't really *address* the issue. To wit:

". . .To date, risk adjustment has been hard to design and hard to implement, both technically
and politically, as we’ve seen in Medicare. That means any new rules will likely always fall
short of fully protecting insurers that offer particularly good care to particularly expensive
patients at the onset of the implementation of Public Plan Choice. Yet Public Plan Choice
can create a safety valve for imperfect rules aimed at managing risk by its ability to take on
high-risk patients who choose the option. At the same time, though, a public health insurance
plan within a health insurance exchange cannot be allowed to become a “dumping
ground” for high-cost patients.

Still, the very availability of Public Plan Choice will help spread risk among plans, just as
existing public coverage efforts such as Medicare and Medicaid do today. Case in point:
Medicaid takes responsibility for certain low-income patients with special needs that
would not ever be offered affordable health insurance on the individual market—if they
were offered insurance at all."

apologies for length

In answer to this, Len Nichols proposed a public insurance plan that doesn't have access to Medicare's bargaining power, and this is the policy that CAP's paper advocates.

Why would any progressive policy organization advocate a public option without "access to Medicare's bargaining power?"

I could understand, say, secretly being prepared to accept this as not-completely-horrible compromise if the political winds ultimately don't prove sufficiently strong in our favor. But publicly advocating eschewing the power of the public sector to keep costs down? Wow.

I guess if we pretend your options are the only reasons then sure. But the other possibility is what it does for openning the door. That's the game changer. The GOP has said as much. But, hey, they got people like you to argue about the leaves on the trees while others are thinking about the forrest.

Ezra,

I'm all for people learning more about health care reform, and subsequently changing their opinions, but its time for a little real "pundit accountability."

Here is you now:

The single payer lite version is worth fighting for. But it will face much the same political problems of, well, single payer. Republicans may not be very good at writing budgets, but they're not stupid. The Left isn't going to open Medicare without anyone noticing. So there seems, in recent weeks, to be a strategy to redefine success as the level-playing field plan.... There are a number of industry concessions that would be more powerful than a neutered public insurer, including systemwide integration or comparative effectiveness that could be used in purchasing decisions."

Here was Ezra Klein, circa 2007.

On Hillary's plan:

More importantly, the plan also creates a new public insurance option, modeled off, but distinct from, Medicare. That's a big deal: The public insurer offers full coverage and is open to all Americans without restriction. Public insurance is what I feared her plan would avoid, and instead, she embraced it wholeheartedly.

On Edwards' plan:

Where the Edwards' plan takes a big step forward is in mandating, along with the private options, that HMs offer "at least one plan [that] would be a public program based upon Medicare." And the intent is explicit: "Health Markets will offer a choice between private insurers and a public insurance plan modeled after Medicare, but separate and apart from it. Families and individuals will choose the plan that works best for them. This American solution will reward the sector that offers the best care at the best price. Over time, the system may evolve toward a single-payer approach if individuals and businesses prefer the public plan."

In other words, the public sector will finally be allowed to compete with the private sector, and consumers will be able to decide which style they prefer. For Democrats, this is a significant step forward.

Krugman on Ezra:

The Edwards and Clinton proposals actually include a public option — that is, people can buy into a Medicare-type plan administered by the government. They are not forced to go to private insurance companies. In fact, the public option was what originally made people like myself and Ezra Klein enthusiastic about the Edwards plan.

On Obama's plan:

If the public insurer is confined to currently disadvantaged groups, it will be considerably less transformative than if it's an across-the-board option. And how it's funded, how much premiums are, and what percentage of payroll employers would pay in decides how likely it is to emerge a viable alternative option. But for now, this doesn't look like backdoor single-payer in quite the way the Edwards or Hacker plans do.

You're free to say that you were wrong back then, and that "systemwide integration" and "comparative effectiveness" should have been the metrics that you should have evaluated the plans back in 2007, rather than a focus on the public option. But it'd be nice to see some accountability on the issue. You were either wrong before, or you think a "single-payer lite" public option should be a line in the sand-- a line you criticized Dean on yesterday. It just feels like a little too much shifting by you according to the current Democratic CW, it'd be nice to see you actually take a stand. The public option used to be an important element of a health reform plan to you back in 2007 (unless Krugman also misunderstood you), now not so much. You're on to the new buzzwords, like comparative effectiveness. It feels a little too much like you're making it up along the way.

Would you like to go to a private swimming pool on a hot day or a public pool?

Would you prefer your children attend a public school or a private school in order to get a first-rate education?

Why would anyone believe that government-run public insurance will not follow the same pattern of other public services?

So in Ezra's opinion, we are really left debating the inclusion of two other "public" schemes, which he labels "The Level Playing Field Plan" and "The Catch-All", both of which he correctly identifies as being meaningless to real reform. Since these "single-payer" compromises are meaningless, he's willing to forgo them --especially the debate over them.

Ezra's just telling us that --inexplicably-- there will be no "true, relatively unrestrained, public plan" up for consideration, and so defining reform in terms of a lesser option is a mistake, and politically counterproductive...and he's absolutely right.

For example, look at how he describes this horrifying compromise "The Catch-All":

• The Catch-All.

I've heard that the insurance industry and some advocates are interested in a compromise that looks a lot like Medicaid choice. Here, you'd have a public insurance option, but only for people making under a certain income level. It's a way of folding Medicaid into the new system. .
Absurdly casual anonymous sourcing aside for a moment, this is the worst f*cking idea I've ever heard of. This isn't a compromise, it's guaranteed suicide and perhaps repeal.
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Let me explain why, because it fits into why I disagree with this un-clarified premise: "...subsidies, Medicare's negotiating power, delivery system reform, comparative effectiveness, and system-wide integration are probably much more important than a public insurance option".
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You see, if one were to (essentially accuse me of purity trolling) describe the debate in terms like "what good does your principled stand get you?", one would miss a great deal of the argument for the public option in the assumption that this is all about ideology, and not about practical politics. I think that the politics before the passage of Health Care Reform is of equal or even lesser importance than its politics after it gets done.

You see, this is Obama's Iraq war after 9/11. In the year after the most terrifying economic conditions the country has faced in three decades, the level of economic insecurity in this country combined with the enormous popularity of the man (and the low popularity of Congress) and the high level of popularity of the idea itself virtually guarantees that --short of some unforeseen disaster-- we will see Health Care Reform, this year, from this Congress. We will get Health Care Reform.

The question is: will the American public like it or will they hate it? Will it be Social Security, or will it be Prohibition...or, more accurately, the Great Society Welfare State?

Unfortunately, the answer that question depends a lot on factors having to do with the actual value of the plan, and not so much to do with the things that make it a sale to Bryan Dorgan or Kent Conrad --the factors that sell the bill before passage.

The best case scenario is that we get Social Security II: the victory that guarantees the Democrats something to run on for the next half a century, the program that lifts ordinary Americans out of the terrible insecurity that faces every one of them, red, blue, whatever. There will never be a repeal of Social Security --it works too well, it actually delivers what's promised. It's not perfect, but its crucial to the lives of so many. It provides confidence to the American public about their personal futures in way that no other program --even defense spending-- can. Social Security is popular because Social Security works for the country.

Part of the reason why it works so well is political. It is because there is no means-testing: if you are an American, you get it. It is truly mandated retirement insurance. Nobody gets more than anybody else, nobody pays an unfair share, everybody collects. It is telling that the most effective arguments against Social Security (the "fix it now before it's too late" claims) have been effective precisely because they argue that people tomorrow won't get what people today enjoy. The argument against is an argument for equal treatment.

The worst case scenario is that we get Great Society welfare. Welfare. The worst case scenario is a well-working program that everybody has to pay for, but that some people get at low cost or for free, while everybody else gets to keep what they already have. That's f*cking suicide in ten years. That's death. That's another politician like Clinton coming along in a decade after Republicans gain power again, and running on "changing health care as we know it" or "work for health care".

In the list of these factors: "subsidies, Medicare's negotiating power, delivery system reform, comparative effectiveness, and system-wide integration", the most important to providing the actual benefits of the program is this subsidies.

Without subsidies, this doesn't fly. Unfortunately, "subsidies" translates to the thing that everybody hates about public programs and bureaucracies in the US: means testing. It means filling out forms, providing proof of income, and jumping through all of the hoops required to get the government to help you when you're getting welfare. The worst part of welfare isn't even for those who need it, it's for those who don't.

We have not made the leap in this vast, mind-bogglingly heterogeneous country to embracing the presumed good faith of our neighbors, the way countries like Korea and Sweden do naturally --because they are essentially of the same ethnicity and culture. When people pay for help that other people consume, and that they themselves do not have access to because they're not poor enough, we have the opposite of social security, and we have a perpetual populist tension with the program that will turn out to be political death. If "Health Care Reform" turns out to be something that only other people get, it will be gone or effectively gone in ten or so years like Prohibition --or subject to a 30 year killing fields backlash like the Great Society.

The only way out of this trap is to provide a public option to every single American taxpayer. The only way to avoid setting classes of people --and let's face it races of people-- against each other, and getting ourselves right back into the "welfare queen" and "undeserving underclass" battles again, is to institute the policy in such a way as to allow everyone to buy into it, regardless of income --just the way that Social Security operates.

Plus, it will actually transition us off of this horrid, inefficient, grossly expensive and unfair system sooner. Everyone in this debate presumes, overtly or covertly, that the public option will eclipse the private options for a majority of Americans, and this is because it will work.

There will not be another chance for another 8 years.

If we fail to do this now,in the moment in which we have the most leverage, the most political capital, the most popular support for the program (73 percent support the public option), we will not get another chance to enact Social Security II.

If we fail to include a real public option, we are simply setting ourselves up for what happened over time to Lyndon Johnson's Great Society welfare state: a populist-based rightist backlash. That's why we must pass Health Care Reform this year --but it must be real Health Care Reform that includes a true public option, otherwise it is just Health Care Welfare.

"Why would anyone believe that government-run public insurance will not follow the same pattern of other public services?"

Plenty of public services are run extremely well, just as, (witness our current economic mess) plenty of "private sector businesses" are disastrously run.

That's an annoying non-argument. I like KJ's point that we should be hammering on the republicans for taking away our choice. I WANT A PUBLIC OPTION - why can't I have it? A lot of taxpayers want that option. All you folks out there who are so worried about losing your private insurance can just keep it - why should you be able to keep me from buying into Medicare if I want to? If you're so convinced that the private system as a priori better than what are you worrying about? All you superior folks can just keep paying through the nose to support the Executives and Marketing Budgets of your beloved private plans, and I'll pay into Medicare (or equivalent) and take my chances there.

I think here's a conceptual problem with all of this - these questions of "uses Medicare's power to negotiate subsidies" etc is kind of meaningless - Medicare is the de facto pricing power across healthcare now, establishing reimbursement rates for services used. I'm guessing what people mean is that the "public plan," like Medicare, would be able to restrict doctors and hospitals from billing above the reimbursed rate... but Medicare already doesn't cover everything patients need or doctors do, so... does the "public plan" offer more coverage than Medicare, or does it create, as Medicare does, the need for a "supplemental policy" (which, maybe, is why AHIP thinks a public plan, in any form, works in their favor)? And keep in mind, this attempt to keep reimbursements artificially low isn't a problem for insurers; it's a problem for caregivers, and for people in private insurance plans that don't pay much above Medicare rates, who are the expected to cover the difference. I think way too much energy is being expended on "the importance of a public option" and it's creating an artificial sense that the battle to be won is on this issue; the real battle is a) figuring out how people just above poverty will pay for a policy (i.e. people who fall between fully subsidized Medicaid and people who are either in employer subsidized plans or can pay their own way), and B) how we will deal with a system where everyone may be on the hook for additional, uncovered charges their insurance won't pay for.

Also, someone may want to ask... when we can't seem to pay for Medicaid now (never mind Medicare), or use Medicaid to actually provide enough care for everyone in poverty, isn't there a real question of how a "public program," that increases the number of people dependent on government financing for healthcare, can be covered?

I think the overarching desire to "stick it to private insurers" is clouding the ultimate goal: increasing access to good, affordable care (and probably, really, good basic care without a lot of add-ons, just to be realistic). It strikes me as a given that we will need some sort of subsidized, "public" option to deal with the fact that without it we can't achieve full coverage; and yes, the deatisl amtter... but they are not, really, what makes or breaks changing healhcare. The real challenge - which the "public program" debate neatly avoids - is the hard parts of cost control: limiting excessive, wasteful and needless procedures, and working harder to rein in hospital and doctor fees. Saying that the program will "work like Medicare" isn't doing something about cost... it's expanding a problem Medicare already creates.

"Would you prefer your children attend a public school or a private school in order to get a first-rate education?"

Where I live, I'd much rather send my kids to the public school for a first-rate education? Why? Because my district actually places a premium on excellent schools. Why is it that people seem to think that profit motive suddenly makes all things wonderful?

The real challenge - which the "public program" debate neatly avoids - is the hard parts of cost control: limiting excessive, wasteful and needless procedures, and working harder to rein in hospital and doctor fees. Saying that the program will "work like Medicare" isn't doing something about cost... it's expanding a problem Medicare already creates.

Thank you weboy, it is so refreshing to hear some sanity amongst the echo chamber of "blame the greedy insurance companies". It's infuriating to me how often people will cite the results of surveys showing that Americans favor a public plan, or single-payer, when so few people actually understand the difficult parts of reforming health care and just want a villain to blame it on.

Would you like to go to a whites-only swimming pool on a hot day or a mixed-race pool?

Would you prefer your children attend an integrated school or a whites-only school in order to get a first-rate education?

The single payer lite version is worth fighting for.
No, it isn't.

But it will face much the same political problems of, well, single payer.
Much better to just go ahead and fight for real true single payer. I'm for HR 676, but Bernie Sanders has a single payer bill in the Senate now.

Also worth throwing in that we could end up having a lot of state-by-state variance. Remember that reform is no doubt going to require states like Alabama, Mississippi, and Texas to vastly expand their Medicaid to catch up with places like Massachusetts and Vermont. If it becomes a political selling point to ease the financial burden on different states somehow, it could end up looking rather patchwork depending on how that happens.

Nice point Thomas... and it's also worth keeping in mind that states like Mississippi and Texas not only don't want to expand Medicaid... but they will insist on a lot more money to do it if that's what's required of them.

Seems to me that we should be going for the full public insurance plan option. Compromising with ourselves before this even happens seems like a weak way towards getting what you really want.

I also don't like the term "single-payer lite," as if this is some weak attempt at single payer. Its a free access option to a public plan. There is no single payer, because there are many other options available. Single payer is a stigmatized term and using it will only hurt the argument for the public insurance option.

Some time in the last two years, the organizations in and around Health Care for America Now decided two things: 1) Democrats must deliver something real in the way of health care reform at the next available opportunity and 2) the preferred policy of the activist base, single-payer, is a political impossibility in that immediate time frame.

So they developed a campaign plan that would harness the energy of single-payer advocates to win a public insurance option as part of a reform plan that largely leaves private insurers and employer-tied insurance in place. Single-payer advocates were sold on this effort (by Ezra, among others) on the basis that the public option would be a possible path to full single-payer in the future.

Now the Center for American Progress, the liberal think tank that is HCAN's closest connection to the White House, comes out for a public option that is much weaker and is very unlikely to be a possible route to single-payer in the future. (Even Ezra doesn't believe it is, though he might pretend to be convinced of it any week now, since he's now purporting to be surprised that Howard Dean has made the public option the focus of DFA's mobiliation on health care.)

Who's zooming who?

I hadn't noticed this critique earlier, but I don't think my opinions on this have changed. The public insurer remains separate and distinct from Medicare. It isn't Medicare. It covers prescription drugs, for instance. And in those bills, the expectation was that it would use government bargaining power, which is why I supported it.

I hadn't noticed this critique earlier, but I don't think my opinions on this have changed.

Ezra,

Which is it-- is a single-payer lite option important to health reform or not? You now seem to be saying that single-payer lite is near impossible politically, and the other variants aren't as meaningful.

Hence your statement now:

explaining my doubts about this debate's importance to health reform.

But if you're willing to dismiss single-payer lite now, why was it important during the election? How can you chastise Dean, when he's pushing for precisely an element that you felt was important during the campaigns?

What El Viajero Really Means

When you have no evidence and more importantly, nothing to say other than that to HATE on those who you do not agree with....do what this drunk in Philly does.....except don't sexually abuse your little boy, as he does.

Here's one problem to creating a "level playing field" and I can only speak to our experience here in Vermont.

Because of our generous eligibility rules, more than 20% of Vermont's residents are on our Medicaid program which has, I believe, one of the lowest reimbursment rates in the country - 56% for hospitals. This means private insurers pay for almost half of total hospital expenditures for Medicaid! It has been variously estimated that this adds 10-20% to private insurance premiums. In order to "level" the playing field any new public program would also have to pick up a portion of that cost.