07 December 2009

I could live with that

Senators Consider A Menu Of Options, Including Medicare Expansion, As Public Option Alternative | TPMDC
Several outlets are reporting, and I can confirm, that Senate Democrats are considering a Medicare expansion as one item on a menu of concessions conservative Democrats would agree to in exchange for weakening or eliminating the public option in the health care bill.

Currently, Medicare exists as a single-payer system for seniors 65 and older. According to Hill sources, the idea would be to allow people under the age of 65 to buy in to Medicare. The option would be limited to people older than a certain age, though that age--and indeed the entire proposal--has yet to be agreed upon.

Not as good as a strong public option, but a strong public option ain't in the cards, and a neutered one is barely worth the fight.  This is better than nothing, and since "nothing" is looking more and more likely what the progressives might get, I'd take it.  From a simple political perspective, liberals have been getting rolled again and again by the centrists and conservaDems, so this meaningful expansion of Medicare represents a genuine "win" for liberals, and those have been in short supply lately. 

I have to see the details and think through the policy implications (adverse selection, anyone?) before a final judgment.  Still, this looks god ont he face of it.  One more thing: Open the exhanges!


  1. If we’re going down this road it seems to me it makes more sense to let people buy into Medicaid rather than Medicare. If I understand correctly that Medicaid reimbursement rates are lower than Medicare reimbursement rates, then people should be able to buy into Medicaid more cheaply than into Medicare. Medicaid also appears to allow some variation from State to State so issues like abortion coverage could be taken care of at the State level.

    As for the Exchange, this replicates the Federal Employee Health Benefits Plan. It's much simpler to just let anyone who wants to buy into FEHBP with a separate risk pool and government subsidies as needed. Why re-invent the wheel? I know this approach doesn't get rid of insurance companies but it gets people coverage which seems to me the most important thing. Then we can all take a deep breath and take some time to consider more radical changes to the health care/insurance system.

  2. Medicaid is indeed cheaper but the problem is that reimbursement is unsustainably low in medicaid. Docs complain that medicare rates are too low, with some merit. medicaid rates are typically half that, and for clinic-based docs they actually take a loss providing services to medicaid patients. For that reason most people covered by medicaid have no access to a primary care doc since the community docs won't see them, and the charity clinics are full.

    For that matter, it's getting to the point that medicare patients are finding access to care limited due to the low reimbursements.

    Yes, I have long been an advocate of opening the FEHBP to small businesses (speaking as a small business owner myself!). The only down side is that while the FEHBP would solve the market-based problem of access to insurance, it does nothing towards the cost containment problem.

  3. You are stating that Medicaid and Medicare "cost containment" measures are not working bcs more + more docs are refusing to take on these patients.

    So is your bottom line really that the only way to effect "cost containment" is to force everyone into a govt run system - and therefore, the docs will have no choice - accept the payment rates or get out of practice. In other words, medicine will have wage controls to keep healthcare costs down.

    Is this your ultimate position?

  4. But there are a limited number of ways to address the cost containment problem and all of them have drawbacks.

    We can receive the same health care and pay less for it. Either health care providers have to get paid less (which has the problems you cite) or we have to hope getting rid of insurance companies means enough administrative savings to yield a boatload of money and we don't worry about the kind of fraud that goes with less overhead - even though that fraud would presumably eat into that boatload of money.

    Or we pay the same for health care but receive less of it which means someone is deciding what is and is not "necessary" health care. That means we're willing to live with someone - insurance company or government bureaucrat - making life and death decisions for all of us.

    Or we let the free market (in health care, not health insurance) sort it out which means we accept that people without money don't get health care and some of them die. I don't think very many of us find this acceptable.

    At this point I think the answer lies in some combination, possibly the catastrophic plans suggested by DeLong and Goldhill. Some free market; some government help; single-payer catastrophic. It might work.


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