Quite a few progressives have taken the position that only a “robust public option” (typically defined as a government-sponsored insurance plan linked to Medicare payment rates) can make a hybrid, private-insurance-based health reform system worthwhile. Otherwise, they argue, any initiative that includes individual and employer mandates will simply give private health insurers more customers and profits, without constraining costs or improving quality.
But barring the use of budget reconciliation procedures or a semi-miraculous act of party discipline on a cloture vote, a “robust public option” is unlikely to be enacted by the Senate, and could even encounter trouble on the floor of the House. So public option supporters (and opponents) have been mulling over a growing number of alternatives being floated by Senate Democrats (and one Republican, Olympia Snowe).
Tim Noah at Slate offers a good rundown of these “half-loaf” measures, including two he considers unacceptable: Conrad’s nonprofit cooperative approach, and Snowe’s public option “trigger.”
Tom Carper has suggested a “opt-in” state public option that would also allow states choosing to go in that direction to form regional public plans. And without a lot of fanfare, the Finance Committee has already adopted a proposal by Maria Cantwell that would allow states to use federal subsidy funds to directly make insurance available to a large category of the uninsured, up to and including creating state single-payer plans.
Sam Stein of HuffPo reports today on another wrinkle that’s being discussed: an “opt-out” variation on Carper’s state public option plan, which would have the advantage of creating a strong national public option that states could take or leave.
All these state-based approaches to the public option have the obvious goal of enabling key centrist Democrats to get out of the way of a public option while preserving the right of their own states to go in a different direction. This might be especially appealing to senators getting a lot of pressure from insurance companies and/or health care providers in their own states to oppose a public option affecting them.
It’s unclear which if any of these alternatives will emerge as the go-to plan, but without a doubt, a crucial factor will be the extent to which “robust public option” advocates, particularly in the House, decide to expand their own definition of an acceptable public option. Remember that many public option fans actually favor a single-payer system, and are disinclined to support any alternative that strengthens the hand of private health insurers. A lot may depend on whether they are reasonably sure their own states, and most states, will take advantage of opportunities to create the kind of public option they favor.
Meanwhile, state-level politicians will soon come to the realization that national health care reform may actually place them in the driver’s seat, and make the basic design of health care an even more dominant issue in their own political lives, perhaps beginning in 2010.