Friday, September 18, 2009

Now Is the Time to Support the Public Option

In late July and early August -- before the farcical theater of the town hall meetings had degraded the public debate on health care to lows previously unseen in this country -- I argued (here and here) that progressives who favor the adoption of a single-payer health plan should not automatically support the Public Option as the next best approach to universal care. The standard argument at that point was that there were three choices: single-payer, the Public Option, and a better-regulated private insurance system.

With single payer unfortunately (and, I would suggest, unnecessarily) having been ruled out of the debate, the choice between the two remaining alternatives was supposedly simple: anti-government conservatives would prefer the non-Public Option aspects of the extant health care reform proposals (elimination of "pre-existing condition" exclusions and other reasons to deny care, enactment of universal mandates to buy coverage, and subsidies to allow lower-income people to satisfy such mandates), and progressives and liberals (who are not "pro government" -- a term with no meaning -- but who do not reflexively believe that the government is per se worse at everything than private actors are) would gravitate toward a plan that includes a non-profit government-provided insurance plan that would be available to everyone.

My argument was two-fold: (1) The advantages of single-payer health care, especially low administrative costs, do not automatically carry over to a Public Option, and (2) Political realities would so limit the Public Option that it would (unfairly but almost certainly) become an under-funded poster child for failed government-run health care.

Underlying that argument was the assumption that the non-Public Option alternative would be a plan that would actually force private insurance companies to change their behavior, to create real competition among private insurers in regions where currently no competition exists, and with real enforcement mechanisms. If the Obama administration had negotiated well, they could have essentially given their opponents that choice: an entirely private system that no longer abused patients, etc. or competition from the Public Option. Because of the fierce opposition among conservatives to anything run by the government, such a hard bargain seemed quite achievable.

Now we have the bad joke known as the Baucus plan, which essentially gave away the store with no concessions received in return. Let's call that Choice #4, after single payer, the Public Option, and effective regulation. With single payer even further from the table, and with no effort having been made actually to design a set of rules that would rein in the worst aspects of U.S. private health insurers, we now are down to a choice between a straight giveaway to the health care-industrial complex or a Public Option. The only real choice for anyone who cares about improving health care outcomes at this point is to support the Public Option and then to do everything possible to prevent the outcome that I predicted in my earlier posts.

This, of course, should not be the set of choices with which we are faced. When our leaders squander the best opportunity for real health care reform in a generation through inaction and a willingness to ignore the will of the vast majority of the public (to say nothing of the people who actually voted them into office), however, we have to make do.

-- Posted by Neil H. Buchanan