The horizon is not so far as we can see, but as far as we can imagine

Finding Common Ground Between Public Option Advocates and Single Payer Advocates

A heated argument is going on about the right health insurance model between those those who believe in a public option and those who believe in single payer.

Or perhaps I should say between those who are willing to take what they can get: public option; vs. those who want to hold out for what they consider the best option: single payer.

By way of reconciling what differences can be reconciled, let me ask a question of each side.

A Question for Public Option Advocates

Do you want to eventually have a single payer or a comprehensive system like the French have?  If not, why not?

A Question for Single Payer Advocates

Are you willing to fight for a public option which could eventually lead to single payer or a comprehensive system like the French one? If not, why not?

At this point what I’m seeing is both sides retreating into moralistic screaming.

The public option folks are saying: “It is better to save some lives than none, and if you single payer purists don’t support a public option which will save even a few lives, you’re responsible for those deaths.”

The single payer people are saying: “The public option is so watered down that all it will do is discredit real public reform, aka single payer.  You public option folks are settling for so little that the few lives you might save are outweighed by all the lives you won’t save and the damage to the chance at real comprehensive health care reform.”

Both sides are assuming the other side is operating in bad faith.  The public option folks assume the single payer folks just want to be pure rather than saving lives, the single payer that the public option folks are just sell-outs shilling for a bad bill.

But what I’m seeing, as someone with a foot in each camp, is that both sides are (mostly) sincere.

Now there is one group that can’t be reconciled.  People who want a public option so weak it either won’t survive, or can’t be used as the basis for a comprehensive system.  The usual suspects like Insurance company executives, for example.  But also some people in the Obama administration, such as Health Secretary Katherine Sibelius, the health secretary, who said that the plan would be drafted specifically so that it could never become single payer.

But for everyone else, for those acting in good faith, there should be some common ground from which we can work together. Let’s start by recognizing that the battle over public option vs single payer is a distraction away from what we could accomplish if we worked together.

United we stand a chance.  Divided, we will lose our chance at health care reform.


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  1. The reason why common ground is hard to find is that there is a maximalist political strategy at work on the part of single-payer activists. It’s based on the notion that the only way to improve health care is to change the discourse, and changing the discourse involves defining politics leftward. That means being unyielding on the leftmost activist solution. It’s the “negotiating with car salesmen” strategy of politics, and it does have some merit.

    The problem with it is that the leftmost solution is the one that the established political system is united in denying any hint of, or admitting any value in that solution. The danger then, is irrelevance.

  2. BDBlue

    A real public option is just as dead politically with the establishment as single payer is. They simply use the phrase “public option” for cover, to make it sound like the current bills give you something they don’t.

    Having said that, if there were a true, viable public option on the table, I’d support it. Just as I’d support any real effort at healthcare reform.

    The problem I have right now is that there is nothing to support in terms of public option except some ideas from articles and blog posts. There’s no legislation. So, to get a true public option, I’d have to decide how exactly to make it viable (some of the questions you posted in an earlier post), the draft legislation that would make that happen, and then get it introduced in the Congress and move on from there. And then it would be opposed by exactly the same forces that now oppose single payer and the opposition would be just as strong.

    The GOP is going to oppose any reform (good, bad or indifferent). You already know what the Democrats think of public option, you’ve seen their bills.

    The reason I’m putting all my energy in single payer is that it’s already done. There’s legislation introduced in both houses. What’s more, we already have a single payer system in Medicare that people like and are familiar with, which makes it harder for the insurance lobby to scare ’em about the plan. And that’s good because it’s going to take a popular revolt to get any kind of real reform so the easier it is to explain it and the more familiar people are with it already, the better.

    But none of that makes me a purist. If the people who really believe a viable public option would be easier and is worth doing, then let them come up with one and get it introduced. If they do, I’m happy to support it. But until they’ve got an actual plan, not just some fantasy plan they like to superimpose over the crappy bills circulating in Congress to try to make themselves feel better, I think my time would be better spent agitating for single payer.

    BTW, I tried to post twice at Open Left and all I kept getting was page not found when I hit enter.

  3. gtash

    I get the same feeling as BDBlue. I think a truly viable public option is not going to happen and it could only have a chance if Obama planted both feet on the ground and fought for it. As it is, I do not think the Obama policy makers either understand what it takes to have a workable one, nor do they care to. They just want half-a-loaf so they can say they got half-a-loaf. What kind of loaf is not much of a concern. I think it boils down to “getting their foot in the door” and hoping to expand the coverage over time by wheedling and needling the Blues and diminished Republicans. All of that strategy depends on thinking you have time to stretch the battle out into multiple terms of office, altering the ratios in Congress, and cajoling a frightened middle-class away from Reagonomics. I am one of those who simply says this whole calculation is wrong. There isn’t that kind of time and Rahmists have overestimated themselves.

  4. BDBlue

    And Obama will now make a stand for the non-viable, useless, doesn’t start until 2013 public option, get something weaker, and still everyone will declare victory thanks to Max Baucus. I’m only kind of snarking. Baucus just did Obama a huge favor by providing the “awful” bill that can be improved in great progressive victory by adding in a public option that doesn’t work and doesn’t kick in for four years.

    And I’m with lambert, if what they had in mind was any good, Obama would want to run on it in 2012 and there’s no way it would kick in after that.

  5. gtash

    And part of the reason we don’t have the time is because our economy is still precarious-to-flat. If you are unwilling to help it by altering the health insurance equation, you will never be willing to fix it when times are “good”. We have over 30 years of previous experience to tell us that.

    Off subject, a blogger offered this to fix the economy: it’s funny and the only thing it misses is health care.

    There are about 40 million people over 50 in the work force. Pay them 1 million apiece severance for early retirement with the following stipulations:
    1) They MUST retire. Forty million job openings – Unemployment fixed.
    2) They MUST buy a new American CAR. Forty million cars ordered- Auto Industry fixed.
    3) They MUST either buy a house or pay off their mortgage – Housing Crisis fixed.

  6. If the public option incrementalist strategy won’t work, and single payer is not on the table (it isn’t), then what’s left?

  7. The main reason I support a public option is that single payer gets no notice in the news or in political discussions among the people who matter. I think going to single payer is the best way to fix what’s wrong with the finance side of our health care system.

    Unfortunately, none of what I’ve heard about coming out of DC sounds like a real solution. My guess is that the Congress and the President will use this as an excuse to make us all buy health insurance if we want to receive any care at all, and they’ll conveniently forget about enforcing all those requirements about pre-existing conditions, denying treatment, etc.

  8. masslib

    What BDBlue said, but also…Also, let’s be real here, if this were about something that could eventually lead to single payer, we’d be expanding the something that was supposed to lead to single payer when it was enacted, Medicare. I’d support a true public option with a start up of around 100 million enrollees, yada, yada, yada, but that’s not on the table, indeed as far as I can see, it never was. I know this reform. It’s the MA health reform. It doesn’t lead to single payer. I’d really have liked it if the progressives had not been so quick to latch on to anything. I was reading this quirky piece by Richard Cohen today where he said Medicare could have been expanding down to 55-65 with one bill, one committee. Is that true? Why didn’t we just do that? Bill Clinton tried to pass a policy that would have basically done that for forever. Man, if we had just done that then. If he had only started out there. Ah well, read between the lines Ian. CBO predicts under the best case scenarios less than 4% of the under 65 pop will be in any of the public options presented so far. It can’t be predicated on medicare reimbursements and it can’t collectively bargain with Medicare. That ain’t robust. I doubt it’s even sustainable.

    As for the French system, I think I’m going to see if there is any interest within the MA state single payer movement to enact a French-style single payer here. The French really now how to do health care, and I’m doubting the Fed’s are going to have much luck enacting something that really changes the for-profit, employer-based, private insurance system in the near future.

  9. masslib

    And, just as an aside, Ian, I am one of those 50 million without health insurance, in yeah, Massachusetts. I asked Ezra Klein, will this policy with the pub. opt. as such create downward pressure on insurance premiums? Nope. So, it isn’t going to get any cheaper here. And, since I’m already familiar with the “Exchanges” and the “public option” firewalls, and since Ezra Klein said it himself, nothing will change in MA, I have a personal vested interest in wanting Medicare for All.

  10. nihil obstet

    I’m a single payer advocate (actually, an NHS-style advocate, but that’s really off the table). I’m “willing to fight for a public option which could can reasonably be expected to eventually lead to single payer or a comprehensive system like the French one more quickly and effectively than alternative political fights?”

    Like you, I’m distressed at the charges of bad faith on both sides, but failure to agree is not itself evidence of bad faith. It is my best judgment that working for some undefined “public option” at this point is counterproductive. We’ll end up with something that politicians can wave around as a “public option” but which leaves the sick at the mercy of a fragmented, profit-seeking industry. I hope I’m wrong; if I am, it is a difference of judgment, and framing a question as moral shaming isn’t going to change that judgment.

    And a side issue: I have a philosophical objection to government requiring me to purchase a private company’s product as a condition merely of being. If I have to have it as a citizen/resident of the country, then it should be provided by the government through tax revenue. As an individual, I should not have to enforce a required contract through the arbitration process that has replaced consumer rights under commercial law in monopoly contracts these days.

  11. Can somebody explain to me how bait and switch can possibly be an act of good faith? I can put some of this down to the nature of sausage making, but an order of magnitude difference between 130 million covered (the bait) and 9 million (the switch)? That’s rather a lot to make up in reconciliation.

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