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The Democratic Strategist

Political Strategy for a Permanent Democratic Majority

The Public Option, Single-Payer and “The Core of Reform” in Health Care

Amid reports that the Senate Finance Committee’s version of health care reform does not include a “public option” for insurance, and after many weeks of line-drawing by various progressive organizations making the inclusion of a public option a sine qua non, Ezra Klein has an important post challenging the whole premise that this issue is central:

The public option, as it exists in any bill moving through Congress, is not the core of reform, nor anything near it. It is, for one thing, limited to the Americans who buy into the Health Insurance Exchanges, and the exchanges are in turn limited to the unemployed, the self-employed and small businesses. In the House bill — which is the strongest of the bills — the Congressional Budget Office estimates that 27 million Americans would be in the exchanges by 2019. That’s not nothing, but it’s not much. Imagine half choose the public option (CBO estimates many fewer than that). You now have 13.5 million Americans in a public insurer with no substantive advantages over private insurance. That’s not a gamechanger, it’s a tweak.

Even if you dispute some aspects of Ezra’s analysis of the substantive importance of the public option, it’s worth listening to his broader, historical argument: progressives have in the past supported a variety of health reform proposals that did not include a public option:

The public option is not now, and has not ever, been the core of the argument for heath-care reform. It is the core of the fight in Washington, D.C. It is an important policy experiment. But it was not in Howard Dean or John Kerry or Dick Gephardt’s plans, and reformers supported those. It was not in Bill Clinton’s proposal, and most lament the death of that. It is not what politicians were using in their speeches five years ago. It is a recent addition to the debate, and a good one. But it is not the reason were are having this debate.

But I would observe that Ezra doesn’t mention one of the reasons for the current focus on the public option: a significant element of health care reformers didn’t really support the Dean or Kerry or Gephardt plans, or the Clinton plan as it was eventually shaped, other than as a compromise with an unacceptable status quo. They supported, and still support, a single-payer system, and now either (a) hope, just as reform opponents claim, that a public option is simply a way-station to single-payer, or (b) want to maintain the priniciple of a public insurance provider as the only way to curb the abuses associated with private health insurance.
So while some progressives view the public option as merely a means to an end that is perhaps less important than several other aspects of health reform, others do indeed view it as “the core of reform.” It’s not clear at this point whether they are willing, this time, to take a dive on health care reform if the eventual legislation lacks a public option, but there’s no particular reason to doubt their sincerity or its origins.
I don’t happen to share the reflexive enthusiasm for single-payer of many progressives, but I do understand why its advocates feel frustrated. There was a moment a few years ago when single-payer seemed finally to be sweeping the progressive world; it was endorsed by Al Gore way back in 2002, and by the Editors of The New Republic, and by most if not all progressive health wonks. But in the 2004 and 2008 presidential campaigns, all of the Democratic candidates other than Dennis Kucinich rejected the single-payer approach.
Moreover, single-payer fans may rightly note that for the second time in fifteen years, a health reform proposal by a Democratic president is being imperiled by its complexity. Single-payer is nothing if not easy to understand, and while a public option in a competitive system isn’t that simple, comparisons to Medicare make it somewhat more comprehensible than, say, health insurance exchanges.
Still, Ezra is issuing the right challenge to those who make the public option non-negotiable out of a displaced preference for another approach to health reform altogether: is failure acceptable, given how rarely the opportunity for health care reform comes around?
Maybe progressives won’t ultimately have to make the choice between a bill without a public option and no bill at all. But I wouldn’t bet the farm, or health reform, on it.

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