Tuesday, September 4, 2012

Public Option? What's That?

Nope. The public option on health care did not make the Democratic Party platform

As Sarah Kliff explains, on health care the platform is mostly backwards-looking: there's a lot more of touting the achievements of the ACA than there are of new proposals for the future. There are some proposals for the future, however...but the public option isn't among them. It's fallen so thoroughly off the radar that Kliff doesn't even mention it.

Has there been any public policy proposal with a stranger path? In 2008, it was a minor point, one among many provisions in the comprehensive plans put forward by all the leading Democratic presidential candidates. It received little attention then. 

Fast forward a couple of years, and all of a sudden it is, for many liberals, the absolute core of health care reform, such that when it is defeated eventually in the Senate it's considered by many liberals a betrayal and a sell-out which makes the entire bill a mistake. 

I concluded from this that the long-term future of the public option was pretty good. Since it polls well among the general public and had intense supporters within the party, the odds were good that all viable Democratic candidates would support it; as long as that was the case, it would stand a good chance of being adopted the next time the Democrats help the House, the Senate and the presidency, at least assuming that the rest of the ACA was in place. After all, the public option can easily be grafted on to what would be in place then, and it can be passed on it's own through reconciliation. No need for 60 in the Senate.

And then...nothing. It's as if it never existed. Leading Democratic Senate candidates this cycle did not put it in the issue section of their web sites, even in liberal states with contested primaries where one would think that candidates would be looking for anything that appealed to liberals. And now it's not part of the party platform, and as far as I can tell no one really cares (Jon Walker at FDL does have an item today mentioning it; a quick search yields pretty much nothing else, and if there was any campaign to get it into the platform, it certainly didn't make very much noise).

I can think of lots of cases of an out-party caring passionately about an issue and then dropping it when they win. For a party, or at least the activists in a party, to begin caring passionately about an issue only after they are voted into office, and then drop it in time for the next election...that's weird. I don't really have any conclusions about it. I'm not sure I even have a theory. 

28 comments:

  1. It's about party unity. Obama never got firmly behind the public option, and so the tacit agreement among Democrats is that they're not going to fight for it right now, especially in light of 2010 (the above poster is right about that). Win or lose, though, it will be back in the next 2-4 years.

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  2. I agree that this is strange. The public option is very popular among Democratic activists and relatively popular among the general public. I don't see where including it in the platform gives any particular opening to the Republicans, any more than the ACA itself does. IMO, the number of people who both (a) support the ACA and (b) don't support the public option is vanishingly small. I wouldn't expect it to be enacted in the next couple of years, but I do think it should be set out as a policy goal.

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  3. It was always a little strange the public option became so important to begin with, and it is not an unreasonable hypothesis it was artificially inflated to give the likes of Lieberman, who was looking for an opportunity to punch some hippies, a relatively low-value target on which to exhaust himself.

    Anyway, my read on the current situation is that the Democrats don't want to remind their own voters of the argument that the lack of a public option meant the whole program was not worth doing, and hence may not be worth defending. That may change once the exchanges start operating, and tinkering with them becomes the new locus of policy debates in this area. Although personally, I would be most interested in the issue of giving more employees a means to opt into the exchanges.

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  4. Some anecdotal evidence to add here. During debates for the CD9 (most swing congressional district in the state) Dem primary in Arizona, all 3 Dem candidates stated they supported the public option and 2 of them also backed importation of prescription meds from Canada. It may not be on candidate websites, but the issue does seem to come up from Dem activists.

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    1. Thanks -- I'm very interested in hearing any evidence (either way) on this one.

      My general sense is that it would have been harder to put re-importation in the platform because there was clearly a deal to exclude it, and so Obama is essentially committed to oppose it. I know there's a lot of talk about a deal on public option, but (1) I'm not convinced that it's true, and at any rate (2) no one (Obama, Pelosi, Reid, the committee chairs) ever said that they were actively against public option or (publicly at least) urged their Members to vote against it, as they did on re-importation.

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    2. Pretty sure Nelson axed the public option.

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  5. With the exception of me, McKinsey, Rand Paul (for about 5 minutes after the SCOTUS ACA decision) and Scott Walker (maybe once or twice), pretty much no one is publicly worried about the perverse incentive in the ACA encouraging widespread dumping of gold-plated corporate health care plans.

    To be sure, no one knows whether McKinsey's (much higher than the CBO) forecast of dumping will occur. Assume McKinsey ends up being roughly correct. The result will be thousands, maybe hundreds-of-thousands, of middle class secretaries, former beneficiaries of BigCo's gold-plated health plan, making too much for a subsidy in the exchange, and thus finding their hc cost share will, say, triple under ObamaCare.

    Suffice it to say those folks won't be happy, and the more of them there are, the greater their opportunity to reshape the American political landscape. The parties will fight to attribute blame; Republicans will say that Obama screwed up your health care, Democrats will say that big companies are all assholes. Suffice it also to say that Intrade will strongly favor the Republicans in that dispute.

    Finally, we can be reasonably certain that all those secretaries, so inconvenienced by ObamaCare, will have no idea the difference between the exchanges and the public option. Says here that the Democratic party knows all of this; avoiding mention of the public option is thus strategic risk mitigation on their part. Its going to be hard enough for liberals to win the fight to attribute blame for massive dumping (should it occur); emphasizing the public option in the runup to that unfortunate day is like purposely entering an already-difficult battle with an arm tied behind your back.

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    1. I don't understand. Why would ACA cause corporations to drop high-quality plans? They should be completely unaffected.

      Do you mean that they were going to drop them anyway, and still will, but now people who don't know better will associate it with Obama?

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    2. Chaz, I should probably link to the McKinsey study every time I go there; if you're interested, here's a link that will get you to their argument.

      Long story short: the typical BigCo pays $12,000/yr for the employer's share of an employee's (gold-plated) coverage; dumping to the exchange incurs a penalty of $2,000. Net, the employer should save on average $10 K/yr for dumping.

      In fairness, you could make the counterargument that if employers really wanted to dump, they would do so today. The counterargument, somewhat covered by McKinsey, is that the exchanges provide a plausible alternative, mitigating the negative effect of a cost-saving initiative.

      We'll see.

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    3. Here is an article (by Jon Cohn from The New Republic) that contains some of the weaknesses of that McKinsey paper:

      http://www.kaiserhealthnews.org/Columns/2011/June/062311cohn.aspx

      Just something to consider.

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    4. Mike, thanks for that, I agree that the Cohn piece puts a different spin on this question. Cohn links to the Robert Wood Johnson and Avalere responses; its a bit difficult to unpack the RWJF argument, with Avalere the volume of data pretty much condenses to "Big Companies Won't Do That Because Employees Would Be Pissed".

      Employees certainly would be pissed. Will that provide enough moral suasion to stop corporations? Moot point...but it raises another angle on the topic for today:

      Given the uncertainty re "the McKinsey effect", this argument frames another reason for Democrats not to promote the future of health reform -

      There's probably at least a weak correlation between

      a) How much liberals promote the awesomeness of the exchanges and

      b) The pushing of the needle toward BigCo pissing off its employees.

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    5. I don't buy that. The penalty for dumping these gold-plated policies right now is $0, but what large company would do that?

      Health benefits will continue to be part of a competitive compensation package. The ACA will not change that.

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  6. I have to disagree. The public option lives on, in the Ryan Plan. The original Ryan Plan is essentially ACA exchanges for old people (plus an assurance that the subsidies won't cover the cost of insurance over the long run). The Ryan-Wyden variant includes the retention of tradition Medicare as an alternative, hence, ACA exchanges plus a public option.

    By the way, the other week Chris Hayes had several (maybe 5) Democratic congressional candidates on his show, and they all said they favored Medicare for all. (Perhaps they only say that on MSNBC.)

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    1. That should say "the retention of traditional Medicare."

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  7. It was never more than a shibboleth.

    A public option would have wound up insuring some fraction -- individuals, but not those covered by Medicaid expansion, or Medicare, or Tricare, or any private insurance company -- of what was already a fraction of the insured population, the lion's share of which gets group coverage through an employer.

    I saw figures in the 7%-11% range when people estimated how much of the population would wind up covered by it.

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  8. I figure it's because those who are loud on the Left aren't influential on the Left.

    I know I supported it but never thought it likely, since so few wanted it. Personally, it's on the back burner until we get the ACA fully implemented and get to see how well it works and who is left out of the market.

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  9. The problem, as I see it, is that the PO, while it may poll well, was never loved by anyone. Progressives wanted single-payer, and they only latched onto the PO figuring it was the best thing available at the moment. That helped get it branded in a lot of people's minds as a policy of the left. But the left never saw it as ideal, and once it got scrapped from the bill, they came to see it as a failed compromise and quickly reverted to their traditional advocacy of single-payer.

    I'm being generous, of course, since in my experience a lot of people, including a lot of progressives, are confused about the difference between the PO and single-payer. (I actually saw someone on a message board refer to the "single-payer public option.") But people who understand what the PO actually is--especially the watered-down version in the 2009 House bill--recognize it as weak tea. It was intended only for a tiny percentage of the populace, it wasn't free to the recipients, and it didn't really set us on a path toward single-payer. Its biggest selling point was as a means of increasing competition in the private market to help bring down costs. So it was basically a centrist proposal that came to be associated with the left even though the left had no real enthusiasm for it.

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    1. (I actually saw someone on a message board refer to the "single-payer public option.")

      This confusion was absolutely epidemic at Democraticunderground.com, so much so that I began to think it was deliberate conflation, and not accidental confusion.

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  10. At this point it seems reasonable to me that having passed the Affordable Care Act, Democrats want to see how it works. After it's fully implemented awhile would seem the time to judge what it needs. It does seem to be an Obama campaign theme to not relitigate that debate but move...forward.

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  11. What Kylopod said. My take is that liberals really wanted all along was single-payer. Public option became a kinda sorta mini-single-payer, and thus briefly took on a huge symbolic significance.

    But those particular circumstances and symbolism no longer apply. The choice is now between retaining ACA and the GOP goal of returning to sauve qui peut. The public option no longer has any rallying significance, which means it has no significance at all.

    ACA itself remains an 'art of the possible' kludge. I'd guess that most liberals hope - perhaps even anticipate - that a combination of broad public support for universal health care, once it is in place, and the kludginess of ACA, will eventually build pressure for a shift toward single payer.

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  12. Maybe the public option was a feint all along. Threaten the insurance companies with the possibility that they would have to compete with a state-run non-profit insurance group, and then let Lieberman kill it. It gives the insurance companies a small victory, of sorts.

    All along, Obama and the Democrats would know that a lot of blue Northeastern states would ask for the exemption to try a public option out. They would be sure to get it.

    I've sort of seen Obamacare as a "reward the doers" kind of program. States that happily implemented exchanges, that work to improve health outcomes, would attract more wealthy, more mobile consumers. States that drag their feet get Obama's version of the exchanges. And there's no reason why it couldn't have a button for "Medicare buy-in" that tells you what it would cost you, and what it would cover, and then not let you buy it because your (red) state says no.

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  13. I really think it's a combination of the explanations above-- progressives never really loved the public option, and then suffered a setback in 2010.

    We know the health-care system we'd prefer isn't coming in the near-term, and at best will be a long process. The public option was just a step in that process. When it seemed likely the step was on the road to single-payer, it sounded great.

    Right now, we're struggling just to avoid stepping back-- getting the whole darn thing repealed. Worrying about the public option now is like worrying about sending astronauts to Saturn before we've sent any to Mars...

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  14. I don't think it's realistic to think of ACA as a stepping stone to single-payer. After the fight to create the new system, the fight to defend it, and then the years-long process to set it up and get it working, people are going to be reluctant to open the issue again in a fundamental way. There will be adjustments but no major rethinking of the system itself, if only for the fear that opponents would use the opportunity to shoot it down. On the other hand, it might work well enough. Places like Switzerland and the Netherlands have systems similar to ACA and seem to function.

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    1. Maybe so, but I still think the basic point holds: It's easier to get excited about something sub-optimal when you feel like you're going in the right direction. So maybe you get your hackles up and fight over a minor point, just to get as close to what you want as possible.

      When things are going in the other direction, it's a very different fight. You surrender the minor details, particularly the ones you didn't love in the first place.

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  15. Hey folks --

    I've removed a long sub-thread that I considered overly rude, substance-free, and otherwise just unpleasant. Never done this before, but rather than go through and figure out exactly which comments were kosher and which weren't, I've just cleared out the whole thing to put everyone on warning to play nice.

    I consider the comments section to be a major value added of this site, and very much appreciate the insights and arguments that y'all make, whether I agree with what's expressed or not. If in my judgement the discussion veers off in a way that threatens that, I'm going to step in to protect it.

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    1. Thank you, Jonathan.

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    2. You censored my comments? Strange.

      But since there was nothing untoward or censor-worthy about my comment, at least on anything but a censorious hard Left site, I'll recreate it. Your original post included the following phrase:

      "I don't really have any conclusions about it. I'm not sure I even have a theory."

      And my comment in response was that in November 2010 there occurred a little event known as a "shellacking", which perhaps you hadn't heard of. Your lefty comrades obviously drew "conclusions" and "theory" from that shellacking, as did the rest of us, even if you still haven't, 2 years later, as evidenced by your post.

      Now, it may be your habit on this site to arbitrarily censor comments, which wouldn't be unusual on a lefty site as we know, but it won't do to accuse me of anything untoward. You'll have to just be a lefty censor and censor speech and thought, absent fig leaves.

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  16. The flame is kept alive where the public option was always The Holy Grail in the first place

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