I see a ton of enthusiasm for the public option. I understand it. Emotionally, I agree. Intellectually, not so much. A public option is attractive on paper but has some serious and real pitfalls in my view. I understand why people don’t want to ‘let insurers win’ on this and also why they hate having commercial insurers as their health insurance choices, but there are still some very practical, non-procedural reasons to stop and think it all through.
The fight rolls on
Many, many senators have now made a public commitment to “the public option.” Notably, one of the key and vocal supporters of a public option is Senator Tom Harkin, who has not made that commitment. When asked, he answered thus:
“If we have a bill sent to us from the House that does not have the public option here, if we were to add it here, it would sink the whole bill.,” Harkin said during an interview on MSNBC, adding that he would not vote to revive the public option “if it meant that it would sink the whole healthcare reform bill.”
This statement confuses, bewilders and angers many public option supporters, I know. Jon Walker of FireDogLake, ardent public option champion and Jane Hamsher’s right-hand go-to HCR dude expressed the same sentiment I’ve seen from many others:
It is an insult to the progressive community’s intelligence to ask them to pin their hopes for a public option on Democrats taking up another health care reconciliation package to pass the public option later this year or next if it is presupposed Senate “supporters” are going to work against its inclusion in the current bill.
What we have here is a failure to communicate. Tom Harkin is arguing process. Jon Walker is arguing principle. The two are not meshing.
What public option are they fighting for, exactly?
Here’s one small process note: You really can’t start from scratch with items planned to go through the reconciliation process. Since the Senate bill, as passed by a supermajority, did not have a public option in it, that leaves the House version. So let’s review what that was, exactly.
- A new agency, required to be self-sustaining
- Funded with $2 billion dollars of federal money to be repaid within 10 years.
- It would be an option available only to individuals who did not have insurance available via their employers, offered on the national insurance exchange.
- The government would be required to negotiate rates with providers in a similar fashion to the commercial carriers.
- Policies would be subject to the same restrictions and regulations as any other policy on the exchange.
- The government could hire contractors to administer the plan; that is, private insurers.
- Under no circumstances could the public option be bailed out by the government. Premiums would have to reflect the actual claims experience and administrative costs associated with maintaining the plan.
That’s the public option skeleton. The first issue that emerges is an important one, and probably why Senator Harkin is shying away: It assumes a national exchange. The Senate bill is based upon state exchanges or co-ops selling across state lines but subject to state regulation. It’s not clear how a national public option that is supposed to be sold alongside private options on state-based exchanges could actually be done. But let’s say that it can.
Why I don’t support adding this public option to that sidecar over there
Three primary reasons:
- Adverse selection: Insurers will make even more profit with a public option because the sickest and oldest people will gravitate to the government option. This isn’t me making it up. The CBO also concurred, which is why they predicted slightly higher premiums under a public option than a private insurer option.
- Cherry-picking: This public option would encourage insurers to price their products just a smidge higher than the public option in order to encourage those most in need to turn to the government plan and ratchet down insurers’ risks. From the standpoint of a citizen with a choice, that’s not so bad until you start realizing what it means to the financial health of a public option. Combine that with a statutory requirement for solvency and adequate reserves, and it’s not hard to see who benefits most from a public option. Not us. Insurers.
- Duplication: I’m concerned that creating a new agency subject to the same rate structure as private insurers will slow a move to a single-payer model (or state-based single-payer) to a crawl or give incentives to privatize Medicare and move everyone to this option/system, which is less advantageous than Medicare.
Bottom line: Insurers will try to kill it with much love, merely by allowing it to exist as a repository for their castoffs, OR they will use it as a way to privatize Medicare with a weak public option for Medicare beneficiaries.
What public option is there, then?
Medicare. I have long believed that if we were to clean up the fraud and waste that is in Medicare right now, get EHRs online, shift reimbursement models toward true outcomes-based rates, a strategy emerges for expansion that goes like this:
- Years 1-10: Expand Medicare participation on an optional basis to two groups: Ages 55-65 and 25-35, with the younger group allowed to include spouse and dependents, the older group to buy in on an individual basis. Expanding Medicare to the younger group begins to build reserves in the trust fund, since the younger participants are less likely to drive costs up. But here’s the deal: Once you buy in, you stay in, voluntarily waiving the right to shift between private and public health care plans. Employers could contribute a portion of the cost for the opt-ins based on the percentages contributed for private plans.
- Years 11-20: Expand optional Medicare buy-in to the 35-55 group with the same terms. Opt-in, stay in. If Medicare solvency from the first group buy-in causes the trust fund to reach a certain benchmark, this group could even buy in earlier. Allow private insurance to exist alongside Medicare buy-in for all, but also permit supplemental policies or other product innovations to emerge.
In one generation’s time, the country shifts to Medicare for all, with a solvent trust fund, states are freed of Medicaid obligations, and health care access is based upon a strengthened Medicare baseline, lower cost curves, with room in the markets for private insurers to compete for other services.
Why Medicare instead of something new and shiny?
I admit that I haven’t crunched all of the numbers. I probably could, or could dig out some actuarial reports, but that’s better done by the CBO. This is what I do know: In the next 10-20 years, we hit the top of the baby boomer curve and peak enrollment in the old-age programs currently in effect. Medicare as it is today places only the most expensive group — the aging and elderly — under its umbrella, effectively creating the absolute worst-case scenario for cost containment.
Just as in private insurance, spreading the risk over a population that includes those less likely to drive up medical costs in the earlier years while including that portion of the population that will enter the system anyway within 10 years and phasing in the “middle group” over time seems like a way to smooth that bell curve of participation and cost while guaranteeing access to health care for all. It is similar to a pure single-payer model, but allows for opt-in during the phasing process; e.g. patient choice. By making the opt-in a one-time opportunity, revenues and offsets can be reasonably projected and accounted for, rather than simply having to calculate the worst-case among those who drive the highest expenditures.
This idea mirrors HR676, but smooths the shock to the system, giving time to build some decent reserves to offset current budget deficits, too. Most importantly, it utilizes a framework that, once modernized and reformed, offers the best and most efficient way to open the doors to a true, robust public option.
Why not just include it via the reconciliation process now?
Because we have not yet established the will of this country to say out loud that every citizen, every resident, every man, woman and child in this country is entitled to equal access to health care. Until we make that declaration by ending all pre-existing conditions exclusions for public and private plans alike, we can’t move to the next square. In this regard, I agree with those who argue for incremental reforms.
Establish the right to health care. Make it the law of the land. Fix what needs to be fixed inside the Medicare framework. Then throw open the doors and invite people in.
Note: @manyko2 on Twitter points out that part of this initiative would be locking down the Medicare trust fund. No borrowing. No shifting. It’s a trust fund that isn’t tinkered with. Also, @avivao pointed out that a lock-in to Medicare involves a great deal of trust. While that’s true, I think objections can be overcome by either setting benchmarks for Medicare before the lock-in happens, or allowing opt-out in certain circumstances (provider revolt, refusal in geographic location, etc.)
{ 13 comments… read them below or add one }
Karoli, Here’s my feedback in tonight’s earlier tweets, but gathered together:
Aviva O .@Karoli: Still reading, but a dubiously-defined public option isn’t worth crashing the passage of an #HCR bill this spring!
Aviva O .@Karoli: Another reason I don’t like the dubious, ill-defined, patchworky #PO; it creates an expensive, duplicative, complex bureaucracy.
Aviva O .@Karoli (2) Yes. Don’t like potential for #PO to interfere w/ states going #singlepayer; or interference w/ eventual national #singlepayer
Aviva O .@Karoli (3) Yes. #PO places Medicare at greater risk for privatization, with #PO foisted on us as poor substitute. Unacceptable.
Aviva O .@Karoli (4) Fundamentally agree w/ shift to Medicare-for-All over time. Requiring permanent opt-in while Medicare is mutable seems unfair.
Aviva O .@Karoli: Mandating opt-in to Medicare as permanent commitment demands reciprocal commitment from Medicare to be a stable product/service.
Aviva O .@Karoli: Similarly, mandating that U.S. citizens all purchase private insurance while there’s no real competition demands huge amt of trust
Aviva O .@Karoli: Just as House faces a temporal chasm in accepting Senate bill while waiting to see if Senate honors reconciliation fix agreements…
Aviva O .@Karoli: …mandating purchase of private insurance + making a choice for Medicare a permanent one is a lot to ask during transition + flux
Aviva O .@Karoli: I’m not sure which of these two (mandates, Medicare one-time opt-in), is riskier when longer-term outcomes are unpredictable.
Aviva O .@Karoli: With those caveats (fair, bilateral agreements between subscriber + provider vis a vis mandates/permanent opt-ins to Medicare),
Aviva O .@Karoli And with the exhaustion I feel, reading this after being up all night, I say with trepidation that you’ve outlined a good scenario
Aviva O .@catawu: You make a good point; Medicare shouldn’t be “raidable” for its surpluses. And Social Security isn’t a bank for whatever goes!
Aviva O .@Karoli: I think there DO have to be (a) benchmarks before lock-in; or (b) exits if certain changes do/don’t occur in Medicare. Complex.
Aviva O .@Karoli I understand your reasoning on why a choice for Medicare MUST be a commited choice; what’s “chosen” must be a known entity, though.
Aviva O .@Karoli: The fact that we’ll be mandated to buy private insurance that’s NOT a known entity really bugs me. I don’t have a workaround, tho.
Aviva O .@Karoli: Good addition; it’s crucial to know what one’s “buying in to” or “opting in to.” Or, what one’s mandated to purchase!
Aviva O .@Karoli: I think you’ve got some meaty, substantive, + viable proposals; the scenario is basically sound; much risk remains buried in it.
Aviva Gabriel´s last blog ..Lifestream
My feedback in those earlier tweets, but gathered together:
Aviva O .@Karoli: Still reading, but a dubiously-defined public option isn’t worth crashing the passage of an #HCR bill this spring!
Aviva O .@Karoli: Another reason I don't like the dubious, ill-defined, patchworky #PO; it creates an expensive, duplicative, complex bureaucracy.
Aviva O .@Karoli (2) Yes. Don’t like potential for #PO to interfere w/ states going #singlepayer; or interference w/ eventual national #singlepayer
Aviva O .@Karoli (3) Yes. #PO places Medicare at greater risk for privatization, with #PO foisted on us as poor substitute. Unacceptable.
Aviva O .@Karoli (4) Fundamentally agree w/ shift to Medicare-for-All over time. Requiring permanent opt-in while Medicare is mutable seems unfair.
Aviva O .@Karoli: Mandating opt-in to Medicare as permanent commitment demands reciprocal commitment from Medicare to be a stable product/service.
Aviva O .@Karoli: Similarly, mandating that U.S. citizens all purchase private insurance while there's no real competition demands huge amt of trust
Aviva O .@Karoli: Just as House faces a temporal chasm in accepting Senate bill while waiting to see if Senate honors reconciliation fix agreements…
Aviva O .@Karoli: …mandating purchase of private insurance + making a choice for Medicare a permanent one is a lot to ask during transition + flux
Aviva O .@Karoli: I'm not sure which of these two (mandates, Medicare one-time opt-in), is riskier when longer-term outcomes are unpredictable.
Aviva O .@Karoli: With those caveats (fair, bilateral agreements between subscriber + provider vis a vis mandates/permanent opt-ins to Medicare),
Aviva O .@Karoli And with the exhaustion I feel, reading this after being up all night, I say with trepidation that you've outlined a good scenario
Aviva O .@catawu: You make a good point; Medicare shouldn't be “raidable” for its surpluses. And Social Security isn't a bank for whatever goes!
Aviva O .@Karoli: I think there DO have to be (a) benchmarks before lock-in; or (b) exits if certain changes do/don't occur in Medicare. Complex.
Aviva O .@Karoli I understand your reasoning on why a choice for Medicare MUST be a commited choice; what's “chosen” must be a known entity, though.
Aviva O .@Karoli: The fact that we'll be mandated to buy private insurance that's NOT a known entity really bugs me. I don't have a workaround, tho.
Aviva O .@Karoli: Good addition; it's crucial to know what one's “buying in to” or “opting in to.” Or, what one's mandated to purchase!
Aviva O .@Karoli: I think you've got some meaty, substantive, + viable proposals; the scenario is basically sound; much risk remains buried in it.
My feedback in those earlier tweets, but gathered together:
Aviva O .@Karoli: Still reading, but a dubiously-defined public option isn’t worth crashing the passage of an #HCR bill this spring!
Aviva O .@Karoli: Another reason I don't like the dubious, ill-defined, patchworky #PO; it creates an expensive, duplicative, complex bureaucracy.
Aviva O .@Karoli (2) Yes. Don’t like potential for #PO to interfere w/ states going #singlepayer; or interference w/ eventual national #singlepayer
Aviva O .@Karoli (3) Yes. #PO places Medicare at greater risk for privatization, with #PO foisted on us as poor substitute. Unacceptable.
Aviva O .@Karoli (4) Fundamentally agree w/ shift to Medicare-for-All over time. Requiring permanent opt-in while Medicare is mutable seems unfair.
Aviva O .@Karoli: Mandating opt-in to Medicare as permanent commitment demands reciprocal commitment from Medicare to be a stable product/service.
Aviva O .@Karoli: Similarly, mandating that U.S. citizens all purchase private insurance while there's no real competition demands huge amt of trust
Aviva O .@Karoli: Just as House faces a temporal chasm in accepting Senate bill while waiting to see if Senate honors reconciliation fix agreements…
Aviva O .@Karoli: …mandating purchase of private insurance + making a choice for Medicare a permanent one is a lot to ask during transition + flux
Aviva O .@Karoli: I'm not sure which of these two (mandates, Medicare one-time opt-in), is riskier when longer-term outcomes are unpredictable.
Aviva O .@Karoli: With those caveats (fair, bilateral agreements between subscriber + provider vis a vis mandates/permanent opt-ins to Medicare),
Aviva O .@Karoli And with the exhaustion I feel, reading this after being up all night, I say with trepidation that you've outlined a good scenario
Aviva O .@catawu: You make a good point; Medicare shouldn't be “raidable” for its surpluses. And Social Security isn't a bank for whatever goes!
Aviva O .@Karoli: I think there DO have to be (a) benchmarks before lock-in; or (b) exits if certain changes do/don't occur in Medicare. Complex.
Aviva O .@Karoli I understand your reasoning on why a choice for Medicare MUST be a commited choice; what's “chosen” must be a known entity, though.
Aviva O .@Karoli: The fact that we'll be mandated to buy private insurance that's NOT a known entity really bugs me. I don't have a workaround, tho.
Aviva O .@Karoli: Good addition; it's crucial to know what one's “buying in to” or “opting in to.” Or, what one's mandated to purchase!
Aviva O .@Karoli: I think you've got some meaty, substantive, + viable proposals; the scenario is basically sound; much risk remains buried in it.
My feedback in those earlier tweets, but gathered together:
Aviva O .@Karoli: Still reading, but a dubiously-defined public option isn’t worth crashing the passage of an #HCR bill this spring!
Aviva O .@Karoli: Another reason I don't like the dubious, ill-defined, patchworky #PO; it creates an expensive, duplicative, complex bureaucracy.
Aviva O .@Karoli (2) Yes. Don’t like potential for #PO to interfere w/ states going #singlepayer; or interference w/ eventual national #singlepayer
Aviva O .@Karoli (3) Yes. #PO places Medicare at greater risk for privatization, with #PO foisted on us as poor substitute. Unacceptable.
Aviva O .@Karoli (4) Fundamentally agree w/ shift to Medicare-for-All over time. Requiring permanent opt-in while Medicare is mutable seems unfair.
Aviva O .@Karoli: Mandating opt-in to Medicare as permanent commitment demands reciprocal commitment from Medicare to be a stable product/service.
Aviva O .@Karoli: Similarly, mandating that U.S. citizens all purchase private insurance while there's no real competition demands huge amt of trust
Aviva O .@Karoli: Just as House faces a temporal chasm in accepting Senate bill while waiting to see if Senate honors reconciliation fix agreements…
Aviva O .@Karoli: …mandating purchase of private insurance + making a choice for Medicare a permanent one is a lot to ask during transition + flux
Aviva O .@Karoli: I'm not sure which of these two (mandates, Medicare one-time opt-in), is riskier when longer-term outcomes are unpredictable.
Aviva O .@Karoli: With those caveats (fair, bilateral agreements between subscriber + provider vis a vis mandates/permanent opt-ins to Medicare),
Aviva O .@Karoli And with the exhaustion I feel, reading this after being up all night, I say with trepidation that you've outlined a good scenario
Aviva O .@catawu: You make a good point; Medicare shouldn't be “raidable” for its surpluses. And Social Security isn't a bank for whatever goes!
Aviva O .@Karoli: I think there DO have to be (a) benchmarks before lock-in; or (b) exits if certain changes do/don't occur in Medicare. Complex.
Aviva O .@Karoli I understand your reasoning on why a choice for Medicare MUST be a commited choice; what's “chosen” must be a known entity, though.
Aviva O .@Karoli: The fact that we'll be mandated to buy private insurance that's NOT a known entity really bugs me. I don't have a workaround, tho.
Aviva O .@Karoli: Good addition; it's crucial to know what one's “buying in to” or “opting in to.” Or, what one's mandated to purchase!
Aviva O .@Karoli: I think you've got some meaty, substantive, + viable proposals; the scenario is basically sound; much risk remains buried in it.
My feedback in those earlier tweets, but gathered together:
Aviva O .@Karoli: Still reading, but a dubiously-defined public option isn’t worth crashing the passage of an #HCR bill this spring!
Aviva O .@Karoli: Another reason I don't like the dubious, ill-defined, patchworky #PO; it creates an expensive, duplicative, complex bureaucracy.
Aviva O .@Karoli (2) Yes. Don’t like potential for #PO to interfere w/ states going #singlepayer; or interference w/ eventual national #singlepayer
Aviva O .@Karoli (3) Yes. #PO places Medicare at greater risk for privatization, with #PO foisted on us as poor substitute. Unacceptable.
Aviva O .@Karoli (4) Fundamentally agree w/ shift to Medicare-for-All over time. Requiring permanent opt-in while Medicare is mutable seems unfair.
Aviva O .@Karoli: Mandating opt-in to Medicare as permanent commitment demands reciprocal commitment from Medicare to be a stable product/service.
Aviva O .@Karoli: Similarly, mandating that U.S. citizens all purchase private insurance while there's no real competition demands huge amt of trust
Aviva O .@Karoli: Just as House faces a temporal chasm in accepting Senate bill while waiting to see if Senate honors reconciliation fix agreements…
Aviva O .@Karoli: …mandating purchase of private insurance + making a choice for Medicare a permanent one is a lot to ask during transition + flux
Aviva O .@Karoli: I'm not sure which of these two (mandates, Medicare one-time opt-in), is riskier when longer-term outcomes are unpredictable.
Aviva O .@Karoli: With those caveats (fair, bilateral agreements between subscriber + provider vis a vis mandates/permanent opt-ins to Medicare),
Aviva O .@Karoli And with the exhaustion I feel, reading this after being up all night, I say with trepidation that you've outlined a good scenario
Aviva O .@catawu: You make a good point; Medicare shouldn't be “raidable” for its surpluses. And Social Security isn't a bank for whatever goes!
Aviva O .@Karoli: I think there DO have to be (a) benchmarks before lock-in; or (b) exits if certain changes do/don't occur in Medicare. Complex.
Aviva O .@Karoli I understand your reasoning on why a choice for Medicare MUST be a commited choice; what's “chosen” must be a known entity, though.
Aviva O .@Karoli: The fact that we'll be mandated to buy private insurance that's NOT a known entity really bugs me. I don't have a workaround, tho.
Aviva O .@Karoli: Good addition; it's crucial to know what one's “buying in to” or “opting in to.” Or, what one's mandated to purchase!
Aviva O .@Karoli: I think you've got some meaty, substantive, + viable proposals; the scenario is basically sound; much risk remains buried in it.
My feedback in those earlier tweets, but gathered together:
Aviva O .@Karoli: Still reading, but a dubiously-defined public option isn’t worth crashing the passage of an #HCR bill this spring!
Aviva O .@Karoli: Another reason I don't like the dubious, ill-defined, patchworky #PO; it creates an expensive, duplicative, complex bureaucracy.
Aviva O .@Karoli (2) Yes. Don’t like potential for #PO to interfere w/ states going #singlepayer; or interference w/ eventual national #singlepayer
Aviva O .@Karoli (3) Yes. #PO places Medicare at greater risk for privatization, with #PO foisted on us as poor substitute. Unacceptable.
Aviva O .@Karoli (4) Fundamentally agree w/ shift to Medicare-for-All over time. Requiring permanent opt-in while Medicare is mutable seems unfair.
Aviva O .@Karoli: Mandating opt-in to Medicare as permanent commitment demands reciprocal commitment from Medicare to be a stable product/service.
Aviva O .@Karoli: Similarly, mandating that U.S. citizens all purchase private insurance while there's no real competition demands huge amt of trust
Aviva O .@Karoli: Just as House faces a temporal chasm in accepting Senate bill while waiting to see if Senate honors reconciliation fix agreements…
Aviva O .@Karoli: …mandating purchase of private insurance + making a choice for Medicare a permanent one is a lot to ask during transition + flux
Aviva O .@Karoli: I'm not sure which of these two (mandates, Medicare one-time opt-in), is riskier when longer-term outcomes are unpredictable.
Aviva O .@Karoli: With those caveats (fair, bilateral agreements between subscriber + provider vis a vis mandates/permanent opt-ins to Medicare),
Aviva O .@Karoli And with the exhaustion I feel, reading this after being up all night, I say with trepidation that you've outlined a good scenario
Aviva O .@catawu: You make a good point; Medicare shouldn't be “raidable” for its surpluses. And Social Security isn't a bank for whatever goes!
Aviva O .@Karoli: I think there DO have to be (a) benchmarks before lock-in; or (b) exits if certain changes do/don't occur in Medicare. Complex.
Aviva O .@Karoli I understand your reasoning on why a choice for Medicare MUST be a commited choice; what's “chosen” must be a known entity, though.
Aviva O .@Karoli: The fact that we'll be mandated to buy private insurance that's NOT a known entity really bugs me. I don't have a workaround, tho.
Aviva O .@Karoli: Good addition; it's crucial to know what one's “buying in to” or “opting in to.” Or, what one's mandated to purchase!
Aviva O .@Karoli: I think you've got some meaty, substantive, + viable proposals; the scenario is basically sound; much risk remains buried in it.
Agreed. When the “Medicare for all” meme briefly caught fire last summer I was, briefly, hopeful that it might have legislative promise. From a policy standpoint, it makes far more sense to expand Medicare than it does to create a second public entity, especially one that is actuarially suspect and seems designed to fail.
Regardless of the merits, trying to force a public option into an already complex legislative calculus seems counterproductive. Publicly endorsing a “strong” public option in no way promises a vote for whatever winds up in the reconciliation package. There's a good chance it could send the whole deal down in flames.
At this stage, expressing support for single payer as a matter of principle is fine. But not at the expense of the biggest advancement in health care policy in a half century.
bll
I've been saying for awhile that Medicare has to have some serious infrastructure changes and oversight before we could move to a single payer model. It's not an especially popular view, but what I see tells me my gut is probably right.
I think keeping the pressure on for a public option in this round is an okay strategy to keep some bargaining chips in play to prevent further erosion of a bill which is already quite centrist. What concerns me is how it's being communicated as a larger issue. Progressives have placed a great deal of weight on this one piece of the picture, and will feel slapped when it's not included. I doubt very much that it will be, and in fact, hope it won't be in order to protect the right to try for a much broader Medicare expansion in the future.
aviva,
thanks so much for putting these together! I was thinking last night I'd like to have this series of discussion points attached to the post. Greatly appreciated.
Like your comments, @bill_free. Agree with them, too!
You're most welcome. Or, as they say in San Miguel, “de nada.” ☼
I'm not sure why you assume that any public option offered through reconciliation would have to be “this public option,” as you put it. Unless I'm missing something, since the reconciliation bill will be a new bill, designed specifically to fix deficiencies and lack of true reform in the Senate bill, what's to stop ANY public option plan from being presented (within the limits of the Byrd rule, obviously)?
I'm not against an expansion of Medicare. But I think it is pure folly to not push as hard on all fronts as we can while the momentum is here and we're this close. Incrementalists love to point out to the tired nostrum that “we can fix it later.” While obviously true, this leaves aside the equally true observations that “we” can also just as easily fail to fix it later due to lack of political will/spine, or we can (some of us, with the tacit support of others) significantly worsen/screw it up later. While it's certainly true that any legislation passed today COULD be fixed later, it's specious to base assumptions on the fact that it WILL (and yes, I know the history of Medicare…). I mean, can anyone name a time when Democrats have failed to muster up the political nerve to attempt something that might very well have been possible? Anyone? Bueller? Actually, perhaps a better cinematic comparison would not be Ben Stein in Ferris Bueller's Day Off, but rather Hugo Weaving in The Fellowship of the Ring – when he says to Ian McKellen's Gandalf “I was there the day the strength of men failed!” Any one of us who've been watching politics for any length of time could easily say that in regard to the Democratic party. We've got an opportunity to put these guys on the record right now, in a way that will likely not be possible again for who knows how long. In fact, if what we pass and retroactively label “reform” turns out to be watered-down and hobbled enough to be credibly portrayed once the data start flowing in as anything BUT reform (or as reform in name only), then we may NEVER again have such a chance…or at least not until the situation is so horrifically dire that people are FORCED to revisit this issue because the cost of doing nothing is far higher than the cost of re-examining some of our most-cherished beliefs about the health care system in America, including the belief that we just can't GET truly progressive reform….because the insurers and their lap dogs in congress wouldn't allow it.
These guys sometimes play a game of “rotating bad guy”: selecting one person to do the dirty work of killing a popular piece of legislation or part of a bill, because certain very powerful special interests are against it. Right now, PCCC's Senate whip count is showing numerous senators simply as “unknown” with regard to the public option. OK, let's put them on the record. Hold the damn vote. Make senators publicly stand up for whoever's interest they truly represent. Why – this late in the game – is Jon Tester allowed to simply go as “unknown” on such an issue. Blanche Lincoln is also listed as “unknown,” but we can be sure that she probably would oppose such a move. Only I wouldn't bet on it. As her own re-election prospects dim (assuming she holds true to her constituent-disappointing MO), she might very well be “gettable” in the sense of throwing a last minute, desperate hail mary. Conrad, McCaskill, Mark Pryor, Jim Webb — we are allowing all of these people to simply, during one of the most momentous and contentious times in legislative history in decades – simply lie in the weeds without taking a position. The President just the other day reiterated his support for a public option (though of course he took the cheeseball excuse of saying “but it doesn't have the votes in the Senate”). Harry Reid says he supports the idea.
Fine. Let's put it to a vote. What is STOPPING us from doing so, in fact? The President thinks the Senate doesn't have the votes? So? The President is no longer a member of the Senate. How 'bout letting them take care of figuring that out, Barack, instead of putting your thumb on the scale? Harry Reid supports it? Why not allow a vote on it, then? I'm less worried about what version of the public option we bring to a vote (though of course that's crucial, too) than I am in actually agreeing to put people on the record one way or the other about it.
Lars, here's where process matters. They can't just pull any old set of provisions out of the air and stick them in a reconciliation bill. There's a tight line to walk between policy and budget items here. Had the two bills gone to a conference committee, I guarantee you they would not have emerged with a shiny new robust version of a public option. If one were included at all, it would have been one very similar to the version in the House bill, as I outlined. Why?
1) The Senate isn't the only issue. The House matters, too. They squeaked a public option through with Stupak language attached the first time. That won't happen a second time. They don't have the votes.
2) Assuming you have 50 and Biden in the Senate, how do you get a public option that matters even a little bit in the House without getting Stupak's coathanger provision shoved down our throats? As it is, getting to 216 without one is going to be a challenge. I can't see it happening at all without swallowing the nasty poison pill that is Stupak-Pitts. If by some miracle it did happen, I cannot imagine it would be worth crowing about.
3) What is the justification for creating a brand-new agency when one already exists? This is probably the most powerful argument the Republicans (and Lieberman) had. The Medicare buy-in would have been a far better option. I suppose we all should have hated it so Lieberman could feel like he was screwing us, but who knew he was so bitter?
You ask: Why not allow an up or down vote on the public option? My answer: Because defeating it will kill it. Not defeating it (or voting on it) with this package gives us all a reason to come back and fight another day.