Proposal for an Oregon medical insurance plan
I wrote this in February, after the defeat of Measure 30, for the Health Care For All - Oregon email list. HCAO sponsored the single-payer universal health care initiative Measure 30 in 2002.
Proposal for an Oregon Insurance Plan
What does the defeat of Measure 30 mean for the future of any initiative in Oregon which would expand medical insurance coverage to the uninsured? The most obvious message is that any proposal to raise the taxes of most people will be dead on arrival.
But there is another message about taxes to be found in the elections of the last several years: People will vote for taxes that OTHER PEOPLE WILL PAY. Oregonians have twice voted to increase cigarette taxes, paid by an unpopular minority, to help finance the Oregon Health Plan. (Although that just went down the tubes, whether the voters knew it or not, with Measure 30.) Oregonians have also twice voted to increase the minimum wage, not a tax but the same principle applies. People in this state do have a rudimentary social conscience, as long as it doesn't cost them anything.
So one way to finance extended medical insurance is to stick it to a minority of the voters. The obvious candidate is employers. I suggest a small tax on employers, as a cost of doing business in this state. We could sell it on the same principle as unemployment insurance, a way of covering medical insurance for the unemployed and those whose employers do not provide medical insurance. Employers would fight it on the same basis they fought the minimum wage raises - "this will cost jobs" - but that argument, so far, has not worked with the voters. Unless it was a factor in the defeat of Measure 30, but I don't think so. I don't think voters put much stock in indirect effects arguments. Too abstract. If it doesn't affect them personally, immediately, it's not real.
As a second finance source, I suggest premiums to be paid by those in the program, with the amount of the premium based on income. (Free for those with extremely low incomes.) With a generous grace period, unlike the present Oregon Health Plan, so we're not kicking people off for slow payment. Advantages of this are:
· It's not a tax.
· It breaks the connection, at least for those in the program, between having a job and getting medical insurance.
· It will sound good to the voters. "Personal responsibility" and all that.
For purposes of discussion, let's call this the Oregon Insurance Plan - OIP.
We could sell this as a voluntary government run medical insurance program for those who are uninsured or underinsured. It would be open to anyone but would not be imposed on anyone. So people who have adequate insurance through their jobs would not have to join or pay taxes to support it. Therefore it shouldn't be threatening to the unions. Or perhaps even the insurance companies, although it would be a possible competitor. If we're going to talk about experimenting with setting up a privatized program to compete with the present Medicare, why not do the reverse and set up a government program to compete with the insurance companies? Actually we might only be competing for the people the insurance companies don't want to insure, or insure adequately. And for those in it, at least, this would be a single payer program. If all the studies about saving money with single payer are right, it seems we ought to be able to work out the numbers so it would fly.
I would not try to incorporate Medicare in this program, as we did with Measure 23, because:
· We would have to get a federal waiver to do it, and that always seemed doubtful to me.
· It would strike a lot of people as very radical, and might sink the proposal.
· We would be accused of "trying to take over Medicare."
· Medicare is a federal program and I think it's funding is safer than anything run at the state level. It has its own dedicated fund.
· Medicare has a clear identity in the public mind and a national constituency. It needs a lot of improvement but there is also a lot of pressure to do that. I just think it's best to leave well enough alone.
However, our plan could serve as supplemental insurance for those on Medicare who choose to join. Again, it's voluntary, we're not forcing anything on anyone.
As with Measure 23, we could try to incorporate the Oregon Health Plan into OIP in order to get the federal matching funds for those clients eligible for Medicaid.
We would need a rule that if you have any kind of medical insurance, that pays before OIP pays.
Others who could join OIP would be the self-employed and people who have insurance through their jobs but it's inadequate. All these groups together - unemployed, self-employed, working but not insured, underinsured, Medicare supplemental - should give OIP a significant constituency, which the plan would need to be politically viable, and a large premium pool.
It's not single payer universal health care for the whole state, but it would be a significant step in that direction with potential for expansion, would solve the problem of the uninsured and underinsured at an affordable cost, and might be politically salable.
Any initiative needs to be simple, something you can explain in a few sentences, both for getting signatures and for the campaign to pass it. I think Measure 23 was too complicated. So was Measure 30. Activists tend to forget that most people don't understand very much, if anything, about politics. Here is the simple explanation for OIP:
"This is an initiative to set up a state medical insurance program to cover everyone who is uninsured or underinsured. It will be voluntary - people can join if they want to. It will be financed by a small tax on employers and premiums paid by those on the plan."
I would have it run by a state agency under the control of the governor. I think Measure 23's plan to have it run by a public nonprofit with an elected board was too complicated and hard to understand. Keep it simple and close to what people are used to.
Its funding needs to be dedicated to the plan so the state legislature, unless it changes the law, cannot move funds to other programs. I think if this passed it would be hard for the legislature to get a majority vote to reduce its funding.
It would be very important to get the numbers right. We don't want that to be an issue like it was last time. And the numbers must work when Oregon is in a recession, as it is now. If we could get a state senator or representative to work with us on this, perhaps we could get the help of the state Legislative Revenue Office in getting the numbers right.
Perhaps we could base costs per person on what OHP cost per person, before the legislature cut benefits.
There should be some reasonable restriction on treatments covered, perhaps similar to what good commercial insurance excludes. It should be similar to the coverage most people get who have insurance through their jobs, so that we don't run into the envy problem.
I would exclude long-term care, leave that to Medicaid, because it would add so much to the cost of the program.
The state legislature, in its last session, passed a bill to set up a Prescription Drug Purchasing Pool to reduce drug costs to those in the pool. Perhaps OIP members could be added to that pool.
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