Health Care Reform: Where Do We Go From Here?

Now that this bill will become law the important question is where do we go from here on health care reform?

I have said before that I think this bill is deeply flawed and, most importantly, does not provide an clear pathway to eventually getting real reform. But now that this bill is the new reality, now is not the time to stop fighting. I do not plan to stop fighting until we have achieved real health care reform. Like it or not, we are effectively forced to work from this new starting point. All the groups that were saying this bill must pass because it is a "positive first step" now need to quickly begin preparing for the next step.

What to do next is a question that has been weighing heavily on my mind lately. I'm going to lay out all the possible actions that I have thought could be pushed for on a federal, state, and organizational level. Some of these ideas, I think, are workable, and some, I think, are more fanciful. This is not meant to be an edict to the progressive community, but just an attempt to ferret out some potentially smart actions. There are many hardworking groups, big and small, that care about real health care reform, and there is no reason that all of them need to push for one particular set of changes.

I would love to hear your thoughts about my list of ideas--and about any other possible, directed actions you think could make health care better. Keep in mind that the main part of the bill goes into effect in 2014, so it is critical to make changes before the concrete really starts to set, and this new, mandated private insurance system becomes entrenched.

Federal Actions:

  1. In the next few days, strongly push for a senator to introduce a public option amendment during reconciliation, which would force an up-or-down vote in the Senate. (This effort is already in the works)

  2. Based on Harry Reid's promise to Bernie Sanders, strongly push to make sure the next budget -- which will shortly be voted on -- contains reconciliation instructions that could be used to add a public option.

  3. Maintain a strong, continuous campaign for the public option. Effectively try to make it a litmus test in all Democratic primaries until the pressure is so strong they pass one. Ask Democrats to vote against any budget that does not have reconciliation instructions that could be used to create a public option.

  4. Try to get small changes to the state waiver provision enacted to allow states to try single payer or other more effective health care systems. (This could appeal to Democrats and Republicans because it would technically allow states a way to get rid of the individual mandate.)

  5. Focus on possible bipartisan efforts to pass drug re-importation.

  6. Focus on regulation enforcement by pushing for a national exchange with a national insurance commissioner to enforce new regulations.

  7. Run a campaign to make exchanges possibly workable by repealing the insurance anti-trust exemption and instituting plan standardization, strong risk adjustment mechanisms, and a central provider reimbursement negotiator (all-payer system).

  8. Try to effectively eliminate for-profit health insurance through direct law or an extremely high minimum medical loss ratio (roughly 93%).

  9. Advocate for a slight re-design of the exchange/affordability tax credit system so that it is less destructive to abortion rights.

  10. Push for single payer through a slow expansion of Medicare and/or Medicaid.

  11. Try to fix the undocumented immigrants language to at least allow them to buy insurance with their own money.

  12. Try to get bipartisan pressure in Congress to adjust the individual mandate, or eliminate it until there is a public alternative.

State Level Actions (which are, alas, somewhat restricted by the bill that passed):

  1. Try to get as many states as possible to adopt the Cantwell “Basic Health Plan” for people making between 133% and 200% FPL.

  2. Try to get as many states as possible to create their own public options with auto-enrollment.

  3. Push to make state based exchanges possibly workable with strong risk adjustment mechanisms and a central provider reimbursement negotiator (all-payer system).

  4. Make all insurance companies in state exchanges sell a defined standard plan to provide apples-to-apples comparison shopping.

  5. Effectively end for-profit health insurance in the state and/or new state exchanges with law or very high minimum medical loss ratio.

  6. Begin laying the groundwork for a better health care system with the state waivers that start in 2017.


  1. Given how much enforcement is left up to the states, create a national campaign infrastructure to ensure that progressives are elected in those states with elected insurance commissioners leading up to 2014.

  2. Using the co-op program money, work with labor unions and progressive organizations to create well-run, cost effective, non-profit insurance companies all across the country.

Thoughts? Ideas? Just please try to say focused on talking about best possible ideas for moving forward.

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