In response to reporters' questions, Rep. Stark said that any plan without a public plan option would not be supported by him, as he did not see any viable alternative. Rep. Stark also refuted the idea that Medicare was currently underpaying health care providers. Rep. Stark said that the timetable for voting on a plan would take at least a year, likely to be early 2010.

To an inquiry on how, if the government was creating the rules of the public plan, it would ensure fairness in the playing field, Prof. Hacker responded that an important element in the public plan would be that the Medicare would not be in charge of managing the plans, but run a higher-level administrative body, which would administer enrollment and competition between the public and private plans.


Parity Issues a Continuing Concern

Following the teleconference, Prof. Hacker further commented to DOTmed News on two inquiries. Asked if a public plan option would address issues that might otherwise escape oversight in regulation, such as gender and racial/ethnic inequities in accessing care, treatment and prevention, and also lack of coverage for mental health treatment, Prof. Hacker responded: "I believe so. First, I would argue for true parity in mental health treatment in the public plan, a feature of my 2007 proposal (http://www.sharedprosperity.org/topics-health-care.html). Second, the evidence is clear that public insurance provides broader access, especially to more vulnerable patients. Elderly Americans with Medicare report, for example, that they have greater access to physicians for routine care and in cases of injury or illness than do the privately insured. They are also half as likely as non-elderly Americans with employment-based insurance to report common access problems, such as skipping a medical test, treatment, or follow up, and failing to see a doctor when sick. Third, the public plan, working with Medicare and private plans, could spearhead the testing and evaluation of potential delivery-system and payment reform; the collection, reporting, and use of ongoing performance data; and the streamlining of paperwork and administration in ways that would not be possible without a core role for public insurance for non-elderly Americans. I see addressing the broader disparities in care as central to this mission."

Long-Term Care: The Next Great Challenge

Prof. Hacker was also asked if in the future, the proposed plan could be built upon to extend to disability or long-term care insurance, a major concern for those of low-income. Prof. Hacker responded, "This, to me, is the next great challenge we face in health care. Medicaid simply cannot be the way in which we handle long-term care, and private insurance is ill suited to deal with protection for long-term health costs. Commercial insurance works well to protect people against risks, such as car accidents, that vary among individuals but average out across a large population. As Harvard economist David Cutler has explained, long-term health care is different: It is almost impossible to predict how costly the care will be in 2040. Insurers face equally serious uncertainties about how much they must put aside to pay future bills. Because the private [long-term care] market doesn't work well, efforts to reduce Medicaid spending by shifting the burden onto private markets won't work well either. Tightening Medicaid rules might reduce public spending slightly. It won't eliminate underlying costs. It certainly won't distribute the burdens with greater dignity or fairness. The alternative is as obvious as it is difficult: The federal government should pay for long-term care through Medicare and the new public plan I propose, openly, for every American. That would staunch the fiscal bleeding that forces states to cut important services. It would also protect everyone from one of life's most frightening risks. But this is an agenda for the future."

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