Health Care, Progressive Action and the Myth of Bipartisanship

This was the weekend when the make-or-break battle for health care reform that may define the fortunes of the Democratic Party for the next several decades began. The President signaled a willingness to get more involved. Citizen town hall meetings were held all across the country. More engagement from Obama is expected, with the public and inside the Capitol.

However, from the policy side, the more significant action came from the Progressive Caucus on Friday, when they mapped out their principles for a public option, and the bare minimum such an option must include to get their votes. Most importantly, they demanded that such an option not be conditioned to a "trigger", and not enacted unless insurers don't meet certain requirements.

The Congressional Progressive Caucus calls for a robust public option that must:

Enact concurrently with other significant expansions of coverage and must not be conditioned on private industry actions.
Consist of one entity, operated by the federal government, which sets policies and bears the risk for paying medical claims to keep administrative costs low and provide a higher standard of care.
Be available to all individuals and employers across the nation without limitation
Allow patients to have access to their choice of doctors and other providers that meet defined participation standards, similar to the traditional Medicare model, promote the medical home model, and eliminate lifetime caps on benefits.
Have the ability to structure the provider rates to promote quality care, primary care, prevention, chronic care management, and good public health.
Utilize the existing infrastructure of successful public programs like Medicare in order to maintain transparency and consumer protections for administering processes including payment systems, claims and appeals.
Establish or negotiate rates with pharmaceutical companies, durable medical equipment providers, and other providers to achieve the lowest prices for consumers.
Receive a level of subsidy and support that is no less than that received by private plans.
Ensure premiums must be priced at the lowest levels possible, not tied to the rates of private insurance plans. (emphasis mine)

In conclusion, the public plan, like all other qualified plans, must redress historical disparities in underrepresented communities. It must provide a standard package of comprehensive benefits including dental, vision, mental health and prescription drug coverage with no pre-existing condition exclusions. It must limit cost-sharing so that there are no barriers to care, and incorporate up-to-date best practice models to improve quality and lower costs. All plans, including the public plan, must include coverage for evidence-based preventive health services at minimal or no co-pay. All plans, including the public plan, should be at least as transparent as traditional Medicare.

That boldfaced bit means that the public plan could potentially use bargained rates to lower costs. This is all very, very good. And unlike the more fractured Blue Dog Caucus, the Progressives seem united around this. Max Baucus now expects a public option in the Senate Finance Committee version, the most skewed to the right of any of the plans. Considering that critics of the public option are using its selling points to criticize it, I'm reasonably certain that public opinion will also line up along with a popular President and the bulk of the Democratic caucus for a public option.

Len Nichols, the director of health policy at the New America Foundation and the co-author of a proposal to level the field through governance and pricing regulations, said that state employee health plans are “proof of concept” that governments can maintain fair competition. “They do not unleash this impulse to take over the world,” Mr. Nichols said. “I don’t see this leviathan behavior.”

But critics argue that with low administrative costs and no need to produce profits, a public plan will start with an unfair pricing advantage. They say that if a public plan is allowed to pay doctors and hospitals at levels comparable to Medicare’s, which are substantially below commercial insurance rates, it could set premiums so low it would quickly consume the market.

Yes, that would be HORRIBLE.

It's brilliant politics to line up the argument as one between those who seek to lower premiums for Americans and those who think the current broken system is the best the world has ever known. I know who wins that politically. My fears, however, are over this myth of bipartisanship that animates discussion of major issues. I don't understand this mentality:

Senator Charles E. Grassley of Iowa, the senior Republican on the Finance Committee, recalled how Mr. Obama made a personal pledge of bipartisanship when he and Senator Max Baucus of Montana, the committee’s Democratic chairman, joined the president for a private lunch at the White House last month.

“I said, ‘Yeah, it’s a problem,’ ” Mr. Grassley said of the public plan, “and he said something along the lines of, ‘If I get 85 percent of what I want with a bipartisan vote, or 100 percent with 51 votes, all Democrat, I’d rather have it be bipartisan.’ ” [...]

Senator Ron Wyden, an Oregon Democrat who is a longtime proponent of revamping health care, said Mr. Obama seemed to be wrestling with how far he could push Congress.

“The president is very much aware that to bring about enduring change — health care reform that lasts, gets implemented, wins the support of the American people and does not get repealed in a couple of years — you need bipartisan support,” said Mr. Wyden, who was among two dozen Senate Democrats who met with Mr. Obama about health care last week. “So he’s grappling with, how do you do that?”

I just don't agree with that. Medicare was a bipartisan vote - and not even very bipartisan - in an ideologically jumbled and mixed-up time period. The ideological cleansing of the parties has basically been completed, and you're simply not going to get more than a token couple Republicans to vote to reform health care in any meaningful way. The durability of the plan after passage relies on its effectiveness. If it drives down costs, if it increases access and quality of treatment, no politician in their right mind would vote it out of existence. And so Obama ought to craft the policy that affords the most chance at success. In 20 years, nobody will be able to name who voted for or against the plan. The cost curve bending or stiffening will not be dictated by the number of Republicans in support. The goal should be to get the best plan with the amount of votes needed for passage. Any extra really is gravy.

The Congressional Research Service has a nice preview document laying out all the issues in health care reform. And Ezra Klein peeks at a document setting October 1 as the soft deadline for a bill on the President's desk. Here we go.