This sounds better than the status quo but the segmentation it creates in the insurance market is absolutely baffling from a policy perspective. First, there is the inscrutable decision not to merge the buy-in program available to the uninsured and small businesses with medicare/HCFA. I can understand, I guess, a desire to preserve a different package available only to seniors, but why not have the single (or at least the largest) agency acting as a public insurer at least administer the program? I can understand this only as an incredibly nimble or overthought dog whistle to the right -- as if the right had decided that any expansion of medicare would be equated with single payer. In this respect its the opposite of Richardson's plan, which modestly expands medicare eligibility in an effort to bring support from those committed to single payer through the expansion of medicare, but, you know, without all that yucky universal coverage. Second, the Obama plan preserves some barrier between the regulated insurance market and the public plan. This basic differentiation tracks the Edwards plan, and there is, I guess something to be said for allowing the systems to compete. But I dont see any reason for Obama to restrict access to the public plan (he does so), which exaggerates the bureaucratic segmentation of his plan, and minimizes the sense of competition between public and private models. Third, the plan also preserves a distinction between the well-regulated insurance market, to which large businesses may buy in, and the wild and wooly private sector, which is restricted only by the long-overdue ban on the use of pre-existing conditions.
So we have got, in effect, five systems under Obama:
1. The British analog, the VA and other government providers
2. The Canadian analog -- HCFA/Medicare/Medicaid
3. A second indistinct Canadian analog managed by another agency (for no reason) -- the new public system to which the uninsured and small businesses may apply
4. A system of managed competition that employers could voluntarily join, with robust community rating practices, and
5. The wild wild west, where anything goes except pre-existing conditions.
The segmentation is not necesaarily a bad thing, but it is a puzzling thing. I suppose you could argue that, again, it allows us to test different models in the American context. Personally, I think the world has given us enough diversity in health care finance to allow us to rationally evaluate our options. I see more politics than policy here. Which isnt to say that it wouldn't be an improvement...