I realize in my discussion of healthcare reform I have rather loosely referred to the public option as offering a choice of insurers. Andrew Sullivan over at the Physicians for a National Health Plan blog is correct to point out today that there is a serious distinction between the public plan as originally proposed by Jacob Hacker or as promoted by various well-meaning progressive commentators and the reality of what is being proposed in Congress or furthermore is likely to pass in this particular Congress. Furthermore, Sullivan points out that pollsters have continued to blur this distinction leading to some misleading polling results that have suggested that the public supports the weak public option when it is not nearly so enthusiastic as reported. In the real, “weak” public options, the “choice” dimension of these public option proposals is noticeably diminished or entirely absent: the option only “kicks in” after private insurance is no longer available to a very small subset of individuals under the age of 65. The supposedly liberal Senate HELP committee restricts the public option to those who do not now have insurance through their employers.
I have lamented the difference between the reality of the public option as advertised and as proposed before but I have also in my last posts left the impression that there would be choice for individuals between a public and private plan, even if that public plan would be weak and purposely made unattractive. In almost every version of reform near passage, most people will not even have any choice of a public plan or a private plan. Instead the public plan will function as a “stopgap” where people who do not have access to private insurance will be offered the public plan.
In Sullivan’s post, he points out that too many in the news media have not called attention to the fact that the public option will not operate as an option. The slippery slope between what is called for and what is offered has many people fooled and allows there to be a wide range of “fantasies” (meaning it’s left to wishful thinking) about what the public option actually will be. ”It’s public and it’s optional, so I’m for it!” Sullivan points out that pollsters have promoted this range of interpretations. In the single poll that asks about the “rump” public option now on the table, the level of support is below 25%. The 65% of the public obviously thought that they would have a choice of a private and a public plan.
Sen. Ron Wyden, has been most critical of the lack of choices and seems particularly exercised about this not because he is attached to the notion of public health insurance but more attached to the notion of choice in the sense of choice of insurers (choice category “1″ in my typology of consumer choice in healthcare).
I would agree with Sullivan that this has the appearance of a bait-and-switch by the leadership of the reform effort. It appears as though the questionable logic behind the bait and switch, for those who are aware of it, goes as follows:
- “we must get a publicly delivered insurance program into health reform no matter how weak and inaccessible”
- “it is OK to blur the differences between a “buy into Medicare” option and the weak public option. It is a white lie.”
- “Strengthen an existing, even failing, program is easier than starting over with a strong one.”
I believe this is the wrong way to build public support for effective healthcare reform. Telling the truth is a good place to start but also as I have pointed out in previous posts, we need to learn from existing universal healthcare systems and not try to “reinvent the wheel”.
