A Healthy Health Care Debate

The following analysis of Saturday’s presidential candidate forum on health care is excerpted from the full essay written by Prof. Jacob S. Hacker of Yale University. Hacker is the author of “The Great Risk Shift,” as well as the “Health Care for America” proposal recently released as part of the Economic Policy Institute’s Agenda for Shared Prosperity.

In a piece written before the debate, Campaign for America’s Future co-director Roger Hickey laid out five key questions that all candidates should be required to answer:

1. Will the candidate’s plan really cover everyone —with a decent guaranteed level of coverage—at an affordable cost?

2. Does the candidate offer a public plan, like Medicare, that has a predictable, guaranteed level of benefits that “cannot be taken away?”

3. Has the candidate thought through how his or her plan will be financed?

4. Will the candidate’s health plan control spiraling health care costs?

5. Is the candidate’s health plan simple and clear enough that they can explain it—and get us to describe it to someone else?

Of the leading candidates, only Edwards answered all five questions.

He promised to cover everyone who works by requiring that employers either provide good insurance to their workers or pay into a new publicly overseen insurance pool. Americans without direct or family ties to the workforce—no more than a tenth of the population—would be signed up through public assistance programs and other outreach efforts, and all Americans would be required to have coverage.

Cost control would come through the administrative savings of insurance pooling, competition among insurers, and, most promising of all, the creation of a Medicare-like public plan option with free choice of medical providers that would be available through the new insurance pools.

As all this suggests, the Edwards plan is still a bit complex, but it’s much simpler than the norm, and Edwards has gotten better and better at talking about it.

The other candidate with a clear plan isn’t a frontrunner, by any stretch of the imagination. But Dennis Kucinich, the Ohio representative who has been an outspoken advocate for a universal national health plan, proved to be a forceful spokesperson for an idea that has been unfairly dismissed as a government takeover of American health care.

(The fairer critique is that it would be a government takeover of American health insurance, a politically unlikely prospect, for both fiscal and political reasons. But government would no more be involved in providing or dictating the terms of care than it is in the operation of Medicare, and it would almost certainly be a lot less heavy-handed as an insurer than are most private plans.)

Where Kucinich racked up the most points was in emphasizing the inherent superiority of public insurance in pooling risks and bargaining for lower costs. He even scored some points against Edwards by noting that Edwards’s call for competition between public and private insurance wouldn’t work because, as with the private health plans that provide insurance to Medicare beneficiaries today, the game would be rigged in favor of private insurers.

Edwards’s and Kucinich’s plans were known quantities, so what was perhaps most notable about the event was how strongly both Clinton and Obama criticized the present system and called for major change.

Reading between the lines of Clinton’s impassioned oratory and Obama’s more apologetic presentation of the principles that would guide his still hazy reform effort, it’s possible to discern a common vision shared by all three of the top Democratic hopefuls.

It is this: a system that is loosely based on the best elements of what we have now, but which decisively moves us away from a reliance on voluntary employer-sponsored insurance and toward a framework in which risk is pooled broadly across the non-elderly population.

This means a new (hopefully, national) insurance pool that provides a choice of public and private plans, and a requirement that employers either provide coverage or pay to enroll their workers into this pool.

It also means a system with enough flexibility to evolve away from heavy employer involvement in administration and financing—not only to ensure health security for all, but also to allow employers to focus on their prime mission: to innovate, produce, and prosper.

This is an attractive vision—far, far better than the complicated blueprints of the recent Democratic past; much more attractive than plans that simply require that everyone have coverage, however substandard that insurance might be; highly consistent with public opinion; and politically and fiscally feasible (or at least much less infeasible than other options).

But even in Edwards’s admirably forthright plan—which rightly says that taxes will have to be raised to create the new system, even if the economy as a whole will save big money—this emerging vision still remains too fuzzy on two key issues.

First, will the cost-control advantages of public purchasing be used to the fullest extent possible? Second, and related, will a good Medicare-like plan be offered on terms that are attractive to Americans and allow fair competition between public and private insurance?


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