If You Don't Like What You Have... Tough

by Tim Foley

categories: National Health Exchange, Obama and Congress

Published October 02, 2009 @ 04:02PM PT

If you’ve been anywhere near a TV these past two weeks when the goings-on at the Senate Finance Committee were discussed, you likely saw committee-member Sen. Ron Wyden of Oregon hocking something called the “Free Choice Amendment.” Last night, the amendment was dismissed without even the benefit of a vote. It took with it an opportunity to solve a major problem in the health care reform plan moving through Congress: how do we answer those who have stable benefits through their employer when they ask, “What’s in it for me?”

Of course, I would argue there are myriad ways that everyone's experience with health care will be better after reform: from more primary care doctors to investments in quality to the protections of insurance market reform. But I understand how those benefits may not feel immediate; many of them may take years before those who have good insurance already even noticed the system was better. But Wyden’s amendment would have been an immediate change for the better. The official mantra for the reform effort is the now cliché, “If you like the coverage you have, you can keep it.” But there’s never been an answer to the question, “What if I don’t like the coverage I have, but it’s all my boss offers me?” Wyden’s amendment would have fixed that, too.

The simplest explanation is that Wyden’s amendment would open up the Exchange to anyone who wanted it, rather than limiting it to individuals or businesses of a certain size. Your choice of health insurance plan wouldn’t be limited by who your employer wanted to negotiate with, and the coverage and costs wouldn’t be limited to how successfully your employer negotiated. You don’t want the unreliable customer service and hassles of Pain in the Butt Insurance? Go find a comprehensive plan that fits your needs on the Exchange, be it Aetna, United, or (dare we dream?) the public health insurance option. As Ezra Klein puts it, “If the Free Choice Act had passed, politicians could have made a very simple argument to the insured: When this bill becomes law, you will have insurance choices just like those enjoyed by a member of Congress or a government employee.” If you’ll recall, that’s the bargain Democratic candidates have offered the American people since John Kerry in ’04.

It’s a radical change, to be sure. But it’s one that would make the rest of the bill work better. The effectiveness of the Exchange depends on how many people are in it. The more people buying from it, the bigger the bargaining clout and the better deals we’d be offered. We’ve spent a lot of time arguing whether a public option should have negotiated rates or rates based on Medicare, but neither one of those choices would make a public option as strong as making it available to everyone. Critics of the amendment claim that it will lead to young, healthy workers spurning their employer’s plan, leaving behind a population of older sicker, workers, making the plan more expensive for the company, and increasing the temptation to drop it. Opening up the Exchanges, they argue, will lead to catastrophe for employer-based insurance. Maybe. I haven’t seen numbers to support this argument (the Congressional Budget Office thinks this result is pretty unlikely). But I’m personally unconvinced. Isn’t the much better answer to this concern to apply the consumer protections and insurance market reforms that are so highly touted -- including risk adjustment, not allowing companies to charge different rates based on health, and severely limiting variance in rates by age -- to employer-based insurance?

Wyden’s amendment fell not because Republicans don’t like it (Sen. John Ensign gave an impromptu speech in favor of it), and not because Democrats don’t like it, since many have often used the inherent inefficiencies and inequalities of the employer-based system when they’ve argued for a Medicare for All single-payer approach. No, the people who really hate it are special interests. “Employers don’t like it,” Jon Cohn writes, “benefits managers don’t like it, unions don’t like it -- in each case, because it means these groups have less control over, or stand to derive less loyalty from, workers over health care decision-making.”  It's also one of the casualties of bending over to make the pledge "If you like what you have, you can keep it" as close to being fulfilled as possible.  Ironically, the same catchphrase designed to assuage us that our coverage won't get worse is getting in the way of making our coverage better.

There is a silver lining in that Wyden is likely to try again from the floor of the Senate. And even if he fails there, too, this isn’t the type of idea to go away. Once we have a stable, functioning Exchange, it can always be expanded at a future date. And rest assured, if we’re only reserving choice and competition to those who are currently uninsured, it’s only a matter of time before the rest of us say, “Yo, what about us?!”

(Photo credit: http://www.flickr.com/photos/pirateyjoe/ / CC BY-SA 2.0)