Cleaveland: Public option still focus of health debate

Cleaveland: Public option still focus of health debate

November 5th, 2009 in Health

Congressional debate over reform of health care has centered most recently upon the public option. So far, the issue has generated a lot of heat and not much light in Congress and in the media. The public option is essentially a Medicare-like plan for people who are under 65 years old. This plan would compete with private health insurance plans in an exchange, or managed, marketplace.

Congress has produced three reform bills -- one each from the Senate Finance Committee (SFC), and the Senate Health, Education, Labor, and Pensions Committee (HELP) and a House bill (HB) that combines earlier bills passed by separate committees.

An insurance exchange is a component of all three reform measures.

Depending upon the bill, an insurance exchange would be organized within state, regional, or national boundaries. A group of private insurance companies would offer through an exchange a variety of health insurance plans to small companies and to individuals who are not eligible for job-based health insurance.

The plans would operate within a framework of benefits and payments regulated by the Federal government. Federal employees and regulators currently obtain their health insurance from an exchange, the Federal Employee Health Benefit Plan.

Each bill's exchange would offer a basic set of benefits with two or three optional levels of care above this "floor." Each plan has a formula for sharing the cost of premiums. Each bill provides subsidies for people of modest financial means based upon a sliding scale of personal or family income.

HELP and HB provide for a public option or government-sponsored plan within each exchange. Supporters of the public option argue that premiums and payments to providers could be more tightly regulated within the government-backed plan. This, in turn, would pressure private insurers within the exchange to control premiums and costs. Opponents contend that a public option would create unfair competition within an exchange and set the stage for a government take over of health insurance.

Instead of a public option, SFC proposes establishment of non-profit, privately-run health cooperatives within each state. Group Health Cooperative in Seattle is one model for this initiative. This long-established, customer-governed enterprise owns its facilities, hires physicians and staff, and offers a variety of comprehensive health-care plans. Other co-ops are limited to negotiating premiums and benefits on behalf of clients. Co-ops require time and a lot of capital to begin operation. They must have a large group of enrollees if they are to compete against private health insurance plans.

Variations of a public option have recently been proposed. One would allow each state to determine if a public option would be included in its state-wide exchange. Another would establish a "trigger" for launching a public option. This mechanism would be activated if private plans within a state's exchange failed to meet certain criteria for cost and coverage.

A variety of polls show a majority of Americans support some form of a public option. A poll conducted by and the Brookings Institute and reported in the Baltimore Sun on Oct. 27 showed 68 percent support for a public option that would provide coverage for individuals otherwise unable to obtain health insurance. A survey in the most recent edition of the New England Journal of Medicine found that 57 percent of doctors surveyed favored the inclusion of a public option. Support was higher --65 percent -- among primary-care physicians.

At this point, it is uncertain if a public option will be included in the final health reform bill that Congress will consider. It is also impossible to predict what form a public option might take -- mandatory and nationwide, a choice for each state, or a fall-back for people ineligible or excluded from private plans within a health exchange. We must stay tuned and stay informed.

The Commonwealth Fund ( ) last month released a publication called "The Comprehensive Congressional Health Reform Bills of 2009." This comparison of the three major bills is concise and clearly presented. A broader survey of health reform that compares U.S. and foreign health systems can be found in "The Healing of America" by T. R. Reid (Penguin Press 2009). Both publications are essential reading for understanding the challenges and potential solutions to our current, troubled health care system.

Contact Clif Cleaveland at