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How to fix health policy.

A Decoy Gambit? How badly does Obama want to impose pricing limits on health insurers?

By Timothy NoahPosted Monday, Feb. 22, 2010, at 6:25 PM ET

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Barack Obama

"Watch out for people who lure you away from the real issue with the Decoy Gambit," warns Roger Dawson, author of Secrets of Power Negotiating. The decoy gambit is a negotiating tactic in which Party A introduces a demand he doesn't really care about. If all goes well, Party B will make a concession to persuade Party A to drop his insincere demand. Dawson claims the decoy gambit is unethical (though he admits he used it once to lower a hotel bill). I say all's fair in politics.

Allow me to explain. On Feb. 22, President Obama introduced a White House proposal on health care reform, crafted from the bills that already passed the House and Senate. The proposal adds some minor features of the House bill to the Senate bill, none of them very surprising to people who followed the House-Senate negotiations that occurred before Republican Scott Brown's election to Sen. Ted Kennedy's Massachusetts seat blew them all to hell. For example, the White House plan makes subsidies to people who purchase nongroup health insurance a tad more generous to people at lower incomes than the Senate provided for. It also adopts a few Republican proposals, none of them of any great moment, aimed mostly at battling fraud in Medicare and Medicaid. And it further scales back the ill-advised tax on high-value "Cadillac" health plans by raising the threshold (which started at $23,000, then rose to $24,000) to $27,500 and by putting off its implementation (for everyone, not just union members) to 2018. To take up the revenue slack, the White House builds on the Senate bill's 0.9 percent Medicare surtax on family incomes above $250,000 by adding, as foretold, a surtax on investment income for families in that same income group. Also unsurprising is what the White House bill doesn't include. It contains no public option, and it doesn't address how health insurers receiving government subsidies may treat abortion. The failure to resolve this last question, which has lately received scant attention, poses the biggest obstacle to health reform's passage.

So far, absolutely nothing to cause Republicans to cry, "I was blind, but now I see." This is essentially the same bill the GOP has opposed all along.

But the White House also added something new. Something bold and somewhat surprising. It added a proposal that would give the federal government veto power over insurance premium hikes. I suspect this provision is a decoy—something the White House added so it could be bargained away later.

Under the Obama proposal (which was modeled on an amendment by Sen. Dianne Feinstein, D.-Calif., that never got a floor vote) the Health and Human Services department would create a new Health Insurance Rate Authority to review health insurance premium increases and determine whether they're fair. Thirty-three states currently perform this task. The Obama proposal would enable such review in the remaining 17 states and provide backup to all 50.

The proposal builds on provisions in both the House bill (Title I, Section 104) and the Senate's (Title One, Section 1003) empowering HHS to conduct an annual review of excessive rate increases. The purpose of these, however, is mere disclosure; HHS would post evidence of price-gouging online. It would then be up to state insurance commissioners to use the data to recommend to the newly created health insurance exchanges that the worst offenders not be allowed to participate. The Obama proposal, by contrast, would empower HHS itself to scale back proposed premium hikes or demand rebates for hikes that have already taken effect. Although this does not constitute across-the-board price controls (each premium increase would be considered on its own merits), it is a form of price control, something conservatives have always hated and that liberals have long shied away from at the national level. Administering it could prove a nightmare.

The central issue, of course, is defining "excessive." Are health insurers gouging prices now? The evidence is mixed. A report issued earlier this month by Health Care for America Now!, a labor-backed pro-reform coalition, showed that the nation's five largest for-profit health insurers (WellPoint, UnitedHealth, Humana, Cigna, and Aetna) saw a combined profit increase last year of 56 percent, yet provided private coverage to 2.7 million fewer people than they had the year before. But the profits weren't across the board; Aetna saw an 8 percent decline. The huge combined increase was driven mostly by Cigna, whose 356 percent increase appears to be unrelated to its core health insurance business. As for declining private coverage: Health insurers argue (not implausibly) that it's largely driven by the tendency of young, healthy people to drop nongroup health insurance in tough economic times.

Profits in the health insurance business aren't as great as many suppose. In a Sept. 25 online column for the New York Times ("How Much Money Do Insurance Companies Make? A Primer"), Princeton economist Uwe Reinhardt calculated the profit margin for WellPoint, parent company to Anthem Blue Cross (which earlier this month caught hell from the Obama administration for raising California premiums by up to 39 percent). In 2008, Reinhardt wrote, WellPoint's profit margin was 4.07 percent. In 2007 it was 5.47 percent. In 2006 it was 5.42 percent. "Relative to other industries," Reinhardt concluded, "these are not particularly high numbers." None of the big five ranks among the United States' 10 most profitable insurance companies, as ranked in 2009 by Fortune; on Fortune's list of the 53 most profitable industry sectors, health insurance ranks 35^th. One expects more from an industry that enjoys so ludicrous a degree of market concentration. A 2007 study by the American Medical Association found that fully 64 percent of all metropolitan statistical areas had at least one insurer that had a market share of at least 50 percent.

The Obama administration is aware of all this, but bashing insurance companies when premiums are rising sky-high is can't-lose politics, especially considering that health insurance is the one major health-industry sector that for the past six months has actively opposed the health reform bill. It's a nice way to paper over the uncomfortable reality that the health reform bills that cleared the House and the Senate do almost nothing to control medical inflation. And it should help shore up Obama's Democratic base, which loves to imagine that health insurance profits are grotesquely huge. That's why they're so evil! Liberals seldom consider that the reason health insurers are so stingy and so untrustworthy is not that they're hugely profitable but that they aren't hugely profitable. Indeed, it's far from clear that the economic model of private for-profit health insurance is viable when we demand that health insurers behave decently. Conservatives would say that's an argument to ease up on regulation. I say it's an argument not to weep too many tears for an industry that may be going the way of the dodo. If the market can't provide decent health insurance, the government (or heavily regulated nonprofits) certainly can. But I don't think making the federal government the referee on premium increases is an especially good way to regulate private health insurance. Neither, I suspect, does President Obama.

Threatening to do so, however, is a great way to drive Republicans crazy. Should they demand he retreat, Obama can do so and then use his bully pulpit to point out that his is the only side in this negotiation willing to make any concessions. I'm not convinced it will get a health reform bill passed. Threatening to create a government-insurance "public option" program was, at least in the minds of some Democrats, similarly a decoy (though the favored term was "bargaining chip"). Yet jettisoning it didn't win any GOP votes. But the decoy gambit isn't a bad way to put an advantageous spin on health reform's demise. I wish I thought the White House expects to achieve anything more than that.