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Howard Dean: Health-care reform 'worthless' without the public option

M1X00103_9.JPGDylan Matthews beats me to the punch with some well-deserved shots at Howard Dean's contention that absent the public option, "this bill is worthless and should be defeated."

No, it isn't, and it shouldn't.

Organizer friends have patiently explained to me that the public option only has a chance if its supporters take a hard line on its inclusion. That may be right, but the problem is that that strategy relies on people such as Dean actually convincing their base that the public option is central to health-care reform's success and desirability.

That's not true. Indeed, it's not even clear how it could be true. The strongest public option on the table -- the House's version -- would serve a couple million folks and cost a bit more than private insurance. It's worth having, for reasons I've argued over and over again. But a lot of things are worth having. It isn't decisive, or even obviously relevant, to the bill's success or failure. If the bill is "worthless," then it's worthless in the presence of the public option. And if it's not worthless, it's not worthless in the absence of the public option.

Which leaves us arguing over the meaning of the word "worthless," I guess. This is a bill that cuts premiums costs. That extends insurance coverage to more than 30 million Americans. That cuts the deficit. That establishes an expectation for near-universal health-care coverage. That really digs into delivery-system reforms. That takes the first, halting steps away from the fee-for-service system. That makes better insurance cheaper for the poorest Americans. If passed, it will be, without doubt or competition, the largest piece of progressive social policy since Lyndon Johnson established Medicare and Medicaid. If this isn't worthwhile, then progressives should pack up and go home, because nothing Congress passes in the foreseeable future will even come close.

I'm not among those who think the public option should be dropped. The bill would be better for the public option's presence, and all the arguments against its centrality also apply to those demanding its removal. If the bill's managers have to compromise on it, then they better get something serious in return for their concession. But it should be kept in perspective, and people shouldn't be misled about its importance, or about the worth of the underlying bill.

Photo credit: By Brendan Smialowski/Getty Images

By Ezra Klein  |  December 1, 2009; 4:56 PM ET
Categories:  Health Reform  
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Next: How many public option compromises can dance on the head of a pin?

Comments

so we should compromise (weak public option currently in the bill) the compromise (stronger public option with no opt out or trigger) of the compromise (public option based on medicare payment rates) of the compromise (Medicare for all that was taken off the table at the beginning of HCR) to subsidize insurance company profits. I don't think that is is fair to people to require them to have insurance and then have to pick from one of the companies whose goal it is to deny payment of covered services to increase its profits. At least, there needs to be a non-profit option available to folks. Until 2014 when this actually starts working, how about letting the currently uninsured and under insured join medicare and pay full premiums until the get to retirement age?

Posted by: srw3 | December 1, 2009 5:04 PM | Report abuse

Can we settle on "much more worthwhile?" And when, exactly should Dean start telegraphing what he'd give in on?

C'mon, let's get real. The opposition is apoplectic about the public option because it provides choice and competition, however modestly. The insurance companies are right to be afraid that they might have to compete with a successful model in due time and want desperately to avoid it.

Dean can see that as well and wants the public option in. It's not insignificant at all.

Posted by: billkav | December 1, 2009 5:14 PM | Report abuse

I guess this is what bugs me about the "legislative realism" you described below Ezra. If all this bill is intended to do is expand employer-based coverage and create an individual mandate structure, why talk like it's The Greatest Progressive Reform of Our Time? That kind of framing will always attract significant attacks from the Right and will usually spook moderates. Where is the political logic in overpromising and underdelivering?

All of that said, I think progressives lost this fight months ago. The "public option" left on the table is little more than a nonprofit with government startup costs. Progressives basically won the name but lost the policy. If Dean and his allies could swap the thing out for a "less controversial" nonprofit or co-op that's actually open to more people -- or even fairer subsidies -- they would be fools not to take it.

Posted by: NS12345 | December 1, 2009 5:17 PM | Report abuse

There are good strategic reasons for what Dean is saying. I didn't believe it either, but there are. For one thing, he's countering Lieberman's stubborness with some of his own. For another, he's laying the groundwork for House progressives to kill the bill if it doesn't contain a public option. Many progressives think we should kill the bill now, but we don't have the votes unless the public option gets watered down further.

Posted by: bmull | December 1, 2009 5:32 PM | Report abuse

Between Ben Nelson insisting on Stupaking the Senate bill and ivory tower liberals like Dean and bmull angling to spike health care reform entirely and let real uninsured people continue to die needlessly, I am now officially completely and utterly fed up with reading about or thinking about this issue. No wonder Democrats are heavily demotivated to vote in 2010, sheesh.

Posted by: Chris_O | December 1, 2009 5:43 PM | Report abuse

How does this bill "extend" health insurance to 30 million Americans? It forces them to buy it; it doesn't "extend" anything. Further, without the public option, it forces citizens to buy a product (health insurance) from private insurers that have proven they will do anything to increase profits, including bypassing regulations and killing their customers.

Further, why should I trust what you say on this, Klein, when every time you defend the merits of the bill you do it with the bald lie that it "extends" insurance to 30 million Americans that don't have it now. Forcing Americans to buy something or pay a penalty is creating a new tax, pure and simple. And in this case it's creating a regressive tax, a tax on those with the lowest incomes, a new tax on Americans least able to afford it.

Dean is absolutely correct that this bill is worthless without a public option. I understand that you and your bosses are thrilled that the medical industrial complex will earn windfall new profits if/when this bill passes with or without the public option, and so of course the bill isn't worthless for them. But for average income Americans, the savings are negligible; and the only thing the bill "extends" is a massive amount of wealth from those with lower incomes to already obscenely wealthy purveyors of the health care and health insurance industries.

Posted by: NealB1 | December 1, 2009 5:43 PM | Report abuse

This reform package is not nearly so progressive as it could be or should be. It is in fact a very moderate effort to correct some major problems and injustices in the current system. The move toward universal coverage, combined with the caps on individual payments and elimination of the insurance companies' ability to deny coverage due to pre-existing conditions encapsulated in the legislation signifies real movement toward the principle that health care is a right, not a privilege. This is something liberal and progressive Democrats have argued for generations, that public health is a public good and that individual health care is a right, not a privilege. These aspects of the legislation are in fact very progressive.

What is not progressive is the fact that this legislation in many ways enhances the competitive position of insurance companies. Insurance companies are in fact the "bad guys" here, yet they stand to reap considerable profit from this legislation. That aspect of the legislation is what really rankles progressives and liberals and why they have become so obsessed with the inclusion of the public option. It is true that the public option has already been compromised down to a level of lesser relevance, and is likely to be compromised further. The legislation is still worthwhile, but it does not go nearly so far to reforming the system as most progressives and liberals would prefer.

It is also true that the legislation makes significant steps toward changing the fee-for-service system toward a system emphasizing quality rather than quantity and toward containing health care costs over the longterm. These are in fact crucial reforms which are essential for the longterm sustainability of the system, and are not ideological in character.

Posted by: OHIOCITIZEN | December 1, 2009 5:49 PM | Report abuse

Neal, there are a lot of things wrong with your argument. Do you think people with pre-existing conditions should be banned from buying insurance? Because if they're not banned, then you need an individual mandate, or premiums would go through the roof. And low-income people get subsidies under the House & Senate bills, and while they could be more generous, that greatly cuts against your argument that it's a transfer of wealth from the poor. Seeing as the House finances this with a surtax on the rich, it's an especially hard argument to make.

And the bills would also "extend" HEALTH CARE to lower income Americans who couldn't get it otherwise. I don't know how you managed to leave that out.

Posted by: Chris_O | December 1, 2009 5:50 PM | Report abuse

its only worthless for those that want government to take over the system like Dean. Those that want it to be affordable realize this is a first step, although a very minor and weak one. Once we get everyone covered we can work towards affordability because this bill does very little towards that goal that President Obama had.

I also think a liberal fear could be that if insurers aren't denying people for pre-ex then their bogeyman will go away. Today they can point to 45,000 that die annually from a lack of health insurance and they're right. When people are choosing a tax penalty as opposed to health insurance its much less easy to give them the benefit of the doubt as opposed to now when insurers are denying coverage for pre-exisiting conditions.

Posted by: visionbrkr | December 1, 2009 5:55 PM | Report abuse

bmull,

so you're saying that you're willing to sacrifice the lives of many without health insurance now (remember those 45,000 that die annually) to get your pound of flesh?

Posted by: visionbrkr | December 1, 2009 5:58 PM | Report abuse

"That establishes an expectation for near-universal health-care coverage. "

Only in the United States would anyone call the proposed legislation "universal health-care".

Universal health care does not mean that everyone is forced to buy some kind of health insurance. It means that there is a UNIVERSAL health plan that applies to everyone. It doesn't mean varying plans for Seniors, children, corporate employees, poor people, almost poor people, etc. Universal health care means that everyone has the same coverage and pays an equal amount toward that coverage -- whether as taxes or an pegged to income.

There is *nothing* universal about what is going on here and honest progressives should stop using the term when talking about the legislation. They should also stop using health insurance as a proxy for health care.

Premiums will go down only when the cost of care goes down and anyone who believes that this bill will reduce actual costs is simply in denial.

Posted by: Athena_news | December 1, 2009 6:14 PM | Report abuse

"That establishes an expectation for near-universal health-care coverage. "

Only in the United States would anyone call the proposed legislation "universal health-care".

Universal health care does not mean that everyone is forced to buy some kind of health insurance. It means that there is a UNIVERSAL health plan that applies to everyone. It doesn't mean varying plans for Seniors, children, corporate employees, poor people, almost poor people, etc. Universal health care means that everyone has the same coverage and pays an equal amount toward that coverage -- whether as taxes or an pegged to income.

There is *nothing* universal about what is going on here and honest progressives should stop using the term when talking about the legislation. They should also stop using health insurance as a proxy for health care.

Premiums will go down only when the cost of care goes down and anyone who believes that this bill will reduce actual costs is simply in denial.

Posted by: Athena_news | December 1, 2009 6:14 PM | Report abuse

The "boogeyman" we're afraid of is being forced to pay large fees to an industry that CURRENTLY performs in such an abusive and unreliable way. I am confident that creative insurance company administrators and lawyers will find new and exciting ways to horribly screw people, even after the current narrowly defined suite of abuses is corrected.

It's important to have at least one other background option. But if it's NOT going to be a truly government-administered one, it should at least be a fully empowered nonprofit.

Posted by: NS12345 | December 1, 2009 6:25 PM | Report abuse

Ezra, what I'd like to see (if there's been one & I missed it, my apologies) is an assessment of the strength-- and by this I mean integrity & endurance, not immediate impact-- of the various components likely to pass. It's all well & good to say that There Will Be No More Denials for Preexisting Conditions, but my bet is that within ten years or so, insurers will still have managed to drive their potential money-losers into ever-widening coverage gaps. What happens once the bill's passed, the public's attention drifts away, and the lobbyists are once again the only people trying to influence the healthcare system? Because a public option, however small, looks a lot harder to kill outright in 5-10 years than most of the other reforms-- it could take a lot of cuts, but unlike various regulatory requirements, *it would still exist in some meaningful way*. Regulations & rules are only as good as their intent and enforcement, after all, and we know what happens to protecting the public interest whenever the GOP gains power.

So could you or Jon Cohn or someone try to look beyond the first few years, not at the dollars and cents, but for the potential changes in what's being discussed? Because right now most of what I see are discussions of how many people will be helped by current proposals, *if* they work as intended, during a second Obama term-- what I want to know is how invulnerable, how absolutely settled, these reforms will be.

My take on the absolute resistance to a public option by insurers, Republicans, and Lieberman is that that's the one thing they know they can't destroy from within. Maybe I'm wrong, but given the history...

Posted by: latts | December 1, 2009 6:34 PM | Report abuse

The relevant sections are S. 212 - 217 of H.R.3962. Look them up at Thomas.gov; if you can spot an ambiguity I guarantee you the insurers will push it.

Posted by: NS12345 | December 1, 2009 6:59 PM | Report abuse

Ezra is a member of the "village", bought and
paid for by his corporate bosses at the Washington Post, a newspaper way past its prime and getting smaller. He is also a liar when writing about this issue. Go to talkleft.com and see the comments by Big Tent Democrat if you really want to understand this issue. Dean is telling the truth. Ezra and his fellow liar bloggers are propagandists. You are dishonest Ezra...and I hope everyone stops reading this crap...because we are all getting hurt. Keep remembering that these smart bloggers brought us Obama, by lying to us in the primaries and discrediting Hillary. Hillary would have fought for real reform. Obama and Ezra not only could care less...but they are dishonest about it. Punish them.

Posted by: klassic34 | December 1, 2009 8:39 PM | Report abuse

Hillary was, of course, proposing almost exactly this plan as her opening bid. Criticize Obama all you want (you have increasing reason to do so), but the Clinton wing of this party isn't any safer harbor. Regrettably, we still need Change...

Posted by: NS12345 | December 1, 2009 8:46 PM | Report abuse

Whatever you might think of Dean's most recent comments (I happen to agree, but whatever), it's tough to deny the basic principle he articulates and which I think underlies most peoples' objections to seeing any bill without a strong public option. In reforming health care, we have to decide whether the government is going to take some fundamental responsibility for the way people receive medical care, or whether they're just going to increase access to insurance for more people.

Sure, it's probably better to have health insurance than not. But having insurance is not the same as having access to decent health care. Insurance companies screw people. Look around.

And while Ezra might love all these 'delivery system reforms', he should remember that the economic collapse we're now enjoying was brought to us in large part by regulators who just chose not to regulate. Is it any more likely that those who are charged with monitoring insurance companies post-reform will do any better at insuring compliance with new laws? Laws are only as good as the extent to which they're enforced, so there's good reason to be skeptical.

A strong public option (yes, nothing now under consideration does it) would give people the choice to buy insurance from the government rather than from an insurance company. Medicare, as we've all heard ad nauseum, works great. I wouldn't mind being forced to buy Medicare. But private insurance for many people just sucks, and a mandate to buy a crappy product is not ok. If the current administration thinks it is, maybe Ezra's right. Maybe progressives should just walk away. But they won't be the only ones walking.

Posted by: andrewbaron78 | December 1, 2009 9:18 PM | Report abuse

Chris_O:

When you say "...if [those with pre-existing conditions] are not banned, then you need an individual mandate, or premiums would go through the roof," I think you prove my argument for me. The only way to prevent premiums from going through the roof when we stop denying coverage for pre-existing conditions, is to offer a strong public option that provides direct competition to private insurers. The public option is the only way to enforce universal coverage. While there are supposedly measures in the bill that will encourage private ensurers to cover more of those that they would otherwise reject or for whom they would severely limit coverage, without the public option there is nothing to enforce it--and premiums will continue to rise according to the most profitable financial models private insurers can get away with. They'll get away with raising premiums through the roof; they'll get away with hundreds of billions in new profits; and they'll continue to get away with murder.

Without a public option, whatever the purported protections and meager subsidies, forcing people to buy private insurance at a rate of 5% to 10% of their annual income is ultimately the same as taxation without representation. It's anti-democratic. It's economically unjust. And it's morally indefensible.

Posted by: NealB1 | December 1, 2009 11:21 PM | Report abuse

I am disappointed in Ezra. He is too young for cynicism.

Posted by: harold3 | December 2, 2009 12:04 AM | Report abuse

This is legislation that accelerates the rate of growth in health care spending. http://3.ly/IY7

This is legislation that raises taxes. http://3.ly/nV7p

This is legislation that leaves millions of Americans uninsured. http://3.ly/V393

This is legislation that puts more Washington middlemen in charge of your health care options(from reproduction to death).

How much healthier will Americans be if the Democrats' legislation passes?

How much longer will Americans live if the Democrats pass a health care bill?

How much more efficient will the health care system in America be if Harry, Barack and Nancy seal the deal?

Remember, "coverage" is not the same thing as "care."

Posted by: rightklik | December 2, 2009 1:03 AM | Report abuse

NS12345,

I love that argument. If they're finding, as you put it, "new and exciting ways to horribly screw people," then how do we spend $2.4 TRILLION on healthcare? They either don't pay any claims or they pay too much. You can't have BOTH SIDES of the argument.

If the argument is then that "some" insurers do things you find offensive then why would we throw out all insurers with a single payer model? Would any industry that is offensive in some way need to be "taken over" by a more kinder, gentler government? How about banking? how about automobiles (oops already done). How about travel and tourism. how about manufacturing? and so on . . .

The fact that several bad apples may still continue to cause problems does not give the government the right or the justification to take over industries. If we did that then we wouldn't have any industries left. The idea of the government should be to "govern" (hence the name). They should govern and regulate industry, not BECOME industry.

Posted by: visionbrkr | December 2, 2009 8:53 AM | Report abuse

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