This column is part two in the series examining various approaches to solving the problems that are likely to be addressed by the next congress and incoming administration. This week it’s health care. I don’t know of anyone who seriously contends that this question should not be addressed at all. If you would prefer no change over the policy we’re likely to get, that’s understandable, but it is immaterial given the likelihood that we will see some form of adjustment to our current system in the next two years.

Here are this week’s competing positions.

First, the plan championed by Hillary Clinton during the primaries. Called “American Health Choices,” it would require every American to have health insurance in much the same way most states require every driver to have minimum liability auto insurance. The government would establish a percentage of family income that should be expected to go towards health care, and would provide tax credits to keep premiums at that level. There would be federal subsidies for those who cannot afford any insurance through a program similar to the federal employee benefit and Medicare. This would be paid for, in part, by reinstating certain Bush era tax cuts, and by eliminating some of the tax exclusions employers receive on health care costs. Big businesses would be required to pay for some or all of each employees insurance. Small businesses would be exempt, but tax credits would entice them to participate. The plan would forbid insurers to deny coverage to anyone and would not allow higher premiums to be charged to those with higher health care costs.

Next, a plan that has actually been instituted on a statewide basis with some success. Massachusetts instituted the following plan in 2006 on recommendation by a panel convened in 2004 by then-governor Mitt Romney. As with the Clinton plan, all Mass. residents are required to have insurance. To accomplish this, the state has two avenues available: Commonwealth Choice and Commonwealth Care. “Choice” is simply a resource that provides individuals, families and employers with information on available private plans along with cost and benefits information. “Care” is a public pool for subsidized care available to anyone under a certain income. This type of insurance is free or cheap, depending on need, and is administered by the state. Most of the fund used to pay for Commonwealth Care comes from taxes on private insurance companies. The plan is continually being tweaked and amended, and is also threatened by legal challenges stemming from certain health care spending requirements the law puts on large employers. Despite a tax penalty that increases yearly for those who do not obtain coverage, a disturbingly large number of people in MA continue to forgo medical insurance.

Are there any plans that don’t involve individual mandates? Yes, primarily two. The first comes from the libertarian perspective. Michael F. Cannon, director of Health Policy Studies at the Cato Institute, advocates elimination of the tax incentives that have caused employer-based health insurance to become dominant at the expense of the self-employed. His solution would couple broad expansion of tax-free health savings accounts with the competitive advantages of nonprofit health care cooperatives exemlified by Group Health in Washington State and Kaiser Permanente in California. In Cannon’s view, when you can save the cost of your deductible tax-free (including any contributions your employer might make) and let unused funds roll over year to year in an account that stays with you your whole life, you will make smart choices about how that money gets spent when you need care. This lowers costs, increases efficiency and, in the case of nonprofit health care systems, forces hospitals and doctors to take responsibility for the quality of care they provide.  All of this would be accomplished without government interference beyond it’s ordinary regulatory responsibilities.

The second plan which doesn’t ‘make you buy insurance’ is called Medicare 2.0. Physicians for a National Health Program, a 15,000-member issue advocacy group in operation since 1987, recommends private health insurers be outlawed and replaced by an expansion of the existing Medicare system to cover all Americans. This approach is simple to understand and doesn’t require explanation. What I find interesting, however, is how they make their argument. In addition to approximating Democrats’ usual criticisms of the current American health care system, two of their authors make the following statement regarding plans like the one proposed by Senator Clinton:

“Some proposals would offer the option of buying a competing public plan, under the theory that the public program would be more efficient and effective. The flaw here is that the public plan would attract those who are unable to afford private coverage or who are paying high premiums or have no insurance because of pre-existing conditions. Placing these high-cost individuals in a separate government pool would make it unaffordable for most other people. This “death spiral” would cause the public plan to fail.”

It seems the far left and far right have something in common after all.

I expect the health care reform debate to take shape around something like the Massachusetts plan. There will be hard-core single-payer proponents arguing with other Democrats from states with big health care lobbies and the marginal Republican presence will dance with the latter so as not to be dis-invited from any participation at all. What is left of conservatism in congress will be in the corner gazing at its feet like a Bizarro Kurt Cobain.

Does that sound about right? Oh, and here’s a cookie for anyone who can’t guess where I come down on the issue. Google ‘Alice Teil’.