Something that I think is getting lost in the internal debate we're having over the public option, and scarcely mentioned at all amid the eloquent pleas for Democratic unity and the timely action diaries calling on us to hold our elected Democrats accountable, is a question that needs to be asked, one we leave unanswered at our own peril. That question: what are we really fighting for as we fight for the public option?
We as a community (including myself, unfortunately) have spent so much time fixating on the question of whether or not a public option will be included in any health care reform legislation, and whether it will be triggered or co-opped, that we're neglecting a very important and much needed discussion about the how the availability of the public option will be structured if we're fortunate enough to get it in the final bill. When we say that we won't accept a bill without a public option, do we mean a public option that allows everyone to participate, or are we willing to accept a watered-down PO that most Americans will be forbidden from choosing? This is a question that each of us should be asking, and I'm surprised that it isn't being asked more often. Why waste our time and energy fighting for a public option if it's a public option that is set up to fail?
As things stand right now, it appears that if we get a bill with a public option, it will be one that is available to only a limited number of people: those who work for large employers that offer health plans would not be allowed to buy into the public option. And now that Obama has flip-flopped on mandates, the final bill will almost certainly contain those as well, meaning that most people in this country will be forced to either obtain private health insurance under their employers' health plan or pay onerous tax penalties. This, it appears to me, is what we're being asked to unite behind - Obama certainly made it clear in his speech (to me, anyway) that he considers a PO that less than 5% of Americans will participate in to be acceptable. In fact, he actually framed this limited participation as a selling point for the public option. What this tells me is that his idea of a PO is something that will be deliberately structured to either exclude most people, or be financially unattractive to them as an insurance choice - or both. I think this is a huge mistake.
First of all, a public option that most people won't be able to participate in, and that will probably be structured to have few if any competitive advantages over private insurance, is doomed to failure. There will be little to no competitive pressure on the private insurance companies, and those companies will almost certainly use pre-existing coverage requirements as a pretext to significantly raise their premiums, as much as the new regime will allow. They'll use a portion of the huge influx of new capital they'll be getting from as many as 30 million or more new clients, who will be locked in by mandates, to maintain the new status quo and undermine any attempts to improve the PO or otherwise further reform health care. And when the public option fails, the corporate media will point to it as an example of the shortcomings of any public solution to the health care crisis, rather than pointing out that the public option was set up to fail. This could lead to the elimination of the public option, meaning that what we'll have to show for all our hard work and effort at the end of the day is mandates for private insurance, and the largest corporate welfare scheme in American history.
Secondly, the public option is very popular with voters, and if we pass a bill with a watered-down PO and mandates, those public option supporters who aren't allowed to buy into it - meaning most of them - are going to be furious that they were misled by a Democratically controlled Congress and Democratic President into thinking that they would be given a choice to do so. They're going to be even more furious about mandates and the accompanying tax penalties. Many, if not most, of these people are going to take out their anger on Democrats by staying home on election night, voting Republican, or voting third-party. This will derail not just the push for meaningful health care reform, but everything that we as progressives are trying to accomplish, and it could leave progressives in the wilderness for a generation.
Now, there are other components of the health care reform debate that I think are getting neglected along with the question of PO availability: the President has indicated that he's flexible on the question of tort "reform", which in my opinion is nothing more than a right-wing canard. The cost of malpractice insurance constitutes something like 1% of the overall cost of health care in this country, and making it harder for people to sue for malpractice and capping awards is going to do nothing but make malpractice more prevalent and more expensive, which will impose new costs on the system to replace whatever little we save by doing so. Likewise, most people here are probably unaware that HR 3200 contains a "religious conscience exemption" that would exempt adherents to cults like the Amish, Mennonites, and Christian Scientists from being fined under the mandates that are included in this bill - it's located on pgs. 170-171 of HR 3200 (PDF) (Part VIII, Subpart A, Sec. 59B, subsection (c), 5A). This provision has gotten no attention at all, and it's something we should be paying more attention to. Speaking for myself as an agnostic, I have huge problems with a health care reform bill that gives a privilege to religious adherents that it doesn't give to me.
Both of those issues deserve more discussion and their own diaries, but the question of PO availability is more urgent because it has a direct bearing on the general question of whether our push for health care reform will ultimately be successful, and whether or not it will enhance or hinder our effort to push a broader progressive agenda. Many of us already have an answer to the question of whether a bill without a public option is worth passing, but it seems that few of us have asked whether we're willing to wait for a bill with a public option that all Americans will be allowed to participate in. My answer: while I acknowledge that there will almost certainly be a political price to pay if we fail to pass any health care bill, I nonetheless believe that we'll pay a much steeper price if we pass a bad bill that contradicts several of the promises that Obama made, and Democrats got behind, during the campaigns last year. A bill with a diluted public option and mandates is a bad bill, and we should wait for something better.
This is my line in the sand: I won't unite behind Obama and congressional Democrats unless they make it clear that they intend to push a bill (1) with a robust public option that all Americans will be allowed to participate in; (2) with either no mandates, or with universal access to the PO from the moment mandates are imposed; and (3) with no triggers, and no weights hung around the PO's neck to make it less attractive to consumers. This is a compromise position for me, as I know that many in this community agree with me that single-payer is the only viable means of ensuring truly universal coverage and truly maximizing the efficiency of our health care system. But it's a compromise I'm willing to accept, if only leading Democrats will grow the spine to fully commit to it. If leading Dems aren't willing to do this, then I'm going back to full-throated, uncompromising support for single-payer, and I would urge the rest of you to do the same for the sake of real health care reform and the future of the progressive movement.