The Treatment

The Public Option Is Important. But How Important?

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Speaking on Thursday before thousands of activists gathered on Capitol Hill, former Governor Howard Dean made clear his litmus test for health reform: “We expect change,” he told the crowd, “We want a public health insurance option now.”

It’s not the first time he has said that and, among many health care reform advocates, it’s not really a controversial notion. Creating a public insurance plan, into which anybody could enroll voluntarily, has become more than a top priority for liberal activists. It has become the top priority.

In many respects, this is a good thing. I happen to be a strong public plan supporter myself, for reasons this magazine laid out in a staff editorial several weeks ago: It will guarantee the possibility of affordable, reliable coverage to everybody; it will promote cost control, by leading the way on reforms of how we pay for medical care; and it will promote a healthy competition with private insurers, keeping them in line and--hopefully--prodding them to perform better. (For a more detailed explanation, please read the actual editorial.)

I also think the public plan’s centrality has produced some obvious political benefits. The antipathy towards--and distrust of--the insurance industry has led many activists to shun past reform efforts that relied heavily on private coverage. And that’s been a major reason why those past efforts failed, since those same activists tend to be reform’s most passionate supporters--the ones who will make phone calls, go door-to-door, and show up at rallies like the one that made headlines last week. The public plan option has given these people reason not only to support this year’s reform push, but to support it enthusiastically.

And yet I confess to a certain ambivalence when I hear, as I frequently do, statements like the one Dean made at the rally. Yes, the public plan is a key element of reform. But it is not the only one.

Just consider what was going on inside Capitol Hill meeting rooms as Dean was speaking. Over the past week, leaders of the Senate Finance Committee have been busy hacking away at their proposed legislation, in order to bring the total price tag in at under $1 trillion over ten years. To accomplish this, the committee leaders have proposed cutting the subsidies that reform will make available to people who have trouble paying for insurance on their own.

If those cuts end up in the final legislation, fewer people would get assistance and, quite possibly, those that still got assistance wouldn’t get as much. The result would be more uninsured and more underinsured.

And that's not the only major issue in play. Among the others:

Will there be a maximum on out-of-pocket spending--and, if so, what will that maximum be? 

Will the govenrment guarantee relatively good benefits for everybody? Or will people still end up taking out insurance that has huge cost-sharing--not to mention skimpy coverage of mental health and other traditionally neglected services?

How much funding for reform will come out of the pockets of the health care industry--and how much out of the pockets of individual taxpayers?

How aggressively will the government try to change the way medicine is practiced, to improve quality and reduce waste?

How slowly will all of these changes be introduced? 

It’s not hard to understand why none of these issues have become as prominent as the public plan. They’re not yes-or-no questions. They’re more complicated, so fewer people (including journalists!) grasp their significance. And these issues don’t always fall neatly along the left-right ideological fault line. By contrast, a government-run insurance plan is everything the left loves and everything the right hates.

Still, that doesn’t (or shouldn't) mean these issues are less important--certainly collectively and, in some cases, individually. Or, to put it another way, reform without a public insurance plan would be a major disappointment. But reform without adequate subsidies, good benefits, and cost control would also be a major disappointment, too. As Igor Volsky, one of the relatively few writers paying attention to these issues, recently suggested, "Health reform that fails to make insurance more affordable is at best an incremental improvement."

To be sure, it's possible that any pressure from the left--no matter what it's focus--helps nudge reform in the direction of greater generosity, stronger regulation, and a harder push on efficiency. But it's also possible that the preoccupation with the public option displaces attention to these other issues--and that, as a result, a lot of people who need help won't end up getting it.

Note: Among those thinking along the same lines has been Karen Tumulty, who recently outlined "Five Big Health-Care Dilemmas" for Time. The public plan is one of those dilemmas, but, as you may have discerned, she came up with four more. 

--Jonathan Cohn

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