Hillary Confirms Commitment to Health Care for All

The big news from Sen. Hillary Clinton’s Monday health care speech in Iowa is that she is going to make a campaign for health care for all — not just small changes but fundamental reform — a central element of her campaign for the White House.

Before the speech Jonathan Cohn [1] was not the only health care reporter asking the question, “Will she flinch? . . . Would she settle on something less than universal coverage, figuring the political support for it was too weak?” She didn’t. She responded to the American majority clamoring for bold leadership to achieve health care for everyone.

Clinton would achieve universal coverage [2] by offering an array of private insurance plans that meet the standards for benefits and premium costs set by the Federal Employee Health Benefits Program — the quality plan covering members of Congress and other federal workers. And she would also offer a public health care plan similar to Medicare.

All of these plans would be portable through life changes, such as when you leave or lose a job. Employers would be required to provide their employees health insurance or pay into a fund to defray the cost of covering those employees. (Small businesses with fewer than 25 employees would be exempt, while getting tax breaks to encourage them to offer coverage.) All Americans would be able to buy into any one of the available private insurance or public plans — with a graduated system of tax credits designed to make sure that no one pays more than an (unspecified) reasonable percentage of their income on health premiums.

It is no coincidence that the basic elements are similar to those already proposed by her main presidential primary competitors. The “ideas primary” between the candidates has been shaped in part by our unique effort — chronicled in this blog all year — to engage the candidates around Yale Professor Jacob Hacker’s progressive health care plan [3], “Health Care for America.”

I’ve been part of a team of experts and advocates [4] who (however reluctantly) agree that political reality requires a health care system that sacrifices the undoubted efficiency of single-payer in order to offer Americans more choice of health insurance systems — including the right to stay with their current private insurance policy if they are happy with it. Having made that decision, the Hacker approach — creating a strong “Medicare-style” public insurance option — establishes universal coverage without keeping us under the thumb of private insurance companies. The plan became our gold standard and our method of stirring a productive debate among the candidates.

The approach worked. Soon after the January release of the Hacker plan, former senator John Edwards unveiled his plan on February 5. It quickly set the standard for the other candidates. The American Prospect’s Ezra Klein [5] observed: “it has widened the field of the debate, and unless the other candidates want to explain why they lack the boldness of Edwards’ plan, they’ll have to offer similarly comprehensive proposals. What they will have to match is full community rating, a public insurance option, total universality, scaleability towards more public involvement, and a willingness to propose something comprehensive enough to require revenue increases to fund. In other words: The goalposts have been moved. To the left.”

Cohn in the New Republic [1] reported that features of the Edwards plan correspond to “the essential idea behind another health care reform plan that has been quietly generating a great deal of enthusiasm among reformers--a plan composed by Yale University political scientist ... Jacob Hacker.”

On May 29, Illinois Sen. Barack Obama unveiled his ambitious health care for all plan. It was instantly obvious that his plan owed a lot to Hacker — as he was determined to stay competitive with Edwards. Obama’s plan offers one particular advantage: if your employer doesn’t provide insurance, you are seamlessly enrolled in the public plan, ensuring coverage. Obama health economist, David Cutler explained how it would work on our America’s Future blog:

Here’s how it works: If you don’t have health insurance through your employer, you will be enrolled into a new, comprehensive public health insurance plan that emphasizes prevention, chronic care management and quality care. The benefits will be similar to those available today to every federal employee. This plan will enjoy the great efficiencies we see in public plans like Medicare but, if you still cannot afford it, you will receive a subsidy to pay for it. Of course, you can choose private insurance if you prefer but the private plans will have to compete on a level playing field with the public plan—without the extra payments that tip the scales in favor of private Medicare Advantage plans today.

This admirable clarity about how the system would work for workers whose company decides to “pay” into the public fund rather than “play” by maintaining the company insurance plan is the kind of reassuring detail that is so far missing in the Clinton plan. We can hope political competition will tease out this kind of detail, because it is not unimportant.

At one end (the “you’re on your own” end) of the spectrum, paying into the public fund could simply be a way for employers to wash their hands of their responsibilities to their workers. At the other, more progressive end, employers would continue play an active role in enrolling workers, making options clear — and presumably providing supplementary health insurance benefits available through continued collective bargaining.

As in everything involving new health care systems — from the design of benefits, to the cap on premiums, to the quality of public information, to the strength of public health and prevention programs — will depend on the mobilized power of the majority of Americans who want the public sector to lead the way on health care for all.

Single payer advocates, like Ohio Rep. Dennis Kucinich, condemn the consensus Democratic approach, warning that we will never have an efficient health care system until the wasteful (and predatory) business practices of the private insurance system are outlawed and health care is made a nonprofit public responsibility.

Edwards, Obama and Clinton start with the goal of creating a mixed system, with an optional public insurance system setting the standard, and a pretty rigorous set of standards and regulations designed to get the private health insurance system to essentially change its business model. Clinton can sound as populist as Michael Moore when it comes to the abuses of the health insurance and drug industries.

More importantly, she (like Edwards and Obama) declares that she is committed to setting the rules of the insurance companies' game so that they offer comprehensive benefits at affordable premiums and, as she promises in her newly published plan, we will have regulation that “ensures that no American is denied coverage, refused renewal, unfairly priced out of the market, or forced to pay excessive insurance company premiums."

Now that Clinton has rolled out her private-public plan for achieving health care for all, it is pretty clear that the Democratic party is not going to try to take the private insurance companies out of business. That would be politically hard to do. But the goal that they have set — to force the private insurance companies to equitably contribute to the solution to our health care problems — will not be a piece of cake either.

Clearly the citizen’s campaign for health care for all must seriously pursue the experiment of holding the insurance and drug industries to a high moral standard. And we’re going to have to make sure that the political power of the American majority is mobilized to make sure we have the power to enforce that high moral standard.