As featured on p. 218 of "Bloggers on the Bus," under the name "a MyDD blogger."

Tuesday, September 08, 2009

Trigger Happy Jack

Over the weekend, Ben Nelson, the most conservative Democrat in the Senate and as such a decent bellweather for where the health care policy might go, appeared to support a trigger for the public option, as long as it wasn't a "hair trigger." DougJ surmised that his conception of a hair trigger would be one that might actually go off, and he would prefer a trigger that just remains hypothetical forever. And he's right. There's a trigger in the 2003 Medicare Part D bill that would allow the government to sell prescription drugs through a public option if the drug companies couldn't do it properly themselves. And that trigger never got pulled. So Ben Nelson wants that same dynamic play out in the overall health care bill.

Ezra Klein argues that the public option on offer would not equal cost control because it doesn't use Medicare bargaining rates and its own pool of customers is too small to bargain for anything meaningful. Which is true - ask Ian Welsh - and why I support both using Medicare bargaining rates and opening up the exchanges to those who get coverage from an employer. It's also true that getting a public option into place will increase the possibility that it can be opened up or paired with Medicare rates in the future, whereas no public option on this go-round will make it nearly impossible to get one later - basically the same exact heavy lift as we're seeing now. There's also a distinction to be made between cost control to the federal government and cost control to the individual premium purchaser. A non-profit public option that still uses the Department of Health and Human Services to bargain for rates will have a lower cost to the individual in that market. The CBO estimate of 10 million subscribers is just an estimate - but it should be said that even with those numbers, the CBO saw the public option as a net savings of $150 billion over ten years, contra Tom Brokaw. If the public plan can offer the same basic coverage at a lower cost, people will buy it. And insurers will lower their premium costs to capture more of the market share. They call it "price wars" in other industries, and it's been virtually non-existent in the insurance market forever. The Swiss version of regulated insurance mandates works because basic coverage is provided entirely by non-profits.

As Matt Yglesias says, Switzerland is a country which "came late to the universal health care game thus did it in a way that involves a lot of compromises with existing interest groups." The single-payer countries all enacted their proposals in the early postwar period at the latest, when the health industry wasn't as large and powerful and medicine wasn't as advanced. It has clearly gotten progressively harder to outflank the more entrenched special interests. That's what we're seeing today with the move toward a trigger that will never trigger itself. That may be evident in the House bill even though it has a public option, considering the meager nature of that option and the too-low coverage subsidies.

But this is a game of inches. And we need to enact as much as possible in this moment of opportunity, and move to the cost controls and refining of the elements later. We need to inscribe universal coverage in the American system with a major check on for-profit insurers. That's why the wavering from House liberals desperate to bargain is extremely troubling.

Amid fresh signs that the White House is preparing to back a scaled-down health care overhaul that would only include a public insurance option as a fallback plan, several House liberals told Roll Call that they could support such a bill depending on how it was structured.

The “trigger” approach has been considered a deal-killer by liberals on and off Capitol Hill, and the willingness of some Congressional Progressive Caucus members to entertain it reflects a recognition that a bruising August recess has imperiled prospects for reform and redrawn expectations for what is possible.

“This is a way to get a bill,” Rep. Bill Pascrell (D-N.J.) said. “I believe it’s worth listening to because I want legislation that is going to, in some shape or form, expand coverage and bring down the cost of health care.”

Liberals stressed that the shift does not amount to an abandonment of their commitment to a “robust” public insurance option. They said they would only support a trigger if that approach guaranteed the same access, quality and affordability.

“I don’t want to give the impression that I’m so flexible that I’m willing to compromise away meaningful reform,” Rep. Jim McGovern (D-Mass.) said. “But there may be a variety of ways of getting there than the one I originally formulated in my mind.” [...]

“We’re the caucus that least marches to a unified drummer — that’s not what we do,” Rep. Mike Capuano (D-Mass.) said. “I’m serious about increasing access and quality, but that doesn’t mean it has to be a grand slam home run. I’ll take a ground-rule double if that’s what it takes. I’m happy to compromise if that’s what it takes. But compromise is compromise — it’s not rolling over.” [...]

Rep. Sam Farr (D-Calif.), a Progressive Caucus member, said he did not support the approach but did not foreclose on it, either. “It depends on how strong that trigger is,” he said. Farr said he has seen triggers implemented effectively in California. “Triggers work, but they’ve got to be really clear as to how they operate,” he said. “The only way I could see it getting progressive votes is by making sure the public option is strong and goes into operation.”

(Farr's actually right, but he won't be writing the bill and the language on the trigger, and surely he knows it will be written to never come into existence.)

There's just no reason to even participate in an article like this. It only serves to weaken the position of the caucus. Mike Capuano in particular clearly has no negotiating skills whatsoever - telling the world that the Progressive Caucus has no unity?

I recognize that these members want a reform bill badly. But use your poker face, fercryinoutloud. The other side of the caucus certainly is.

...They could play it like John Conyers:

“It is clear that real reform means injecting real competition into the insurance market to improve affordability and drive down health care costs. The centerpiece of this reform is a robust Medicare-like public health insurance plan tied to the Medicare provider system. Like many of my colleagues in both the House and Senate, I will oppose any health care reform bill that lacks such a plan. I will also oppose any legislation that seeks to replace a robust public health insurance option with health care cooperatives or which ties the availability of the public option to a trigger mechanism. In this effort, I stand in solidarity with House progressives, the majority of my friends in organized labor, millions of health care providers, and 72 percent of the American people.

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