The 19.5 Years Test
"[E]ven if getting any bill called 'health care reform' passed would be good short-term politics," writes political scientist Scott Lemieux, "it's worth further emphasizing that signing a bill without (at a minimum) a public option would be a substantive disaster." Elsewhere, he says, "the public option is the core of the reform; a Blue Dog bill isn't so much half a loaf as a few meaningless crumbs." And, finally, "a bad bill would be worse than no bill."
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.
But it's also worth offering a more general reality check here: 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.
Rather, what has kept health-care reform at the forefront of liberal politics for decades is moral outrage that 47 million of our friends and neighbors are uninsured. That medical costs are one of the leading causes of bankruptcy in the United States. That an unemployed machinist gets screwed by fly-by-night insurance schemes while a comfortably employed banker need never worry. That the working class ends up in emergency rooms with crushing chest pains because they didn't have health insurance and didn't get prescribed cheap blood pressure medications five years before.
There are many themes in the sad and frustrating history of health-care reform. But one of the central ones is that there were many points when Democrats could have accepted a compromise and did not. Richard Nixon, for instance, proposed a plan that could have passed Congress but that liberals thought comically inadequate. It was more comprehensive than anything we will get this year. George H.W. Bush also offered a pretty good proposal but got no support among Democrats.
Opportunities at health-care reform do not happen frequently. The average between major attempts is 19.5 years. That's 19.5 years in which the uninsured stay uninsured and their ranks grow. Where a situation that is already bad gets a lot worse. This year, Barack Obama is popular, and there are 60 Democrats in the Senate and huge majorities in the House. There is no reason to believe that Democrats will be in a stronger position anytime soon. It is not like when a weakened Nixon, or a fading Bush, offered a compromise.
If reformers cannot pass a strong health-care reform bill now, there is no reason to believe they will be able to do it later. The question is whether the knowledge that the system will not let you solve this problem should prevent you from doing what you can to improve it. Put more sharply, the question should be whether this bill is better or worse than another 19.5 years of the deteriorating status quo.
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