Obama's Plan for Not-Universal Health Care

Barack Obama unveiled a health care plan today, and the most misleading part of the AP story is the title, which claims that it's a universal plan. Ezra Klein explains that it's not.

Mandates: I want to be very clear on this point. Obama's plan is not a universal plan. After it is implemented, it will not have 100 percent of the population covered. It will increase coverage by forcing some employers to begin offering insurance, but it is not particularly heavy-handed even there. This is a plan that makes universality possible -- that is budgeted for 100 percent coverage -- but does not use a government or individual mandate to force global buy-in.

This is why a lot of us think that Obama is wary of transformational change, while willing to attempt to take incremental steps. There is no individual mandate, and considering that this doesn't get rid of the insurance companies that's probably a good thing. But without some mechanism for insuring universal coverage, you're not going to add to the risk pool, which is the best way to reduce health care costs. Obama's plan tries to create the conditions for universal coverage - by offering reform in the insurance system to make it more affordable, requiring employers to pay a little more, and setting up a parallel government-based system (The National Health Insurance Exchange) to take care of the unemployed or self-employed.

The thinking goes like this: You need to get the system set up for universality before you actually demand it -- lest you find coverage remains too expensive, or too inaccessible, for some. So the hope is that by reforming the system, you'll be able to create universality softly, by just making coverage accessible and cheap. If not, the Obama campaign swears up and down that they're committed to 100 percent coverage, and if that means a second round of coverage-increasing policies in a few years, so be it. I don't particularly understand the thinking here, but the end result is this: The Obama plan will not bring us to 100 percent coverage in the short-term. It just won't. But it will take us much further along the road, ensure full coverage for all children, and create a system in which mandates could be more easily added later on.

This is more like a "double-payer" option. It preserves the current broken health care system while trying to regulate it. And then it sets up a second system, a public one, that targets specific groups of people:

The Public Option: Unlike in the Hacker or Edwards plans, the public option is not a general purpose insurer. Major companies cannot choose between insuring their employees on the private market and buying into the national program. Rather it is an insurer of specific groups, in the way Medicaid covers many of the poor, or SCHIP is targeted at children. In this case, it's looking at small businesses, the self-employed, the unemployed, and those employed by companies who don't offer insurance.

All of these programs (even the Edwards one, which I essentially like) are very complicated because they seek to preserve the current system and build upon it, instead of very easily saying "everybody gets health insurance paid through taxes" and end it at that. This is pragmatic, because removing an enormous industry from the United States is unlikely. I like the Edwards plan better because it uses a free market model to put the private and public plans in competition with one another, and my belief is that will bring about the end of the for-profit insurance industry because people could choose a plan that values health instead of profit. Hillary's plan is probably the worst of all of these, because it focuses on incremental things to make the current health care system more affordable, like a "prevention initiative" and changes to the medical malpractice system. As a caveat, she claims that it's just the beginning of a rollout, so comparing her plan to the comprehensive ones of Obama and Edwards is a bit unfair. But nobody's being truly bold and favoring a full single-payer system. I think that's actually almost too bold to be done at the federal level, at least at first, which is why I support the efforts of Sheila Kuehl to make SB 840 a reality in California, where it can be a model for the nation.

So to sum up, Obama's plan is not as good as Edwards', better than Clinton's (so far). And Ron Wyden, who has his own plan in the Congress, criticized it. Nobody wants to be truly bold, however, and go after the system as a whole.