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Public Option Advocacy Strategy Needs Rethinking

mass's picture

From advocacy groups like HCAN and MoveOn.org to prominent blog sites like Daily Kos and Fire Dog Lake, single payer is the policy which must not be named. There seems to have been a strategic decision by several advocacy groups and progressive bloggers not to have a policy discussion or front page reporting relevant to Medicare for All once the policy was proclaimed "off the table" by the Democratic leadership and the President.

People and groups from Helen Thomas, George McGovern, Marcia Angell, PNHP, 1payer.net, NOW, California Nurses Association, Representative Weiner, and Mad as Hell Doctors, etc., have had their arguments against the current proposals being bandied about by Congress, and for single payer, either outright ignored, or marginalized to fit the advocacy for the so-called "public option". This has been a strategic blunder for the "public option" advocates.

What harm "public option" advocates see in reporting on or discussing more ambitious policy ideas, like Medicare for All or single payer, I have no idea. But eventually "public option" advocates need to rethink their failing strategy. In Congress thus far, we've seen the so-called "public option" reduced to what looks like a small safety net program practically designed to fail. What was once to be a robust Medicare-like insurance option open to all takers, now has CBO estimates of 10 million by 2019(under the best version from HR3200) or zero by 2019 from HELP.

The difficulty in arguing for something as amorphous as the so-called "public option" is it is unclear what the policy is, who should support it and why. Is it a mechanism to "keep insurers honest" as President Obama likes to say, or is it a viable alternative to private insurance, as the "public option" advocates maintain? Is it a national program open to all takers as "public option" advocates argue it should be or is just a "sliver" of private insurance reform, as President Obama contends it will be?

The problem the "public option" advocates have created in dismissing Medicare for All as politically infeasible is that they have not educated the public on either the benefits of public insurance or even what public insurance with a large market position could and would look like. In their silence, other media sources are busily defining Medicare for All in the most unhelpful terms. When "public option" advocates say "this was the compromise from single payer" they assume Americans know and understand what single payer is. They don't. Therefor, not only is it hard for the public to appreciate the compromise, but it doesn't form a basis of understanding amongst regular Americans of what public insurance looks like or what it can achieve.

Via Madison.com:

But while they blame the giant health care industry and Washington politicians, local health care reformers admit there is another contributing diagnosis for what ails the single-payer health plan. Even after - or perhaps because of - months and months of debate, many people in Wisconsin and across the country still don't know what the heck a single-payer plan even is.

Minutes before the Mad as Hell rally, an informal survey of the crowd around the Capitol found many were at a loss to describe their understanding of a single-payer system, including some of the people who said they support it.

"I would think that it should come covering everything, basically," said one young Madison resident who chuckled when he realized he had not provided a very clear answer. "I'm not really sure, to be honest."

Another Madison resident paused for several seconds as he gave a halting explanation of what he felt the plan meant. "I think it's ... it's one payer for everything," he said. "I think the payer is ... part of the taxes. I'm here to encourage this to happen."

Robert Kraig, program director for Citizen Action of Wisconsin, says these Madison residents are not the only ones confused by the current debate. "People just don't get this," he says. "It's a very abstract concept. It's something that's understood by a well-educated group of progressive activists. But the problem is that the average voter has no idea what the words 'single payer' mean."

Marcia Riquelme, a grandmother and a local organizer with the Dane Grassroots Network who has fought for single-payer coverage full time since 2008, agrees: "A lot of peoples' lives are too busy and hectic to have time to figure out what this all means."

As a result, she says, some people end up falling for conservative "lies and distortions" that the single-payer plan is nothing more than socialized medicine, and will lead to "death panels" and rationed care.

The Mad as Hell doctors offered local activists a prescription. "To win the war and the argument at the water cooler, it is important that everybody here have clear in their minds what single payer is," Adam Klugman, the group's national creative director, said during a forum at First Unitarian Society.

Klugman said the Oregon doctors had come up with a one-sentence definition, which he asked the audience to memorize: "A system of payment that redirects all current health care monies, both public and private, into a single public fund that covers everyone."

Despite the public's ignorance on single payer, most Americans favor it, suggesting that many if not most of the public are not happy with the insurance they have.

For those who think a "public option" is the only politically feasible step toward single payer health care, or at least that it can dramatically reduce the power of the private insurers, by not having that debate in the larger context of what Medicare for All can do, they lose valuable talking points on the virtues of public insurance(for instance that it can save over 350 billion a year, or that it can stimulate the economy), and thus they make the ever reducing role of the "public option" easier for legislators to exploit.

What's happened here is what started out as a policy based on a large public insurance role for the government, has become a policy based on a small regulatory role over private insurers for the feds, with a possible public option as threat to private insurers, rather than a viable alternative in it's own right. We can not have this conversation in a vacuum. Public option advocates will not prevail with a massive expansion of public insurance if they do not put their so-called compromise position in context the public can understand.

Even if we did not implement a single payer system, the principles single payer brings to the table in the health reform debate could lead to a more aggressive approach to reforming the health care system, rather than the current Romney Care role Congress is currently crafting. If we are not proposing a massive expansion of public insurance, than we must attain the most stringent regulations of private insurers. It's not enough to count pledges on the so-called "public option" when the value of the "public option" being written in Congress is indeterminate.

Public option advocates need to reassess where they are and how to proceed. They need to acknowledge the short comings of their advocacy strategy and work to improve it. This approach not only alienates the strongest advocates of health care reforms, single payer proponents, it short changes the public debate over the role of public health insurance, and leaves legislators free to claim victory in passing the most meager of the ever shrinking "public option" proposals.

As Representative Weiner recently said, it appears the "the last thing we want to do is policy discussion", but at some point before health reform is declared done, we really ought to:

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dblhelix's picture
Submitted by dblhelix on

a small safety net is exactly what it is.

See my comment in vastleft's post. We're are getting a craptastic bill. You know, the only person I have respect for at this point is Olympia Snowe. I listened to her NYT interview. She does amazing things that no other pol does -- she admits that guaranteed issue already exists in some states (ohmigod!). She talks about linking subsidies to the Silver level in the exchange vs a separate low-income product, like Commonwealth Care. This is really a crucial issue -- do you condemn people with a little less to "no choice and competition?" And today, she put in a trigger amendment for a "safety net." You know what? My politics aren't identical to hers, but I appreciate that she cuts to the chase.

Public option advocates need to reassess where they are and how to proceed. They need to acknowledge the short comings of their advocacy strategy

I 100% agree, and as I said in my response to vastleft -- if these folks would demonstrate how this "public option," seeded by the medically uninsurable and low-income members could possibly ever pose a threat or competition to the private insurers, I'd get on board. But ... I've gone through the numbers of the 34 high-risk pools in existence, and it looks bleak, mighty bleak.

Make no mistake, Baucus sets up a high-risk pool so that the medically uninsurable can get insurance right away. It dissolves in 2013. These folks either go into the exchanges with us or get sent to their own special place -- the "public option," compliments of progressives -- but remember: we beat the wingnuts, and that's what's important!!!!!

At this point, I prefer for everyone to go into the exchange, preferably just a "Commonwealth Choice" w/ no "Commonwealth Care." Peg the subsidies to Silver. I don't want to see the concept of a public plan get trashed via this public option nonsense.

Submitted by hipparchia on

Make no mistake, Baucus sets up a high-risk pool so that the medically uninsurable can get insurance right away. It dissolves in 2013.

and obama said this in his 'greatest health care speech evah' the other night:

Now, if you're one of the tens of millions of Americans who don't currently have health insurance, the second part of this plan will finally offer you quality, affordable choices. (Applause.) If you lose your job or you change your job, you'll be able to get coverage. If you strike out on your own and start a small business, you'll be able to get coverage. We'll do this by creating a new insurance exchange -- a marketplace where individuals and small businesses will be able to shop for health insurance at competitive prices. Insurance companies will have an incentive to participate in this exchange because it lets them compete for millions of new customers. As one big group, these customers will have greater leverage to bargain with the insurance companies for better prices and quality coverage. This is how large companies and government employees get affordable insurance. It's how everyone in this Congress gets affordable insurance. And it's time to give every American the same opportunity that we give ourselves. (Applause.)

Now, for those individuals and small businesses who still can't afford the lower-priced insurance available in the exchange, we'll provide tax credits, the size of which will be based on your need. And all insurance companies that want access to this new marketplace will have to abide by the consumer protections I already mentioned. This exchange will take effect in four years, which will give us time to do it right. In the meantime, for those Americans who can't get insurance today because they have preexisting medical conditions, we will immediately offer low-cost coverage that will protect you against financial ruin if you become seriously ill. (Applause.) This was a good idea when Senator John McCain proposed it in the campaign, it's a good idea now, and we should all embrace it. (Applause.)

dblhelix's picture
Submitted by dblhelix on

and, it's actually called "high-risk pool" in the Baucus doc.

Submitted by hipparchia on

that's refreshing. at least there's transparency there. i'm actually feeling more kindly toward baucus than toward obama at this point.

dblhelix's picture
Submitted by dblhelix on

here is the language from the framework doc:

High Risk Pools. In 2010, the proposal would increase funding for state high risk pools, so long as the funds are not used to replace current premium assessments and are not distributed to high risk pools that have a waiting list.

I take ... not used to replace ... to mean that the money doesn't go to insurance companies/hospitals that make up for the operating losses.

Don't have it handy, but the language in the more recent proposal specifically states that the "high risk pool" is to be disbanded in 2013.

Currently, we have about a 1/4 mill in high-risk pools, so let's say that gets scaled up to 2mill - 5 mill (it won't be hard to estimate once the dedicated funding numbers are available). What you have here is localization of high cost in the 19-64 private individual market, and how these members are dispersed in 2013 is pretty much the ball game.

Obama made clear that a "public option" would have to sustain itself via premiums. There are only two states or so that manage this feat -- via very high premiums, gender discrimination and very small member pools (probably nobody can afford it!). The larger pools, or the ones with "affordable" premiums (remember, always more expensive than the private individual market) are bleeding $$. If you put a lot of unhealthy people in one group, they will gobble up the costs.

I wish I knew where to find it, but I once saw a power point presentation on public option plans sponsored by AHIP types. It made clear that from their point-of-view, there's the untenable version (seeded by healthy/unhealthy in proportion to representation in the GP) vs a "safe harbor." A high-risk pool in constant need of govt bailout works well to maintain profits in the "healthy" exchange, I guess.

Truth in labeling is important. At least in the Baucus/Snowe discussions, I am recognizing the various experiments in the states. It's actually quite shocking how many loopholes are getting preserved. For example, some states, like MI/OH/VA don't have a high-risk pool, instead they have guaranteed issue open enrollment once a year, subject to quotas. I see this same language maintained in current "guarantted issue" pledges. Or, on rescission, the continued exception for "fraud."

Submitted by hipparchia on

how are those people supposed to get off those waiting lists then?

I take ... not used to replace ... to mean that the money doesn't go to insurance companies/hospitals that make up for the operating losses.

that sounds to me like the funds can't be used to pay for any taxes that are assessed on insurance policy premiums, but i could be confused here.

Don't have it handy, but the language in the more recent proposal specifically states that the "high risk pool" is to be disbanded in 2013.

this makes sense at least. with the exchanges opening in 2013, high-risk people will theoretically be able to buy insurance there instead.

Obama made clear that a "public option" would have to sustain itself via premiums. There are only two states or so that manage this feat -- via very high premiums, gender discrimination and very small member pools (probably nobody can afford it!). The larger pools, or the ones with "affordable" premiums (remember, always more expensive than the private individual market) are bleeding $$. If you put a lot of unhealthy people in one group, they will gobble up the costs.

yep, 'sustain itself' via premiums is a death knell, or at least a barrier that a lot of people won't be able to get past.

a point that i keep trying to make: medicare is basically a high-risk pool. it's disingenuous for health policy wonks to talk about its costs being out of control -- it's doing its job as a high-risk pool by taking on all the people who cost a lot.

Or, on rescission, the continued exception for "fraud."

yep. this is another issue people don't seem to get. fans of the current 'reform' see 'no more rescission' and stop reading. we've already got examples of insurers being fined for rescissions and refusing to pay the fines, and we've got insurance company execs saying they'll continue to rescind policies no matter what the law. and i don't remember seeing anything in any of the proposed bills that had any actual teeth on this. apparently you'll get to appeal such things, but depending on the bill you look at, this avenue could range from difficult to hopeless.

Submitted by jawbone on

health care policy than our ostensibly Dem prez.

I've never heard Obama praise Nixon, but he sure has praised St. Ronnie.

Actually, Obama may be more dangerous than a batshit crazy Repub--think FISA and how he's trying to implement BushCo Done Better on torture, rendition, unlimited detention, civil liberties.

Scary.

Submitted by jawbone on

health care policy than our ostensibly Dem prez has done.

I've never heard Obama praise Nixon, but he sure has praised St. Ronnie.

Actually, Obama may be more dangerous than a batshit crazy Repub--think FISA and how he's trying to implement BushCo Done Better on torture, rendition, unlimited detention, civil liberties. Oh, and the Bankster Comprehensive Care Plan? Don't look back to learn from capitalism's mistakes, just look forward to new bubbles?

Oh, and undercutting Gov. Paterson of NY? A Repub could never have done that and gotten away with it.

Scary.

Submitted by hipparchia on

the obama/paterson thing. doesn't look good so far.

i've read that nixon's plan was more liberal than obama's is going to be, but i haven't seen the details of what nixon proposed, so i don't know.

on the environment, it's looking like obama is going to be to the right of nixon, but that's a problematic judgment to make, since the epa only came into being on nixon's watch, and he had a congress that was pushing/pulling from the left.

mass's picture
Submitted by mass on

here, but I posted it all over so I thought I'd share it here as well. The problem with "silver" is it treats health care like a commodity. Unless the subsidies are huge people won't be able to afford silver. And, then what? People with subsidies get silver, people just over the income threshold for subsidies get I don't know... "copper"? Doesn't make a lot of sense.

dblhelix's picture
Submitted by dblhelix on

you really made me LOL today ... saw your "I vote Obama" at the email harvesting exercise. Very naughty.

mass's picture
Submitted by mass on

If I didn't laugh...well, you know.

a little night musing's picture
Submitted by a little night ... on

when he said that line about not discussing policy. (The FDL interviewer was getting on my nerves, as well, interrupting Weiner every time he tried to go into depth.)

[And this was supposed to be a reply to the post, not to your comment - but I cannot reply to the post: the reply box is gone. Lambert?!]

Submitted by lambert on

And the reply stuff should be back -- the comment setting had spontaneously mutated from newest last to newest first, and I had to reset that. So I think your comment was caught up in that change.

Submitted by lambert on

Since the single payer advocates weren't ever at the table when "progressives" decided to fuck their policy and try to steal its branding, there never was a compromise to begin with.

What is now labeled a compromise is a classic Overton Window positioning, somewhere in the middle between left and right. What this trope conceals is that "progressives" made no effort whatever to drag the Overton window left whatever, and so the terms of the debate were never changed. And here we are!

mass's picture
Submitted by mass on

I still say many of these folks are so invested in Obama "succeeding" (Not Jane, but many, many others), that they have tossed out their own principles.

Submitted by Paul_Lukasiak on

its why she refuses to go on the offensive against him.
_
face it, the overall betrayal on health care reform is being directed from the White House -- and Obama is aware enough of what is going on that "blaming it on Rahm" is pure misdirection.
_
But Hamsher also knows that if she goes after Obama directly, she'll lose a very big chunk of her audience --- and the contributions and advertising revenue that keep her empire (and it is now an empire) afloat.

dblhelix's picture
Submitted by dblhelix on

obviously, i think paul is on target.

a few bloggers moaning that obama doesn't think highly of blogs doesn't scare anyone.

People actually organizing and pooling their resources, time and $ for real action is another story. Hence, all the busy bee work. Nose to the grindstone, there's always another electronic petition to sign or another ad to donate to.

Electronic ward heeling.

JMO. Happy to be proven wrong.

selise's picture
Submitted by selise on

ok, i like jane and so maybe i'm too inclined to give the benefit of the doubt. i should have written that i don't think there is enough evidence to conclude as paul did. but, likewise i can't claim enough evidence to conclude the opposite.

will try to keep an open mind, but it hard to reconcile that with my desire to see good intentions even though i massively disagree with jane on this issue. i advise my comments on this topic be taken with truckloads of salt.

Submitted by jawbone on

to listen to the MCM and its public wannabees which are now almost totally dependent on corporate donations to stay on air, playing within the lines drawn by...MCMers and the BHIP (Big Health Industry Players, of whom I count Obama).

NPR had a segment on health care and the problem of costs and how that was leading to a probable tax on "Cadillac" plans--with cost of the plan seeming to be the sole basis for whether it was "Cadillac" or...Taurus or junker...or public transit with limited schedules, etc.

It seems any plan over a certain cost would be considered taxable, no matter what it actually provided. My NJ plan would be considered "Cadillac"--with expensive co-pays and deductibles and only 50% prescription coverage. Wow.

Almost every problem mentioned would be solved and prevented by Medicare for All...with a robust private option. Every one. Costs, cost containment, comprehensiveness, equality of care...and on and on and on.

Never brought up, even as a counterpoint to other argujements. Never.

No discussion of whether in this nation we want tiers of health care---which we already have. Do we really want the Democratic Party to be the party responsible for setting in stone this inequality? This class system of health care?

That's what Obama and his ConservaDems are bringing us to.

But mention single payer? It's name not dare be spoken! Single payer...the Voldemort of health care plans.

mass's picture
Submitted by mass on

My mother works for a French company so of course, since we have no system comparable to the French, even our vaunted Exchange, they pay her insurance in full. She's older so I assume this costs a lot. However, she's older, so she needs more care, which means more co-pays, more medications, etc.. She has a good job, but it took her decades to get there, and she accrued a lot of debt along the way, what with raising two kids on her own, paying for her graduate education, time she was out of work, etc.. So now what? They are going to tax her insurance? That's not good policy.

Did you hear the Mayo CEO afterward say he supports a "public option" so long as it is the private insurers exchange Congress uses, but Medicare is going "bankrupt" so we don't want a PO based on that? Unbelievable.

Submitted by hipparchia on

but only sometimes.

foxx's picture
Submitted by foxx on

was made by "single payer" advocates when they did not adopt the slogan Medicare for All from the beginning, with bumper stickers and t-shirts.

mass's picture
Submitted by mass on

They've long done that. Indeed, the bill in the House is "improved and Enhanced Medicare for All". They sell stuff that says "Medicare for All" :http://www.cafepress.com/1payerdotnet/

The slogan has long been "Medicare for All. Everyone In, Nobody Out". President Obama said it himself when he endorsed, single payer, Medicare for All five years ago.