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My theory of the public option fight, and of health care

Digby has a great post on the politics of the public option:

Ezra believes that if the votes aren't there for a decent public option then the horse trading should be around getting something good in return for giving up the public option rather than negotiating the terms of the public option. That would make sense if the public option were just another feature of the health care bill. But it is not. It is the central demand of the liberal base of the Democratic Party in this rube goldberg health care plan and has long since gone way beyond a policy to become a symbol.

Perhaps that is wrong on policy grounds. People will argue about that forever. But that doesn't change the fact that it is no longer a matter of policy but rather a matter of political power. And to that extent it cannot be "bargained away" for something like better subsidies, even if it made sense. "Bargaining away" the Public Option is also the bargaining away of liberal influence and strength.

I'm a policy guy, arguably to the point of myopia. The public option compromises that are on the table at this point aren't really compromises worth having. It's my job to say that, I think. Pointing this out has led a lot of longtime readers to give up on me as some sort of establishment dupe, and I see where they're coming from. Here's where I'm coming from.

It might have been a necessary thing from an activism point of view, but convincing liberals that this bill was worthless in the absence of the public option was a terrible decision, wrong on the merits and unfair to the base. The achievement of this bill is $900 billion to help people purchase health-care coverage, a new market that begins to equalize the conditions of the unemployed and the employed, and a regulatory structure in which this country can build, for the first time, a universal health-care system. Thousands and thousands of lives will be saved by this bill. Bankruptcies will be averted. Rescission letters won't be sent. Parents won't have to fret because they can't take their child, or themselves, to the emergency room. This bill will, without doubt, do more good than any single piece of legislation passed during my (admittedly brief) lifetime. If it passes, the party that fought for it for decades deserves to feel a sense of accomplishment.

But bills like this one have failed before, even in my (admittedly brief) lifetime. Indeed, pretty much the only thing that bills like this one have ever done is fail. But somewhere along the way, a fair swath of people convinced themselves either that this legislation was pretty much a done deal, and the argument could move toward its margins, or that the legislation wasn't worth passing without the public option. Neither was true, and a lot of the difference between me and some of my progressive friends came because I placed a higher probability on, and had more of an aversion to, the failure of the underlying bill.

Basic passage here is a liberal win, and evidence that liberals are running the country. Channeling $900 billion towards the un- and underinsured is Jay Rockefeller's addition to the agenda, not Ben Nelson's. But structurally, liberals only have what power and influence they actually have. And that's not 60 votes' worth. The incredible organizing that's been done on the public option was, on some level, an effort to suspend that reality, and it worked a whole lot better than I thought it would. But it wasn't enough -- couldn't have been enough, really -- to overcome the math of the Senate.

Some will take that as a criticism of the folks organizing on the public option. It's not. There's no chance to win if you don't play the game. But constructing liberal influence and power is a project with a longer time horizon than health-care reform. It's not going to happen before this bill is passed, and I disagree, strongly, with those who think it will profit from this bill's failure. This was something of a test case. Democrats had their 60 votes. They had a majority unknown in modern times. A majority that isn't going to get bigger. And what we learned is that, in this game, that majority simply is not big enough.

The U.S. Congress is hostile not only to liberal power, but also to conservative power, and for that matter, to majority governance. The rules trump the election, trump the organizing, trump the 50-plus senators in support of the public option, trump all of it. Liberals will never have 70 votes in the Senate, and, in a useful symmetry for the purposes of coalition building, nor will conservatives, and nor, it seems, will people who want to make hard decisions to solve pressing problems. The story of the public option -- and of the preservation of employer-based health care, and the insufficient cost controls, and the protection of providers, and all the rest -- isn't just a story for liberals. It's a story about our system of governance and its inability to respond to problems even when you stack the deck in change's favor.

That's why the focus of this blog has shifted somewhat. The first problem for people who care about policy outcomes -- regardless of which direction they care about those outcomes from -- is that the Congress has developed an overwhelming bias toward inaction and the status quo. It is much stronger now than it has been in the past, and it's exacerbated because we are much more divided now than we have been in the past. The answer to the systemic dysfunction on display in the health-care reform debate does not lie elsewhere in the health-care reform debate. For now, you get the best bill you can given the constraints we have. But seeing those constraints clearly is, I think, a step forward, because it's a useful guide to where we need to go next.

By Ezra Klein  |  December 4, 2009; 11:00 AM ET
Categories:  Health Reform  
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I think that this is a tactical question, which you made clear when you described yourself as a policy guy set apart from activists. Policy-wise you're right but tactically you don't start talking about giving up before you have to. Also, after thinking about your suggestion to trade away the public option for something better, I don't think we're going to get anything worth that trade. Keeping a weak public option's foot in the door is the best way to go. I want to see what happens in and after conference.

The time to sell the merits of what will undoubtedly be a less-than bill is after we get the best one we can.

Posted by: eRobin1 | December 4, 2009 11:28 AM | Report abuse

Another reason that I disagree with the proposition that liberals/progressives should torpedo the whole bill if it fails to include a public option, or the stupak amendment, or any specific individual provision really, is that we aren't content to just let the world burn to score political points. In my view, liberals believe fundamentally in the ability of government to solve problems, to write laws and regulations that make society and the economy safer and more open for everyone. Centrists, the current republican minority, and a few choice others are content to let the world burn because they don't share that view. I hope congress passes the best bill possible, and I hope liberal congresspeople fight stupak and fight for the strongest public option, but most importantly fight to pass the best $900 billion bill possible.

Posted by: eglabe19 | December 4, 2009 11:30 AM | Report abuse

May be because you came from the Liberal stock, Ezra you had to write so much to respond this contention of Public Option as Political Rally cry for Left. But it aren't worth it. Those wrong headed Left folks need to understand and they should not need to spoon feed this - what is good for this country.

What the focus of your blog has been and should be is about cost control. What we need from you is how many folks on Left are also misleading about the current cost control measures in the bill and their argument that those are sufficient. Krugman comes to mind. He is actually misleading here and that is bad. As Karen Tumulty at Time argues how Sen. Reid has essentially rendered Medicare Commission useless (and what you pointed to earlier too); it is clear that anyone who says that these bills control costs are lying essentially.

We need Media to keep high lighting all those games Congress plays. That is where we need more reporting and analysis. Public option - that is all theater and we had it enough.

Posted by: umesh409 | December 4, 2009 11:32 AM | Report abuse

I absolutely agree that passing a bill is significantly more vital than the inclusion of public option. To paraphrase someone famous, you go to war with the Senate you have, not the one you wish you had.

But what this debate has highlighted in startling detail, is the degree to which Senators are utterly unresponsive to the interest of their own constituents. I know that this is to a certain degree by design, but the ability of business interests to not only dictate how the debate will proceed, but to actually create an environment where blatant falsehoods are the starting assumptions around which everything revolves, has stripped the veneer of public interest off the face of Corporate America and revealed something quite ugly underneath.

That's going to have a lasting effect.

Posted by: PhD9 | December 4, 2009 11:33 AM | Report abuse

The liberal metric for success here shouldn't be "the public option no matter what it does," it should be "a meaningful alternative to for-profit insurance no matter what it's called." The tendency to get hung up on symbolic labels rather than policy outcomes has been an unfortunate element of this fight, IMHO. It makes one very easy to coopt.

At the same time, I think this fight has been very valuable for other reasons. It's pretty clearly demonstrated that the Democratic party now effectively consists of two separate and ideologically divided camps. At this point the Dems are less a single party than a coalition government like the ones found in parliamentary systems. The interests of the Reid-Baucus-Landrieu-Nelson wing are just materially different from those of the Durbin-Boxer-Kerry wing. And yet we still organize around single-party institutions. The failure of this fight (and we HAVE failed -- even if a "public option" gets in at this point, the chances it will do anything valuable are minuscule), proves that the Left needs its own institutions independent of the formal ones belonging to the "Democratic Party".

Posted by: NS12345 | December 4, 2009 11:37 AM | Report abuse

"It is the central demand of the liberal base of the Democratic Party in this rube goldberg health care plan and has long since gone way beyond a policy to become a symbol."

This is taken as read by much of the blogosphere, but I wonder if it is really true. Steve Benen mentioned a poll a little while ago that said that only around 3% of HCR supporters listed a public option as the most important part of the package. My guess is that what matters to most liberals is that a bill passes that can creditably be called "universal" and that makes insurance cheaper and better. But liberal bloggers do tend to see this issue in Digby's terms. I think Digby is indulging in a little blogosphere solipsism--blogopsism,if you will--here.

The people who I would imagine are dead set on a public option are hard-core single-payer advocates who see it as a part of their strategy. And with that motive in mind, their actions make sense.

Posted by: TheLev | December 4, 2009 11:38 AM | Report abuse

Digby is a great blogger and a strong and necessary progressive voice. But I'm with you on this one, Ezra. The math isn't there in teh Senate, but also the vision isn't there, the courage isn't there, the integrity and independence aren't there. Never in my (admitedly about double your) lifetime have there been such small people in the Senate. Even (or especially) the bad guys used to be outsized. Mary Landrieu vs Richard Russell? Mitch McConnell vs Everett Dirksen? Don't make me laugh. At least some of the Dixiecrats were populists (as long as too much didn't go to "those people"), and the GOPers still cared about the coutry.

This smallness is the real problem here. It is starting to seem like the generation that couldn't solve the problems that culminated in the Civil War. Sure, they were hard problems, but the war was infinitely worse than any compromise would have been. They really do have to try.

I'd much rather see the progressives compromise on health care for stronger subsidies and exchanges and make a strong stand on war funding. There their refusal to go along just might make a positive difference.

Posted by: Mimikatz | December 4, 2009 11:40 AM | Report abuse

Well said, Ezra and eglabe19.

One of the disturbing trends that I seem coming from the more activist arm of the left blogosphere is growing desire for liberals to acquire power as an end in of itself.

Posted by: JEinATL | December 4, 2009 11:47 AM | Report abuse

I'm still not convinced that the inertia of Congress is much stronger than in the past. Again I refer to the beginning of Robert Caro's story of LBJ's years in the Senate, Master of the Senate. Caro relates the long history of the Senate and its traditional role slowing down change and upholding the status quo. The Senate was designed to slow down change. The tactics used may have changed over the years as the rules changed, but the essential role of the Senate remains. Because only a third of the Senators are up for election in any two-year period, two-thirds of them don't have to worry about the short-term reaction of the voters.

I think you are determined to show that the inertia of the Senate is a recent development in order to refute those who see it as a hallowed tradition which has served the country well. But Caro makes a persuasive argument that for the most part it has not served the country well. He does cite the Senate's role in preserving the Union up until the Civil War, in refusing to remove Andrew Johnson from the Presidency, and in refusing to stack the Supreme Court during FDR's presidency as examples of the Senate doing what it was supposed to do -- resisting populist pressure in an attempt to serve the long-term interests of the country. But Caro also discusses at length the ways the Senate thwarted the public good during much of its history, and stood in the way of popular reforms.

During the era between the Civil War and the Great Depression, the era of government corruption and robber barons and monopolies and union busters and unsafe working conditions and no social safety net, the Senate stood on the side of the wealthy. It took the Great Depression to get that to really change.

During the era between World War II and 1964, the era of the civil rights struggle, the Senate was ruled by the Southern Caucus. It took massive upheaval and a true supermajority (the vote was 73 to 27 on the 1964 Civil Rights Bill) to get that to change.

This struggle with the inertia of the Senate is not new, but that does not make it healthy. The Senate is not a truly democratic institution. It has changed in the past, and it can change in the future. It should change in the future. I support getting rid of the filibuster. On the whole, it does more harm than good. (Just remember that in the future, Republicans may hold 51 seats again -- maybe as soon as 2012 if Democrats cannot overcome the enthusiasm gap.)

I think you undermine your credibility, though, when you imply that the Senate's fundamental inertia is a new development. Yes, the technical ways that inertia plays itself out may be new, but the inertia itself is very old.

Posted by: tim37 | December 4, 2009 11:51 AM | Report abuse

Political realities are just that, realities. Or for enacting legislation, VOTES.

Sad they are not there, and the country has become so utterly tribal when it comes to making common sense changes. But thems the apples we have.

Progressives are not that, when they deny progress.

Posted by: arnold104 | December 4, 2009 11:52 AM | Report abuse

Good post Ezra.

Posted by: ElBlot | December 4, 2009 11:52 AM | Report abuse

Discussion of policy without acknowledging political reality is an empty and pointless exercise. Otherwise we should just be talking about single payer, which has been a success in just about every other major industrialized country. You implicitly acknowledge that when you talk about the public option not being achievable in the current senate.

So here is another political reality: if the Democrats pass healthcare reform that requires mandates, and offers no alternative to the rapacious health insurance industry that has so signally failed, they are going to be destroyed in the 2010 and 2012 elections.

I think they are in big trouble anyway because of their failure to be more aggressive in job creation and their blatant kow-towing to Wall Street. But I mean that, with the fiasco that has resulted from the healthcare insurance reform process, they may be heading for an electoral catastrophe of historic proportions, damned equally by motivated voters on both left and right.

The bigger story here is that we now clearly live in a client state, run by large banks and corporations, and where the political process has relegated itself to little more than a sideshow. The politicians and journalists in DC seem to regard the whole thing as a game. They didn't see the economic catastrophe that came in 2008, and they don't see the (for them) political catastrophe coming in 2010 and 2012.

We live in interesting times.

Posted by: GeorgeTaylor1 | December 4, 2009 11:53 AM | Report abuse

Interesting topic, I think Digby is a little off on the politics of the public option.

The public option was an idea developed by those with an ultimate aim of single-payer who believed that this incrementalist approach would be 1) politically realistic 2) a way of building support for single payer. Hacker, et al.

Edwards then made the public option as part of his health care reform platform, to be a marker that established himself as THE liberal candidate among himself, Obama and Clinton in the Dem primary. Obama and Hillary, not wanting to cede that ground so easily, added the public option to their plan as well. Obama first, then Clinton second, IIRC.

This cemented the public option as the "liberal measuring stick" for health care reform. HCAN and others, that believe a la Hacker that the public option was an incrementalist approach to single-payer, further pushed this measure during the election and after. This led to the public option being the rallying cry for the left. In my mind, where Digby is a little off, is that the Dem politicians are reluctant to give up the weak public option, not because of a concern of appearing weak, but because of a concern of pissing off the activist left that have worked themselves up into a frenzy about a public option. So we've got a dynamic where the Democrats are looking for ANY type of public option to pass, just so they say that SOMETHING passed that's a public option. The actual utility of the public option itself, is of secondary importance to making the activist left somewhat comfortable that something DID pass on a public option.

Posted by: wisewon | December 4, 2009 11:57 AM | Report abuse

"I think you undermine your credibility, though, when you imply that the Senate's fundamental inertia is a new development. Yes, the technical ways that inertia plays itself out may be new, but the inertia itself is very old."

Except that, for the most part, all the old tactics for slowing down legislation are still there. Making the filibuster routine and metastasizing holds into a routine procedural element (e.g. forcing you to take three days before you can even vote on a single amendment) changes things considerably. It makes a "slow house" an effective block.

I agree with you that the whole idea of a house purely intended to slow everything down is inherently problematic. But 60 votes were enough to pass moderate legislation on basic issues in the past. Things have changed.

Posted by: NS12345 | December 4, 2009 12:01 PM | Report abuse


One other thought. It'd be easy for me to put up a slew of posts from 18 months ago, where you explained why the public option was 1) important and 2) the best path forward to single payer. Something that you stated as your ideal system, and that the public option route was the "incrementalist approach" for getting there.

You HAVE moved on this issue.

Posted by: wisewon | December 4, 2009 12:07 PM | Report abuse

Excellent post. We need more policy guys.

More importantly, we need more "policy guys" in the Senate.

Watching Republicans demagogue on how the bills will create huge deficits AND then watching the same people support amendments that gut every cost control feature just makes my head explode. Do these people have any principles?

It's frustrating that we have to even fight for the opportunity to *buy* our own stinkin' insurance from a Public Option. It's depressing that that fight is likely to be lost.

Still, we should pass the best bill that we can. Everyone involved should take a deep bow, point out what huge step forward we've finally taken. Even if there's still work to be done to make it better.

Posted by: bswainbank | December 4, 2009 12:07 PM | Report abuse

Well said, Ezra. I mostly agree, but I am less willing to give up the PO until the last damn minute. I don't think it's completely dead yet, call me crazy.

Further, I agree with some of your past posts that legislation is inevitably crappy at first and is improved over time, so I'm not sure a crappy PO isn't worth having. Even if we get a level-playing field, opt-in turd, it has to be there at all in order to be improved upon.

I'd consider trading it for a full Free Choice amendment or large-employer exchanges, though. ;)

Posted by: roquelaure_79 | December 4, 2009 12:07 PM | Report abuse

Very, very well said Ezra. I've been wondering how long it was going to be before the blogosphere started admitting what was political reality months ago.

The folks at Daily Kos and others seem hell-bent on destroying this legislation over the PO, which shows how little most of them know about public policy. At least there are outlets like this.

Posted by: truth5 | December 4, 2009 12:15 PM | Report abuse

I'd trade the public option for allowing the uninsured to join medicare until the exchanges are set up. Then they can switch over to the exchange. Of course, no one will want to and poof...single payer. A fantasy, I know, but what is really worth trading the public option for? Slightly higher subsidies? Those subsidies go right to the insurance companies via higher premiums. Better cost controls? Riiiight. The repiglicans and conservadems are basically saying no no no. Why do we keep trying to win them over. Reconcilliation for the public option. A separate bill for the insurance reforms and other cost controls.

Posted by: srw3 | December 4, 2009 12:17 PM | Report abuse

Piffle. Exchanges won't work and we needed a Plan B and that was the robust public option. Once we lost that--due to inadequate Presidential leadership I contend--we needed to go back to the drawing board and ask the public what they wanted in light of the fact that Democrats can't hold their caucus. Instead Dems decided to ram the bill through and pretend like they "did" health care reform. It won't work. How much of a disaster it will be remains to be seen, but it will be a disaster.

I don't want my progressive Congressmen to vote for this bill because it will not help working families, thus discrediting our movement. Remember, $900 billion (or whatever it turns out to be) doesn't go to poor people. It goes to an essentially unreformed health industry, and it's paid for by largely by the middle class. It is a moderate Republican bill and moderate Republicans should pass it. If they won't, so be it.

Posted by: bmull | December 4, 2009 12:35 PM | Report abuse

"This bill will, without doubt, do more good than any single piece of legislation passed during my (admittedly brief) lifetime"

Certainly debatable. Were you alive for welfare reform, NAFTA, or Medicaid/SCHIP expansion? I'd rank all those higher.

Separately, the public option that progrssives desire was NEVER viable. No one has ever explained to me why doctors and hospitals would ever allow a public option to be tied to Medicare rates. It's a non starter. Congress can't even cut doc payments in Medicare one time. Why would they be able to basically shift 20%, 30%, or 50% of doctors' patient base to Medicare reimbursement thru a public plan???

Posted by: MBP2 | December 4, 2009 12:38 PM | Report abuse

As several have pointed out, the story behind the story is the incredibly depressing spectacle of our congress in action. There are certainly some good people laboring away, but the overwhelming impression given is that they are continually thwarted by people who lie blatantly, with impunity, and who are clearly operating in their own personal self-interest versus the public's. Watching Lieberman or Landrieu's ever evolving rationales for opposition to the PO is infuriating and creates a sense of complete powerlessness.

It's all about them. Serve the public? What a laugh.

Even the good guys continually retreat from applying any real pressure or accountability to the Liebermans, Nelsons, etc. which creates the impression that our Senators will willingly sacrifice US to the alter of Senate collegiality.

With respect to the bill itself - certainly, even without the PO, there's a lot of important improvements. But, again with the depressing, here we are being expected to celebrate passage of changes that are no-brainers in the first place. We need the Congress to spend a year to pass a law that ban rescission? Really? As though rescission isn't so self-evidently appalling that it should have been outlawed years ago?

Posted by: Melinochis | December 4, 2009 12:56 PM | Report abuse

I actually think Digby is 100% correct.

As Senator Brown said yesterday, the PO has already been "compromised" 4-5 times, which has won 0 votes the last few times out.

Instead, we still have people like Nelson offering up the Stupak amendment while Blance, Mary and Snowe are trying to kill state regulation of insurance.

Political reality check: the other side know how to play hardball when they know they are the 2-6 votes it takes to get this thing passed. They feel that the other 50+ aren't willing to blow the thing up, no matter how bad the bill is because it gives them a few health care green shoots. Yes, some important ones.

But they're also being ask to give away on the Stupak amendment.

They're also being asked to give away on state regulation of it means getting Snowe's vote (and keeping Blanche's) to pass the bill.

They're also being asked to give away on that item that Ezra more than a few times indicated is the worst aspect of the bill but seems to be ducking reporting at all on what's being done to get it out of the bill.

Progressives haven't asked for the whole Pie. They started by asking for half of the pie... hell, that's probably genrerous. A quarter of the pie perhaps.

They are now being told by the ConservaDems with Leadership, the White House and reporters like Ezra backing them that just one slice of pie might be all we get out of this.

I don't think that Leadership, the White House and reporters like Ezra quite get that once you agree to a pieace of pie, the hardball players will either comeback to take the filling to leave you with the crust, or force you to have some poison with that pie (the Stupak amendment).

I'll go back to what I've said a few times:

A lameduck President with less than 30% favorables and ridiculous negatives was able to get a Congress run by Democrats and filled with a bunch of Republicans that were running like hell from him to pass Telecom Immunity.

For passing that bill, the Dems got nothing.


The President wouldn't even agree to a trade off such as *not* veto'ing SCHIP.

At some point Progressives and Liberals needs to draw lines in the sign or they will continue to get raped. The Stupak Amendment is quite simply legislative rape. And for all we've seen from Ezra on how it just might maybe kill the bill (though it didn't in the House), I've yet to see the Policy Wonk in his say whether it's worth killing the Healthcare Bill if it remains in it.

Care to take a stand on the one?


Posted by: toshiaki | December 4, 2009 1:10 PM | Report abuse

" The first problem for people who care about policy outcomes..." to be clear about the objectives for which we are fighting. I don't care one bit about a public option -- it is basically another fantasy that a "uniquely American solution" will do better than the proven straties that have been used to deliver universal coverage without bankrupting individuals, employers, or governments. None of the successful programs include anything like what has been discussed here (either weak or robust).

Insurance is a side show without a coherent health policy and all the tweaks in the world can't make this into a coherent policy and I'm surprised that someone who labels himself a "policy wonk" can't see that.

At some point, healthcare was pushed aside and the objective became yet another bonanza for the financial sector. Insurance companies do not deliver care; they deliver financial products. The fact that neither journalists nor our legislators understand the distinction is a major reason that we are now being asked to settle for non-reform.

Posted by: Athena_news | December 4, 2009 1:25 PM | Report abuse

"60 votes were enough to pass moderate legislation on basic issues in the past. Things have changed." (Posted by: NS12345)

First of all, thanks for the response. It's nice to know someone is reading and cares enough to respond.

Now, do you consider an attempt to institute universal health care "moderate legislation on basic issues"? I don't. Nor do I consider the stimulus bill to fit that category. Nor the carbon tax, which has not yet come to a vote in the Senate. Those are the three bills I've seen where everyone is talking about 60 votes, and none of them is moderate legislation on basic issues, even though I think they are all vital bills.

I know that appointments have been delayed, and I agree that something needs to be done about that. Appropriations bills do not require 60 votes, right? So other than appointments, is there other more routine business of the Senate that is being blocked by the threat of filibuster? Or is it just these three major, historic bills, one of which passed, one of which will apparently pass in some form, and one of which may not get off the ground this year? If so, I'm not sure I see how things have changed since the 1890s, 1920s, and 1950s.

Posted by: tim37 | December 4, 2009 1:56 PM | Report abuse

These comments are very constructive, but quite different from the comments I see on blogs I do on other sites. I wish I knew how large the "hard core" public option or NOTHING constituency really was, but I have unsubscribed from some of my favorite progressive sites, not because I don't think you need to fight to the end, but because their points of view are that if you don't win the fight, nothing matters.

We are going to need ALL the base when it comes to the 2010 and 2012 elections. We will need to fire everyone up again, and those who fought these latest fights in an inflexible way, demanding their way or the highway, are not going to have the enthusiasm to compromise with Obama.

As for me, I'm in it for the long haul. I think the reforms that are there, minus the PO, are truly significant, and I just hope that most of our party will come around to understand that before we have to reorganize them for the next round.

Posted by: LindaB1 | December 4, 2009 2:02 PM | Report abuse

Lets face it.

There is something fishy about this straight-up give-away to the insurance industry. Sure, the reform aspect is significant, but the math is wack. Are the rescission and pre-existing hits really that significant in relation to the certainty of 45 million new customers? Think of the financial instruments that will be created just off that certainty? (think of the bubble). This smells of the Conservative's proposed Social Security privatisation swindle where they wanted all that money to go to Wall Street (much of it reached its proposed destination anyways).

1. Are the insurance companies (or institutions exposed) solvent?
2. The Single-Payer system or Robust Public Option (w/ regional negotiated rates) or Non-profit (heavily regulated) Insurance systems are superior, mostly proven, cost-saving effective, policies/models.
3. Most Americans want a Public Option.
4. Most Doctors want a Public Option.
5. It is difficult but not that terribly hard (Taiwan went to a form of single-payer in a year...not apples to apples; but damn, a year?):

Those who are against the Public Option or Single-Payer or Non-Profit (and heavily regulated) insurance on policy terms are hard put to come up with substantive counter arguments. Yes, this is Political but Ezra did not mention that the chief political influence in this debate is Corporate.

We have to deal with that reality. Part of dealing with it is naming it.

Posted by: perhapsnot1 | December 4, 2009 2:22 PM | Report abuse

Just look at Mike Enzi's 2007 "Ten Steps to Transform Health Care in America Act". If you don't still have your copy of the bill, you can see a summary on page 6 of this link:

Enzi's bill is fundamentally similar to the bill the Senate is poised to pass. In some ways Enzi's bill is better.

So, I ask you: Is this is a progressive victory? Is this is why we kept Lieberman in the caucus? Is this is why we elected Obama?

Posted by: bmull | December 4, 2009 2:39 PM | Report abuse

I am sick to death of hearing that a public option is the next best thing to a single payer system -- which is assumed to be the holy grail. I want universal coverage and the fact is, the best universal coverage programs are NOT single-payer. IMHO, liberals have dug a hole to nowhere with the "if we can't have single-payer, we insist on a public insurance company" argument.

BMull: "in some ways Enzi's bill is better"

The Senate bill does not eliminate the corporate exclusion for benefits. And even though it requires everyone else to purchase insurance on its own, it doesn't create an above-the-line deduction for individuals who are paying 100% of their own costs. So yes, Enzi's bill looks a whole lot better to me.

Posted by: Athena_news | December 4, 2009 3:24 PM | Report abuse

"Yes, this is Political but Ezra did not mention that the chief political influence in this debate is Corporate.

We have to deal with that reality. Part of dealing with it is naming it."

Very, very true.

Posted by: Melinochis | December 4, 2009 3:44 PM | Report abuse

So, conservative governance is impossible? I guess I just imagined Afghanistan, Iraq, tax cuts, No Child Left Behind, and the prescription drug benefit. It seems like when you have a party and a president ideologically committed to the core goals they ostensibly believe in (in their case, war and rule by the rich) they manage to muddle through quite well. They try really really hard at all levels, raising hell and spitting fire in Congress, the WH and the MSM until they get what they want, including threatening the nuclear option (OMG, the filibuster isn't actually sacrosanct?).

What we've seen is the Democratic party and its "leadership," including A-list bloggers like Ezra, aren't that committed. They won't demand real reform and a really affordable system for all (single payer or a tightly regulated system on the Swiss or Dutch model) either because they don't really believe in it or are too cowed by 40 years of conservative reaction and bullying to ask for it. I hate what the conservatives believe in but admire the way they go about it - they demand results and they go after them, scaring the hell out of their leaders until they win. Guys like Ezra tell us that the most we can hope for is settle for the same failed overpriced private market and try to stem the bleeding on the margins by giving out subsidies. I'm all for the subsidies, but when are we actually going to demand a system that's affordable for all? Ezra says "some day," but when? He will never, never say that it's actually time to demand affordable health care as a right and not as a privilege grudgingly and expensively doled out by the private health care market. We've been talking about universal, affordable health care at least since FDR and seriously since Truman. I think the time for waiting for "someday" after 60+ years is over and that it's time to insist on results and accountability from Congress, the President, and guys like Ezra. Ezra failed that test, and he's no liberal or progressive worthy of the name as a result.

Posted by: redscott | December 4, 2009 3:57 PM | Report abuse

Athena, Universal Coverage can be had many ways and well. Don't make a straw man of Single-Payer.

You seem enlightened enough to know this legislation is some tortured candy-coated feces. Yes maybe through a form of time-release alchemy it will be transformed into your vaunted universal coverage, But it is what it is and that is it is NOT the best universal coverage or anything close.

Posted by: perhapsnot1 | December 4, 2009 4:03 PM | Report abuse

Ezra's analysis of the bill boils down to it is "better than nothing". Since there is a history of failure in health care reform, I agree it is best to start the process of improvement.

This analysis that what is on offer is better than nothing is correct so far as it goes. It misses the key point (elaborated by Matt Yglesias) about how what is politically possible gets defined: the progressive position scales back its aims and starts timid, limiting real benefits for real people to try to fit "existing" political realities. This timid position is defined as the extreme left of the mainstream. Additional compromises are made to better fit what is "politically possible". This generates further limits to the real benefits of progressive proposal. More importantly, as the definition of "extreme" left creeps rightward, more and more progressives are defined as "extreme". Majority positions-- like including a public option-- are defined as extreme.

I am tired of having my moderate views described as extreme, while corporate shills are described as moderates.

Digby is trying to stop the rightward shift of the Overton window, but at the end of the process of redefinition. Yglesias' point is that we need to set the extreme position at the start of the process, not at the end. We also need to set it closer to a position that truly extreme.

Of course, I come from a country with real campaign financing laws, socialized health care, and government media, so I am dreaming about how we can set the extreme progressive position.

Oh, and another day of Repubobstruction, another 123 Americans condemned to death by inadequate healthcare/ health insurance.

Posted by: jamie_2002 | December 4, 2009 6:05 PM | Report abuse

"The first problem for people who care about policy outcomes -- regardless of which direction they care about those outcomes from -- is that the Congress has developed an overwhelming bias toward inaction and the status quo."


Congress didn't create the bias toward the status quo -- the founding fathers did.

Laws aren't supposed to shift widely depending on who is power. Democracies (and for the matter capitalism) work best when the law is stable and predictable.

One reason the economy is not recovering faster is that entrepreneurs don't know what future tax and regulatory burdens they will face when they make investments for the future of their business.

Posted by: StanSSO1 | December 4, 2009 8:16 PM | Report abuse

There is also a certain institutional inertia that Reid and other Democratic leaders have utilized wisely. The fact that the public option is in the bill under consideration and the fact that there is a 60 vote threshold for any amendment, means that it will be damned hard to get rid of the public option.

Lets just hope Lieberman doesn't act on his threats. Seeing as how he is a spineless opportunist hypocrite, I have confidence that when push comes to shove, he'll take it 30 pieces of silver.

Posted by: zosima | December 5, 2009 2:34 AM | Report abuse

"If it passes, the party that fought for it for decades deserves to feel a sense of accomplishment."

Yeah, a sense of accomplishment. Like the one that Oskar Schindler had: "I could have got more out. I could have got more. I don't know. If I'd just... I could have got more."
'nuff said.

Posted by: Gray62 | December 5, 2009 7:01 AM | Report abuse

Perhapsnot1:"Athena, Universal Coverage can be had many ways and well. Don't make a straw man of Single-Payer."

It's not a strawman; the liberal fascination with single-payer as the only true universal care solution is a major reason that we will not be getting anything that could reasonably be called universal coverage. I read countless articles about healthcare every day and less than 5% deal with other strategies to deliver universal coverage -- virtually none from popular columnists/bloggers like Ezra.

If you read over Ezra's posts from the past 6 months he consistently sets single-payer as the liberal goal then bargains down from there. He always references single-payer when discussing various incarnations of the public option. IMHO, analysts like Ezra have done us all a big disservice by not starting with full coverage of alternative ways to achieve universal coverage.

Liberal legislators have the same problem. Think about it, Dennis Kucinich didn't propose that each state be free to construct its own universal health program; he pushed single-payer as the only alternative to the exchanges. In fact, what we should be doing is encouraging experimentation on a state level with different forms of true universal coverage -- which would put every man, woman, and child in the same basic program.

This bill does not fix anything; it simply perpetuates what is fundamentally wrong with our health financing model: over dependence on employer-paid programs and unregulated provider charges.

Posted by: Athena_news | December 5, 2009 10:23 AM | Report abuse

I wish I believed that systemic inertia applied to conservatives as well as liberals -- but I don't. Democrats just roll over and ask to have their bellies scratched when out of power. Conservatives these days are willing to burn the house down.

Posted by: janinsanfran | December 5, 2009 12:04 PM | Report abuse

Get out of my face with that tired blame the liberals crap. You know Single-Payer advocates have been excluded from these negotiations.

I swear you people suck.

Posted by: perhapsnot1 | December 5, 2009 2:47 PM | Report abuse

" You know Single-Payer advocates have been excluded from these negotiations."

And you have just proved my point. Instead of whining about how single-payer was excluded from consideration; why haven't we seen proposals for other types of universal coverage?

Having actually worked in countries with single-payer and other forms of universal coverage, I would definitely prefer another model.

The point though is that liberals have been all hung up on single-payer and done ZERO to educate either themselves or their readers about other universal health care models. Instead, they whined about single-payer having been shot down then put all their energy into somethinig that I see as a truly assinine fallback: a public insurance company to compete with private insurers. The idea that a public insurance company with a tiny sliver of the market will have any significant influence in moving us onto a more stable path is pure fantasy.

And yes, I do blame liberals for this. They have spent the last 15 years doing nothing but moaning about how Clinton's plan was done in by the industry. While every other major industrialized country was actively studying how their universal systems could be improved, liberals here squandered years that could have been used to ready the public for an actual debate about the about the advantages and disadvantages of universal single-payer, all-payer, and individual payer systems.

Health reform was my number one issue in last year's election and I am not going to shut up just because a bunch of liberals with dubious credentials pronounce the currently proposed legislation "good enough".

It is NOT reform and it is NOT good enough. People will continue to go bankrupt due to medical debt, companies will continue to shoulder outsized medical expenses, and all level of government will continue to devote increasing levels of funding for health care.

It only took a year to repeal the poorly architected conceived catastrophic medicare coverage. In this case, it will probably take a little longer for the population at large to realize that nothing has changed and we will be right back where we started.

Posted by: Athena_news | December 6, 2009 11:33 AM | Report abuse

Athena, to blame this bill on Liberals is to be
Stupid; Cockeyed; Deceitful; or all three (IMHO you're all 3).

Ted Kennedy, John Dingell, the American Medical Students Association, and a host of other liberals and organizations have fought for years to get to universal healthcare coverage and they are not responsible for what's bad in these bills. Some tout Single-Payer, some do not, but all have worked to improve healthcare coverage.

Kennedy Kassebaum
Connecticut's SustiNet
and a host of other incremental reforms were either initiated or co-authored by Liberals as part of a CENTURY's-long effort against Most Conservatives (I include the now conservative minority of the AMA) Corporations and back-biting know-nothings.

In the international examples of mixed approaches to universal healthcare, for-profit insurance when it is present is highly regulated and its activities restricted (as supplemental, etc.). For-profit insurance OUT of the bulk of ANY proposal/scenario makes sense. A strong Public Option in the current proposal makes sense.

You blaming Liberals for bad legislation makes no sense at all.

Posted by: perhapsnot1 | December 6, 2009 3:58 PM | Report abuse

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