Pearlstein on Health-Care Reform

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Steven Pearlstein
Washington Post Columnist
Wednesday, August 19, 2009; 11:00 AM

Washington Post business columnist Steven Pearlstein was online Wednesday, August 19 at 11 a.m. ET to discuss health-care reform.

Pearlstein won a Pulitzer Prize in 2008 and is co-moderator of the On Leadership discussion site.

Read today's column: It's Time to Give Up On the Public Option.

A transcript follows.

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Atlanta, Ga.: Can you explain to me what the following comment means? And is it true? "Everyone will eventually be forced to take the public option except government employees."

Steven Pearlstein: What it is is a lie perpetrated by Republicans to defeat health care reform.

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Rockville, Md.: I am a federal employee. I have a choice among many possible insurance plans. I have chosen one of the more expensive ones (I pay a little over 30% of the premiums)and have been very pleased thus far with the range of doctors that I can access and especially the speed with which my claims are processed. I recently called to ask if a procedure had been pre-approved and was informed within just a few seconds that my plan did not require pre-approval for that procedure. It is clear that the computers at the other end are online and the people answering questions are well-trained. Last year a scheduler at a testing center nearly cried with relief when she heard what my insurance plan was.

I presume that I get this excellent service in part because if I had a bad experience, I could switch to another provider during the open plan period. Unlike a person working for a private employer with a choice of perhaps two or three plans both from the same provider, who would have to appeal to the deaf ears of the employer's HR department, my choice is meaningful. I might have to wait out 13 months in a plan I didn't like, but that is it. No worries about pre-existing conditions, or qualifying for coverage or anything.

So, could this model actually work for the uninsured pool of people? Could the government demand that the insurance companies offer the same plans available to federal employees to the pool of uninsured or not let them participate in the program? Could it just be negotiated that way since the potential pool is so large and the premiums will be subsidized for some? Could non-profit cooperatives have the clout to get this?

Or do I only get service this good because the Senators and the Representatives are in the same plan that I am (or at least their staff are) and the insurance companies treat us better so they don't make the powerful people who share our plans angry?

Steven Pearlstein: The Federal Health Plan provides the model for the so-called exchanges that are at the center of the Democrats' health reform proposal. Everyone who buys insurance through the exchange would basically have the kind of choices you do, and be able to move around from plan to plan in a way creates an ongoing competition among the plans, not only on the issue of price but quality of service and depth of network, etc. That is the kind of competition that will improve the whole system and, to a degree, help to bring down cost growth.

And no, it is not because Congressmen are also in the plan.

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Monmouth, Ore.: Good morning, Mr. Pearlstein. I hope to see a public option but I am growing increasingly pessimistic. I do not fully understand "co-ops" but think they might be somewhat acceptable if, like minimum wage laws or smoking restrictions, they are left to the states. I live in a "blue", progressive state. I would envision Oregon joining Washington and then California to form a West Coast regional co-op with clout. I would expect something similar in New England, Great Lakes, etc. I would also guess that the "usual suspects", i.e. Kansas, Alabama, etc. would have pretty meager offerings. I do not like this have/have not scenario but would find it preferable to the existing situation and think some states would do some really good, innovative practices. Is any of this valid in your opinion? Thanks.

Steven Pearlstein: You could have all sorts of co-op models, but the one I like is the one where the hospitals and doctors groups are part of the ownership and control structure and assume some or all of the insurance risk -- that is, they accept a fixed annual payment per enrollee to provide all or most of that person's health care. In a sense, the providers also take on the role of insurer. If this sounds like an old fashioned, closed panel HMO, it should. It remains the best model for rationalizing the use of a fixed amount of resource (monetary as well as human) and better aligns the incentives of providers, patients and payors.

The size of the co-ops is a good question. You would want them to be large to the degree they contract for services, as in the case of the more populous states. But to the degree that they are built upon local monopoly providers in rural areas, they need not be big.

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Longmont, Colo.: There are repeated references to U.S. business's relative disadvantage because of the high cost of health insurance for employees. In your view, what would be the best possible change in the system for the health of American business? How likely are we to get the change you believe would be most helpful?

Steven Pearlstein: If you make that argument in front of most economists, they would chastize you because, in theory, the money employers pay for health care actually comes right out of workers wages. There is a lot of truth to that -- that Americans have given up wage increases for health care coverage. But I do think there are wrinkles on that general theorum that put US exporters at somewhat of a disadvantage. It would be good to begin a process of transferring more of the cost of health care back to the individual so we all become more cost-conscious consumers, at the margin. And in the process of doing a better job of controlling costs, we could also improve the cost competitiveness of American businesses.

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Washington, D.C.: Steven,

I thought the real advantage of the public option was creating competitive health-care coverage independent of employers that everyone would have access to. To me, that independence is key. It changes the competitive dynamic b/c insurers have to then offer competitive coverage that is not limited to employer plans.

Steven Pearlstein: I think you are conflating two issues.

Most people still get their insurance through their employer, and those people would not have access to the public option unless the employer were to give up the current arrangement and buy insurance for his employees through the new exchanges. That might be good for everyone, and many will do that over time. But at least initially, the exchanges will be limited to people buying individual insurance for themselves, and small businesses. The hope is that over time the exchanges open up to larger and larger businesses until they effectively become the health insurance market for almost everyone. That would be a sign that they are working, since it would mean that they offer the best value and choice.

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Anonymous: I haven't read that much hogwash about health care in quite some time. Throughout the article you can literally feel the pro-industry bias. How dare you compare a fundamental need, health care and insurance, to cars? A car is something optional. I can go out and buy an old clunker, but health care? Even you should see the difference. You argue against a public option, but than you want other country's public or socialized health plans to keep the cost of medicine down. The same plans that you argued just a paragraph before would not and could not keep cost down.

Health care is a little bit more than just making the almighty buck! It has something to do with morals and social responsibility, which all insurance companies lack. A government-run health care system would surely not be perfect, but way better for the people than what we have now.

Steven Pearlstein: Well, I'm wondering what industry you think I'm in the bag for. Doctors, who I want to put on salary? Drug companies, whose prices I want to cap at 150 percent of those in England and France? Insurance companies, whose loss ratios I want to peg at 85 percent? I think before you question my motives, you should read what I say and understand how this market works. I also believe a minimal level of health care to be a fundamental right, which is why I care a lot about passing this bill to provide it to all Americans regardless of income or employment status, at a fair price.

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NBC/WSJ Poll shows Republicans believe lies over facts in health care debate: The fact is that your side of the debate has failed the fact test and you have failed to correct your fellow right wingers on their lies.

Your side depends on lies like "death panels" (Palin) and "killing Grandma" (Grassley), lies like the bill giving health care to illegal immigrants, lies like the bill paying for abortion, and lies like stopping care to the elderly. These lies are believed by your side in overwhelming proportions.

People like you who habitually favor the interests of business over the interests of people at least have a requirement to tell the truth and speak out against egregious lies.

Where are you in correcting outrageous lies that favor your side?

Steven Pearlstein: I don't know what side you think I'm on. I probably wrote the earliest and toughest column criticizing the Republicans on their death panel lies. But when liberals overplay their hand, I criticize them too. I'm an equal opportunity critic, which is what most Washington Post customers have come to expect of me and what real journalism is about. I'm a journalist, not a blogger. You?

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Kensington, Md.: Mr. Pearlstein, would you be so kind as to disclose all of your associations (paid and otherwise) with the various players in the health care reform battle? Because I found your column today quite misleading.

You blithely swept aside the extremely high efficiency of the Medicare system with vague claims that the things it currently doesn't need to do would magically make it as inefficient as the current collective of bloated corporate welfare queens we have in the private "insurance" middleman industry (who don't really produce any good or service, but simply enrich their profit takers). Do you have any tangible basis upon which to base your hand-waving, industry-serving dismissal? Thank you in advance for your response.

Steven Pearlstein: I have no affiliations other than being a customer of Aetna. And I have read several rather authoritative studies on Medicare's efficiency. It is very efficient at what it does. But all it really does is play claims, which is not all that a successful insurance company does in a competitive market.

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Ridgecrest, Calif.: Why do most leave out tort reform?

Steven Pearlstein: I don't. Read my last column. Or the ones before that. Can't deal with every subject every time I write about health care.

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New Haven, Conn.: You accuse "public option" enthusiasts of lacking an understanding of the market. But you leave this reader with the impression that you don't understand the interaction of politics with the highly concentrated, oligopolistic insurance market.

You write that "cooperatives could significantly contain costs, provided the cooperatives are big enough" and use annual-per-patient billing. Do you seriously believe that Congress, which appears to be wholly in the thrall of the insurance lobby, will make these as-yet-ill-defined "cooperatives" into entities with sufficient market power to cut seriously into insurance company profits? No way. The cooperatives are going to be entirely neutered, precisely so that they cannot eat into insurance company margins. Your antitrust-related ideas are pipe dreams for the same reason. Look -- the reason people like me favor a public option (or some similar nonprofit or whatever that is NATIONAL in scope and has the power to bargain) is that only something that huge stands a chance of fighting the incredible market power of the insurance companies.

David beats Goliath in the bible story, but economics teaches that it takes a Goliath to beat a Goliath. You say our side doesn't understand markets? J'accuse!

Steven Pearlstein: Basically, you're just spouting liberal talking points, and you're confusing all sorts of things. There are well run cooperatives right now that are quite competitive. And the kind I have in mind, where the cooperative actually is made up of major providers, doesn't need "market power", as you use the term, because it doesn't have to negotiate with doctors and hospitals for a good rate. It IS the doctors and the hospitals.

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Arlington, Va.: A few questions:

1. I'm confused by the reasoning in your article. How is it that regional co-ops might work, but a national public option won't work? Is this a political judgment, or an economic one? If based on the economics, based on what evidence?

2a. If private insurers can compete on cost, and there are in fact no potential savings with the public plan, what's the harm in putting the hypothesis to the test?

2b. If the private insurers can't compete on cost, but they can compete on quality, then it would seem that there will still be a place in the market for the best companies, correct? (This is the case in Germany, at least, where they have a hybrid public-private insurance system -- albeit a heavily regulated one).

2c. If the private insurers can't compete on price or quality, then what's the basis for their existence in the first place?

Steven Pearlstein: A national public option could work, but not if it is Medicare for All, which is what most liberals have in mind when they think about it. If it piggybacks on Medicare rates to providers, then it will have an unfair advantage and will morph into a single payer system, which is why some liberals like it -- it is a Trojan horse to single payer. If it doesn't get to piggyback but is just another non-profit fee for service plan, like Blue Cross, then it won't add much. If it is structured as a new way of delivering care that is better at holding down costs and improving quality, that it could really be useful and I'd be for it. That's why I like the cooperative idea.

My problem with the public plan is both economic and political. Economically, the people pushing for it want the worst version, Medicare for All. That won't do much except in areas where there is one hugely dominant firm. Politically, it has proven to be a disaster -- the political equivalent of leading with the chin. It just gives the Republicans the opening to talk about a government takeover of the system, invites opposition from the insurers and the doctors and the hospitals and, frankly, makes too many Americans skittish. Politically, there are just better ways to accomplish the same goals of creating more competition and holding down costs.

Why do liberals cling to it now so tightly? That's simple. It has nothing to do with policy and everything to do with politics. They want to win. They won the election, they hated George Bush, they hate the Republicans and they want to prove that they are in charge and can do what they want and don't have to compromise with people they despise. It's Hatfield and McCoys, it's partisan warfare and they're out to crush the other side once and for all. That's what animates them, not some longstanding, abiding love of a public option, which most of them didn't hear about until two months ago. Universal coverage -- now that's something to go to the barricades over. But public option -- its just become this huge political metaphor for the liberal agenda.

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Chicago, Ill.: Hey Steven, is there a good way to erode if not break the link between employment and health care without a public option?

Steven Pearlstein: Yes, there are lots of ways to do that, but the public option has almost nothing to do with that.

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Kalamazoo, Mich.: I've heard that the reimbursement rates paid by Medicare and Medicaid result in cost shifting to private insurers.

Since private insurers can recover the higher costs in premiums, is this really cost shifting or are the private insurers less motivated to drive the hard bargains necessary to get similar deals?

Isn't this a failure of the market to provide competitive pricing? What am I missing?

Steven Pearlstein: There is cost shifting, and the reason is that hospitals have more bargaining power, on average, than even insurance companies, for the reason I mentioned in today's column. The reason hospitals accept lower Medicare and Medicaid rates is because they sort of have to if they want to stay in business -- those programs are just too much of the market in most places. But your question is a good one, because it points out that hospitals do have the power to cost shift onto all private payers.

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Washington, D.C.: Steven: I have often read of the government not being able to negotiate drug prices for Medicare, etc., but I am not familiar with the history of that prohibition, or the logic. Can you explain? Thanks.

Steven Pearlstein: The law says they can't negotiate, which in the case of Medicare isn't really negotiation but dictating prices, since Medicare is so big it can say. Here's what I'm willing to pay, take it or leave it, and in most instances drug companies would be better off taking it. That's because Medicare is so big and in the case of drugs most used by seniors, it IS the market. Without the ability to "negotiate," Medicare is forced to pay whatever the drug companies charge unless it wants to threaten to take a drug off the approved list. But that is a cumbersome process that is frought with politics and, except in the case of these drugs that cost $100,000 a year, Medicare has not chosen to do that. It would be good, however, if in this bill Congress were to set up a process of assessing the cost/benefit of all new and existing drugs that can be used in a more active process of deciding which drugs Medicare will pay for and which ones it won't. Remember, until recently, a lot of drugs weren't covered under Medicare until Part D was passed in the Bush administration.

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Pittsburgh, Pa.: Hi,

I'm pretty unclear on what is in the health-care reform bills beyond a public option (or not) and counseling about living wills. One thing that does seem to have bipartisan support is preventing insurance companies from using "pre-existing conditions" to deny coverage.

How will this be accomplished in practice? It seems like the insurance companies are always going to be trying to avoid doing business with unhealthy people who cut into their profits. Even if they are prohibited from using pre- existing conditions explicitly, can't they just do things like construct policies that provide lousy coverage for chronic conditions? Is this going to evolve into a cat and mouse game where the companies are always coming up with new schemes to mostly cover healthy people, and the regulators are always trying to keep up?

Steven Pearlstein: People do worry about those kinds of games that insurance companies can play to discourage sicker people from signing up. Regulators can try to prevent those practices. But the better disincentive is that most of the plans envision some form of what is called risk adjustment, so that insurers what wind up with a healthier pool of enrollees will be required to make a payment to competitors who wind up with a sicker pool. The aim is to remove the incentive to cherry pick, since if you get a young, healthy set of customers, your premiums, net of risk adjustment, will be reduced to reflect that fact. The idea is to get insurers to focus on other things.

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Midlothian, Va.: The reason liberals and the progressives like the public option because in their judgment that is the only way to ensure there is a health coverage for everyone. Not because they want to win or they hate Republicans. I did not expect that kind of logic from you- I thought that kind of talk was reserved for folks from Fox News. Why are you being abusive to liberals?

Steven Pearlstein: There are lots of different ways to insure universal coverage without a public option. Even those supporting it don't argue that as the rationale. If you tell everyone they must buy insurance, give subsidies to those who can't afford it, and require insurance companies to take any customer that wants to buy a policy, you can have universal coverage within the context of a private system.

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Washington, D.C.: Ummmm... Steven... the public health insurance plan option has been widely discussed and dissected over at least the last three years in health policy circles, journals, conferences, etc. The cooperatives idea was resurrected from the dead (last death by withering in the 1990s) three months ago or so by a Senator desperate to find a compromise position that isn't the public plan option.

Steven Pearlstein: Yes, in health policy circles. But most people didn't hear about it until the last few months.

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Princeton, N.J.: You may be surprised to learn that I agree with much of what you say today, at least in the first half of your column. You say, "But if a government-run plan had to spend its own money to collect premiums, market itself to customers, maintain a reserve, and manage care in a way that lowers costs and raises quality -- none of which Medicare now does -- then you can be sure its administrative costs would be nowhere near 2 or 3 percent." Right, but you, of course, realize that none of these objections apply if we simply give Medicare to everyone; we would thus keep the low overhead as other countries have achieved.

But your remedies are not only as impossible to achieve politically as HR676, they would simply be putting band aid on a TB patient when the rest of the world is using antibiotics. For example, you say, "There is also a provision requiring that companies participating in the new insurance exchanges use no more than 15 cents of each premium dollar for administrative costs and profits." Not only will this undoubtedly be cut, but it would be a pale imitation of single payer systems which spend less than 2 cents on anything other than benefits. Work it out. That's about $140 Billion each and every year that you would be happy to pay private insurers who add nothing to health care. And you didn't mention the enormous compliance costs.

Face it. I know I've lost, but you have lost also. It is now clear that nothing that interferes with the obscene compensation of insurance and drug company executive or with the high returns to their rich stockholders will be passed. I will bet you dollars to doughnuts that none of your half-hearted proposals will pass. (Why should we pay 50% more for drugs than everyone else when drug companies spend 3 times as much on marketing as on R & D?)

Frankly I place a large part of this failure of democracy on the media. As Ezra Klein as pointed out, single payer advocates have for years quietly presented well-informed proposals which have been totally ignored by the media. Since 2003 every poll (except for Rassmussen) has shown that the public prefers Medicare for All to a system based on private insurance through employers by 2 to 1. I can understand how the insurers have bought our politicians. I can not understand how they bought the Washington Post.

Steven Pearlstein: Len, I'll just let you have your say, without further comment.

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Comment on Latest Column: Steven: Posting early. We are holding up progress by accepting nothing less than a perfect bill. This will be the first in a series of bills needed to fix our health care system.

In many states, there is not much real competition, with only a few carriers that don't write new policies for pre-existing conditions. Cars and toilet paper can be understood by most folks, like commodity items (sugar, flour, gasoline). Most of us (including docs) can't understand all the rules and regs for health care, nor our own policies. I want them to get out of the conversation between my doctor and me.

I wouldn't worry about losing the war, because even after bi-partisan negotiations, no Reps in the House voted for the stimulus bill, and are unlikely to do so here.

I don't think co-ops are going to be enough to do this work; they certainly aren't doing it well now. What is working well is outcome-based reimbursement.

Btw.... My insurer spends 28-30% on admin (according to their annual report), including multi-million executive pay and perks. This will be unnecessary with a government plan that can optionally collect premiums through electronic payments.

Steven Pearlstein: I sincerely doubt their loss ratio is 70 percent. But if it is, that would be outrageous. So, let's deal with that. A public plans is not the only way to deal with it.

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Princeton, N.J.: You are a dreamer. Can you imagine a government panel telling Pfizer that it's taking Lipitor off the list in favor of generic statins?

Steven Pearlstein: Yes, I can. That doesn't mean somebody can't have Lipitor if he wants -- he just has to pay the difference between Lipitor and a generic out of his own pocket. Those big bad private insurers do that all the time now, in case you hadn't noticed. And it has worked in helping to keep down drug prices and health expenditures.

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Batesville, Va.: You state that a public plan will be unable to match Medicare's 2-3% administrative overhead. However, you neglect to provide the typical overhead and profit numbers for private health insurance companies. You also fail to explain exactly why we pay more than twice per person than other advanced countries.

Steven Pearlstein: It's not because all the money is going to insurance company profits, if that's what you are implying. Its because we pay more for drugs, because we pay our doctors more, because we have the administrative and profit expenses for hospitals and insurance companies, because we demand more services, because we have doctors who encourage overconsumption of tests and procedures. Its complicated. But its not just because of big bad insurers who can finally be tamed if we would only bring in a public option to keep them honest. That's tooth fairy thinking.

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Atlanta, Ga.: Steven, your description of the risk adjustment mechanism proposed for private insurers in a previous question sounds like a roundabout way to achieve a national pool, which seems to be an economic requirement for true efficiency in a universal coverage system. Back door, for-profit way to outfox single payer advocates.

Steven Pearlstein: The initial observation is correct -- it is a way of achieving universal coverage within the context of a private insurance market in a way that is fair. Got a problem with that?

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Fairfax, Va.: Mr. Pearlstein,

You wrote this morning:

"But there's no particular evidence that a government-run insurance plan will be any more successful than what we currently get from big private insurers -- unless, of course, the government-run plan is so big or so powerful that it can dictate prices to providers, as Medicare now does. Proposing that, however, would immediately unite doctors, hospitals and drug companies in opposing reform."

So, it sounds like Medicare is the evidence that government run insurance IS the evidence that costs can be brought down. The only "obstacle" is the union of medical special interests to oppose reform. Since the government makes the laws, why is the opposition of special interests a problem? Why can't the government show resolve and take on the special interests and do what's right for the American people?

Steven Pearlstein: Its not the special interests that are opposing reform. They are working with the administration to advance a reform that they can live with. And by and large, it is yielding a pretty good result. The opposition is mostly coming from narrow slices of the industry (Blue Cross plans, for example, rural hospitals) but more generally from Republican partisans and conservative ideologues. In many instances, the special interests are running TV ads promoting health reform.

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Washington State: First rule in negotiating: Ask for much more than you actually want.

Perhaps the public option was chiefly a negotiating tool to get the actual reforms like the uninsurable/preexisting condition individual and get sick/go bankrupt reforms?

Steven Pearlstein: Maybe it was. At this point, however, it is the weapon that reform opponents are using to cause ordinary people to back away from reform. It's not worth holding on to any longer.

One of the things Washington insiders tend to forget is that this battle needs to be waged at two levels. One level is the inside game here in Washington. But the other is the effort to get the American people behind this thing. You can't get health reform by just focusing on one of these or the other. If the American people start to turn off to health reform, then Democrats can's simply "ram it through Congress" based on their majorities. Too many Democrats will bail out.

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Atlanta, Ga.: Are you tired of being accused of being a conservative or liberal partisan? It's as if half of the country really believes that you can only be in one mindlessly partisan camp or the other.

Steven Pearlstein: Yes, I AM tired of that.

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Salinas, Calif.: "...the one I like is the one where the hospitals and doctors groups are part of the ownership."

That's assuming the medical hospital as health-care center remains the model. Denis Cortese, CEO of the Mayo Clinic, describes that model as "sickness care", not health care.

Where would a change from fee-for-service to a closed fixed cost system leave alternative licensed practitioners, like chiropractors, in this model?

Steven Pearlstein: It would leave them wondering if they shouldn't join a coordinated care group.

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College Park, Md.: It sounds like the insurance exchange may not be as profitable as the employer insurance market. Why would insurance companies participate in the exchange? Or will it be a requirement? Thanks.

Steven Pearlstein: It won't be as profitable as the individual and small group markets are now in most states, you are right. But the insurance industry is willing to live with that if they can get an extra 40 million customers.

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Washington, D.C.: I don't like the sound of your response to Monmouth, Oregon above. Isn't it a huge conflict of interest to have doctors decide to control costs if their paychecks depend on ensuring costs are cut? They could easily decide providing some care, for example, to terminal patients is not really cost-effective, and so not offer it. I can also see some huge lawsuits resulting from this sort of operation. We buy health insurance so we get the valiant efforts from physicians. This co-op idea seems to mean an end to valiant efforts to save lives.

Steven Pearlstein: Any insurance plan that earns big profits, or big salaries for its doctors, by denying coverage won't be very competitive in the long run, will it? Consumers, rightfully, are very sensitive on this issue and if your insurance company is known as the one that denies coverage for everything, you won't be in business for long. The market isn't perfect, I grant you, but it isn't totally dysfunctional either.

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Burlington Vt.: I am sure, Steven, that you have health care from your employer. How would you feel about the issue if you were, say, uncovered, and self employed, and like me supporting a family of four, all uninsured? I am sure you'd love a public option. We don't want health care for free; we just want it for a competitive price. Is that unreasonable?

Steven Pearlstein: What you would love is a good insurance exchange where you get the equivalent of large group rates on a wide range of different policies, and premium subsidies if your premiums exceed 12 percent of your income. The public option is not necessary to provide you with a choice from among a number of private options that you can afford.

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washingtonpost.com: For those interested in further discussion on health care reform, join our chat with David Certner, legislative policy director at AARP, live now.Health-Care Reform: The AARP Perspective

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Richmond, Va.: Why the insistence on making the "public option" the rallying cry of the far left? The Far Left would prefer a single-payer system. The middle ground is a public option. Recent polling showing a slight disfavor for the public option only proves that the misinformation campaign (death panels, free health care for illegal immigrants, and "socialism")has worked.

Steven Pearlstein: That comment reminds me of the Saul Steinberg map of the United States where New York takes up half the map. Your perspective seems a bit skewed toward the left. The evidence is that the center of gravity of American politics is not at a public option.

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Washington, D.C.: Thanks for your as always thoughtful column today, in which you said, as the president did, that the public option is not a big deal. But what about the politics? There are 60 Democrats + Independents in the Senate and a 78-seat majority for the Democrats in the House, and yet it seems that it's the Republicans that are setting the agenda. If the public option isn't a big deal, shouldn't the Democrats just insist on it? Whether she's right on the merits, isn't Rachel Maddow right when she says the Republicans really don't want health-care reform at all, and the Democrats should just go ahead and pass the best possible bill now, while they can?

Steven Pearlstein: It looks like the Dems will have to pass health care without much input from Republicans until the final vote, when I suspect more than a few will vote yes rather than have to defend a no vote to their constitutents. Maybe that is the way it has to be. But Dems shouldn't take that as a signal that they can go ahead with an overly liberal bill, because it still has to pass muster with the American people and the American people have made it pretty clear they don't want a government-run health plan. They may be stubborn and wrong about that, but that is where they are and Dems would be better to start off with a somewhat more centrist program and, once it has proven its worth, continue to perfect it. My experience is that if you can get three quarters of a loaf, take it.

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Steven Pearlstein: Out of time. Good discussion. "See" you next week.

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