Policy Alternatives, Actor, Interests & Implementation
The health care policy debate was by no means a settled issue after President Obama signed the Patient Protection and Affordable Care Act (PPACA). Policy alternatives to the PPACA are insignificant and in just over a years time has pretty much come full circle. Using Stewart, Hedge & Lester’s political and ideological continuum, listing from left to right; a single-payer system, a “public option”, catastrophic coverage insurance, and private health savings accounts have at one point been seriously proposed as a policy solution to expand coverage, and to cut rising costs (Stewart, et al). Health insurance exchanges with an individual mandate fit tightly in the middle of those four alternatives. Republican’s control of message in the health care debate and gains in the 2010 elections have brought some of the more conservative alternatives to serious public debate. The following is an analysis of each of those alternative policy proposals, the vested actors and interests, and the likelihood of implementation.
Single-Payer
Since health care has been an issue on the popular (policy) agenda as a recurrent issue, the alternative proposals titles are for the most part familiar to most of Americans. The proposals are those that characterized the health care debate over the 2008 presidential election and heated health care town hall summer of 2009, except one - Single-Payer. Non-profit organization Healthcare-Now explains a single-payer system as “one entity—a government run organization—[that] would collect all healthcare fees, and pay out all healthcare costs (Healthcare-Now. para 1). “In a single-payer system, all hospitals, doctors, and other healthcare providers would bill one entity for their services” adding “everyone would receive comprehensive medical benefits” (Healthcare-Now, para 4 ). Using this framework the need for an easily accessible insurance exchange market wouldn’t exist because the government would be the sole insurer. It is noteworthy to mention that because most policy is implemented incrementally, shifting to single-payer would undoubtedly cause disruptions.
Traditionally it is the more progressive political parties, like the Green Party that favor a single-payer structure to receiving health care in the United States (Green, sec F, para 1.) Liberal Democrats too support a single-payer system. "A majority of [Progressive Caucasus] members prefer single payer," said liberal Democrat, Raul Grijalva of Arizona. In 2009 H.R 676 the “Expanded & Improved Medicare For All Act” was introduced to the 111th Congress in the House of Representatives by John Conyers of Michigan with 87 co-sponsors, including Grijalva on January 26th (Library of Congress). The following day it was referred to the House subcommittee on Health where it eventually died. Two years later, the same bill was introduced by Rep. Conyers Jr. to the 112th Congress and referred to the same committee where it “sits” currently with only 39 co-sponsors; including Rep Cummings of Maryland 7th District (Library of Congress).
Activists bloggers on left-wing sites like the Daily Kos mince no words about what will be needed to obtain a single-payer health care system. “Obviously, getting to single payer is a long-term project. It's not just about moving a piece of legislation; it's a movement. It's going to require ongoing commitment, an enormous amount of effort, organizing, and education (Kos, para 3). The sentiment expressed speaks to the hard work needed to fulfill implementation of a single-payer system for all. An “enemies of single-payer” list was comprised with organizations like AARP, Kaiser Family Foundation, Lewin Group, PHRMA each of whom has a vested interest to keep the current private insurance market (Mokhiber). In terms of public opinion, in a January 1st 2010 Rasmussen Poll reports 34% of voters nationwide favor a single-payer health care system, 54% oppose and 14% are not sure (Rasmussen). However Vermont has chosen to reject that framework completely, by their House passing single-payer legislation (WPTZ) .
The “Public Option”
The public option [...] is a government-run health insurance plan, like Medicare, that would compete along side private insurers in a new health insurance exchange that the [PPACA] set up” (Shaw, para 2). A government insurance option has been on popular agenda for about as long as Medicare for all has been on the agenda. What’s the distinction? Health exchanges. “With a significant feature of the insurance exchanges [being] a public plan, the controversy [...] centers upon the extent to which [the public option] could compete with private insurance plans (Shaw, para ?). It was broad agreement between centrist Democrats and moderate Republicans in Congress on replacing the current system with non-profit insurance co-ops (exchanges) that pushed the public plan, an “option” in the exchange(s) to the front burner of the partisan health care debate (Shaw, para 1).
In late August 2009, President Obama gave his weekly web address. In it he took time and effort to “debunk” myths surrounding the health care debate. By that time the public option had the stained “government takeover of health care” perception, and Mr. Obama was trying to clear it up (Obama video). “This is one idea among many to provide more competition and choice especially in the many places where one insurer dominates the market place” (Obama video). “This alternative would have to operate like other insurers on the basis of the premiums it collects” adding “let me repeat, this is just and option” (Obama video). Interestingly, health exchanges did not arise to the level of controversy and were not discussed; most members of Congress who were honest brokers in the negotiations agreed health exchanges were a bridge to achievement.
The controversial “public option” was advocated for by President Obama’s in his health care reform attempt of 2009/2010 . The Democratic controlled House of Representatives of the 111th Congress passed their version of health care reform H.R 3962 that included a public option on November 7th 2009 (Library of Congress). However, most senate Republicans and a handful of conservative senate Democrats were not sure that voting for a “public option” was in their political interest. H.R 3962 was not working model for the senate bill. The “public option” so hoped for by progressives died in the US Senate. “The fact of the matter is there are not the votes in the United States Senate for a public option” (Conrad, para 1). “There never have been", conservative Democrat Kent Conrad in August 2009 (Conrad, para 1). Last month in a public opinion poll, Rasmussen reports (a significantly high) 47% opposed the public option (Rassmuen).
Catastrophic Coverage
“Cost of catastrophic illness” language found its way into a 1986 proposal during the second Reagan administration attempt to expand Medicare (Conrad, p. 311). In February 1987, a catastrophic care plan was sent to Congress with endorsement of the major provider groups like The American Hospital Association (Conrad, p. 311). On July 1st 1988 Congress enacted the Medicare Catastrophic Coverage Act with huge bi-partisan majorities in both houses of Congress (Conrad, p. 311). The bill capped the amount beneficiaries would have to pay for hospital and physician care, amongst other provisions (Conrad, p. 311). While the term is the same from the late 80’s the definition has since evolved.
Catastrophic insurance coverage currently is an option in the private insurance market. According to Catastrophic Health Insurance Plans, an online informational source, catastrophic coverage is also called a “high deductible health plan” (CHIP.net) because it’s characterized by low monthly premiums, but deductibles that can range between $1,500 and $5000, with a minimum of $500 (CHIP.net, para 2). “Some insurers describe these plans as those that only cover certain types of expensive care, like hospitalizations” (Healthcare.gov).
“There are two basic types of catastrophic plan: comprehensive and supplemental” (Jeffries, para 4). A comprehensive plan offers coverage comparable to more traditional health care plans” adding” there is still a high deductible and monthly fees are still relatively low” (Jeffries, para 4). A supplemental plan [...] acts as a supplement to other insurance plans (Jeffries, para 4). This type of alternative does not directly challenge health exchanges, but neither does the public option. In fact, catastrophic coverage would likely challenge the public option in terms of cost cutting for healthy individuals within the exchange structure. A hard number of exactly how many Americans currently hold catastrophic coverage has remained elusive in my research.
Private Health Savings Accounts
“A health savings account (HSA) are tax sheltered savings accounts coupled with high deductible health insurance plans (FamiliesUSA, para 1). [A]n alternative to comprehensive health insurance [like catastrophic coverage]; it is a savings vehicle that allows people a different way to pay for their health care (HSAI.com, para 1). However, in many cases “you must be covered by a High Deductible Health Plan (HDHP) to be able to take advantage of HSAs (HSAI.com, para 5). Using a Guy Peters typology, HSA’s would fall under a craftsmen type of policy due to a low knowledge level of the number of people who would actually participate positively and effectively in the plan, couple with the high knowledge of causation of why a different approach is need to address the current systems problems.
In the past Health Savings Accounts (HSAs) [were] promoted by President Bush and conservatives in Congress as a way to bring down spiraling health care costs. “Only if consumers have "skin in the game," they argue, will Americans start to shop around for cheaper health care” (FamiliesUSA, para 1). Currently, “four Republicans in Congress -- Sens. Tom Coburn (Oklahoma) and Richard Burr (North Carolina) and Reps. Paul Ryan (Wisconsin) and Devin Nunes (California) introduced [the] Patients' Choice Act, it provides a path to universal coverage by redirecting current subsidies for health insurance to individuals. It also provides a new safety net that guarantees access to insurance for those with pre-existing conditions by redirecting the $300 billion annual tax subsidy for employment-based health insurance to individuals in the form of refundable, advance-able tax credits. Families would get $5,700 a year and individuals $2,300 to buy insurance and invest in HSAs (Antos and Turner, para, 3).
In 2008 Sen. John McCain offered a similar plan as his health reform proposals when he ran for the presidency (webMD). That model was roundly rejected for a more ideological, liberal, procedural, redistributive, and (controversially) regulatory policy approach. Again health savings accounts in terms of a true alternative to the exchanges of the PPACA do not match up. Chances are they will be offered as in option within the state exchange framework. Whereas “the [...] debate in Congress reform generated many proposals [on both sides] to change the rules on HSA’s, nothing seriously was done to the fundamentally change the structure and understanding of HSA’s Allan Rubin notes that “more than 10 million people are enrolled in high-deductible health plans linked to HSA, up from 6.1 million in 2008, according to a recent survey by America's Health Insurance Plans, an industry trade group (Rubins, para 7).
Conclusion
In an issue area as large as health care, when so many stakeholders and interest groups jockey to control the crafting of policy, legislators prefer to formulate incremental implementation. The common yet different alternatives to the health exchanges of the current health care reform law, with exception of single-payer, do not remove health exchanges as the compromise framework for health reform. The reason health exchanges trumped all others is due to both positive and negative inducement found in the law. Having both types of inducements in the PPACA it won enough bi-partisan support to pass both houses of Congress.
References
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