October 26, 2009, by Jocelyn Richgels.

 

As they say, only two things are certain in life, death and taxes, but each day, it looks more and more likely that a public option will be included in health reform legislation that makes it to the Senate and House floors.  What that public option looks like is still anyone's guess, as there are at least half a dozen different ideas being floated around the halls of Congress.

 

In the Senate, it seems likely that one of three different suggested versions of a public option will be included in the merged HELP and Finance committee bill that is introduced in the next few weeks.  The different options in the Senate are all routes to how and when a public plan might be implemented. The first option, a public plan with a trigger mechanism, has been proposed by Senator Olympia Snowe (R-ME), whose every comment is analyzed for a yes, no or maybe vote on the final bill.  Under this option, a public plan would only be "triggered" if certain market conditions are not met, such as adequate choice of plans and affordable premiums.   Another option, proposed by Senator Tom Carper (D-DE), would allow states to opt-in to a government plan or create their own version of a public plan.  A modified version of the opt-in proposal has been suggested by Senator Chuck Schumer (D-NY) and would require states to opt-out of a public plan instead of allowing them to opt-in.  If a straight public option cannot be achieved, the opt-out version is the one most likely to be supported by the progressive end of the Democratic Caucus.  As recently as today, however, Senator Snowe continues to voice her opposition to a public plan, including an opt-out version.  Health coops, as approved in the Finance Committee bill, appear to have fallen-out of favor, primarily because very few progressive Democrats want to consider it and it is not clear how they would be structured. 

 

In the House, Speaker Nancy Pelosi has begun surveying Members on the type of public option they would support.  The versions being discussed in the House all have differing payment structures to providers.  The "robust" public option, which provides Medicare payment levels + 5% is the version favored by Speaker Pelosi and the liberal members of the House because of its ability to reduce costs.  The Congressional Budget Office has indicated it would cost about $871 billion over the next 10 years.  More conservative Democrats, including many rural members, are less supportive of the "robust" option.  Rural members fear that Medicare +5% will not pay their rural providers enough to stay in operation.  The other option being considered would offer negotiated payment rates to providers, which would not be as robust at keeping premiums lower.  This would also keep costs below $900 billion, however, but only with an additional expansion of Medicaid to 150% of the federal poverty level (which is cheaper than providing subsidies for people to buy insurance on their own) from the 133% currently proposed.  And a final version being considered would include a public plan option that initially allows negotiated rates, but could switch to Medicare + 5% rates if certain criteria are not met.  While Speaker Pelosi has publicly stated that she is close to 218 votes for a Medicare-based public plan, close is not good enough in the final vote tally.