If I Were President: How I Would Have Answered the Public Option Question

Perhaps the most prominent event in the healthcare debate during the Congressional recess has been President Barack Obama’s August 15^th Town Hall in Green Junction, Colorado. I can’t seem to shake my feeling that one moment in that session captures the lost opportunities of the whole month.

From a front page story in the Los Angeles Times-08-16-09:

During an otherwise placid town hall meeting in Green Junction, CO, with 1,600 people packing a high school gymnasium, one University of Colorado student challenged Obama to an "Oxford-style debate" over the so-called public option.

"How in the world can a private corporation providing insurance compete with an entity that does not have to worry about making a profit, does not have to pay local property taxes," or face local regulations? Zach Lahn asked Obama. "How can a company compete with that?"

I had been watching the debate. This was I think the last question, and as I watched the video screen, I offered encouragement to the President, “Go for it, man. This one’s right down the middle. Don’t foul it off.”

But soon I ended up screaming some more – this time in frustration -- as Obama joked a bit with the questioner about his chutzpah and then launched into a wonky defense of the public option, basically bragging about how if you tied both hands behind its back, it might not offer such tough competition.

Here’s a rough draft of how I would have answered:

“You’re right it might be hard for private insurance to compete with public not for profit health insurance. But that’s really not my #1 priority. My #1 priority is the health of Americans.

We spend more than other nation per person and as a percentage of GDP on health and we don’t get the results. I’m committed to that changing. When I leave office, whether in three and a half years or in eight, I want the American people to be healthier.

Too many may think its unpatriotic to say the US doesn’t have the best healthcare system in the world. But that’s just a way of avoiding facing the problem and having to deal with it.

By the way, the dictionary defines courage as “the willingness to face and deal with things recognized as difficult, dangerous, or painful rather than withdraw from them.”

We have the best research hospitals. We have the best medical schools. We have the best doctors. We have the best equipment. But we do not have the best health. We do not have the best heath outcomes.

So instead of denying the truth, recognize the problem. If we’ve got the best and we’re not achieving the best – then the system is broken. We should figure out how it got broken, and we should do everything we can to fix it.

This is too important, to our economy, to our competitiveness, to our morale as a nation, and, most important, to the health and peace of mind of you, your children, and your parents.

My goal is about health. My administration will do things about prevention and education and access to early care for all. We’ll do everything we can, but your health will still be up to you and so will your healthcare. What I aim to improve is how we pay for it, and if giving more people Medicare type healthcare does that, it’s worth doing.

You see there’s a problem that explains some of the bad news – why we spend more and don’t get what we pay for. We may have the best doctors, hospitals, researchers, scientific advances, but the big reason the numbers don’t add up: Profits. Health is essential – like safety – and we don’t expect firefighters or police to make a profit.

Medicare works, and by the way, for those who don’t want government getting its hands on Medicare, I’ll let you in on a secret: Medicare is government healthcare.

Medicare has overhead of 4%. That means 96 cents out of every dollar goes to your health. For-profit insurance has higher overhead, naturally – they’ve got to make a profit, market, advertise, do tons of paperwork, and pay thousands of people to try to not pay for your medical bills. Medicare doesn’t have to do that, neither will a public program.

Think of it as giving everyone the choice to join Medicare no matter his or her age. Difference is you’ll pay premiums until you’re 65. If we can cut costs – then maybe we can lower that. It would be my goal that in the future it might be free at 60 then maybe 55.

But for now it’s not free, but your premiums are going to be lower than private insurance. Why? Because, like Medicare, a public plan doesn’t have to make a profit, doesn’t have to market – we’ll do public education to let people know it’s available, and make it easy for them to sign up, but no advertising. Just like anybody else, we’ll have people looking out for fraud – and we will commit to cutting that at every turn. Every dollar lost in fraud is a dollar not helping Americans get healthier.

And in the public choice, we’re not paying anybody to try to figure out a way to not pay your bills or to cancel your policy, or to make any decisions that are better for their bottom line than for your health.

So yes, if I were a private insurer and I looked at Medicare’s overhead and my overhead, and I saw a difference of say 15 cents per dollar, I’d be concerned how I was going to compete.

But remember, my goal as President is not to save private insurance and it’s not to eliminate it. It’s to improve the health of Americans. You know whose job it is to figure out how to compete with a simple not-for-profit alternative and make a profit -- it’s the insurance companies.

Let’s look at it two ways. If a pubic plan, that is something like Medicare, ends up doing all the terrible things so many are screaming it will do, then only the most desperate will sign up, and the private insurers will continue to make their profits on everyone else.

But if the public option isn’t half bad, if it’s as good as Medicare, then maybe they’ve got something to worry about. Then they’ve got to show that for profit insurance is worth the extra cost. They’ve got to treat patients better than the public plan, they’ve got to bring down premiums which means they’ll have to work harder to bring down costs without sacrificing quality – because now people have a choice.

And so let me return to the issue that I brought up at the top of this. All other advanced countries offer a public option, and they spend less and get better results. By the way I say "option" on purpose, because many other countries offer private insurance as well. So it is up to for-profit insurance to prove that it’s got a significant role to play in providing for the health of Americans in the future.

If the public option serves some people who prefer it and drives for-profit insurance to improve, we all win. And remember my first priority is the overall health of all Americans.”

That’s what I would have said, but, hey, I’m just a citizen.