All Life Is Problem Solving

This post is a comment on an exchange with Jason Rosenbaum appearing as replies to ralphbon’s blog post entitled “Seniors Already Have A Public Option. Does It Keep Private Insurers Honest?” Here is the exchange:

LetsGetItDone:

“ralphbon, Thanks for a very good analysis. Jason, in view of Paul Krugman’s recent analysis of the health insurance “market,” and the constraints placed on eligibility for the public option in HR 3200, can one reasonably anticipate that, even if HR 3200 is enacted without major change, it will have an appreciable impact on health insurance costs and price inflation over the next six years?”

Jason:

“Six years? I don’t know. I’d have to look at the graphs again, but I’m not sure you saw a big differentiation between Medicare prices and everyone else’s prices in six years. However, those differences did emerge, as will these. Especially because I’d expect the public option to work so well that the Secretary of HHS would exercise her right to expand the exchange (and therefore the public option) in 2015.”

LetsGetItDone:

“Thanks for your reply. Sorry to be so persistent. But I’m asking why you think that will happen. Evidently CBO doesn’t think so, and Kip Sullivan gives a pretty good argument here suggesting that it won’t. So, again, why do you believe what you do? Or to put this another way, why do you think that your view of the future stands up to critical evaluation better than Sullivan’s?”

Jason:

“Because both Kip and the CBO are looking at this like a wonk, focused solely on policy, and not looking at how things work in the real world, which includes things like politics.

“First, the CBO. They only project out 10 years at the most, but they really are only accurate within 5 years. The public option won’t have expanded too much in their time frame.

“Now, my counter example is to look at other large social programs like Social Security or Medicare. Those programs have done nothing but expand. Why would this be any different?”

LetsGetItDone:

“Thanks for your reply. I’ve decided to blog about our exchange later today under the title “How Things Work in the Real World?”

So, that’s the background for the following reply.

Forgive me the vernacular, but wonk, shmonk. The most wonkish proposal on health care I’ve seen in the recent past is Hacker’s public option. It’s much more complicated than single payer and, the fact is, it’s proven very difficult to get people excited about it. Not too long ago, 76% of the public wanted a public option. But with what intensity do they care about it? I’ll bet the 59% who prefer single payer have much greater intensity in their preference for it, than they have for a public option like HR 3200, which they probably think is just barely acceptable for the time being, and which they probably don’t care very much about. If your organization and the President had gone their single payer way, it would have been a lot easier to mobilize the public in back of this reform and to get pressure on Congress and the Blue Dogs.

I agree that CBO forecasts over 10 years are nonsense, and also think that they are probably nonsense in a lot shorter time frame than five years, especially when the economy is volatile and one can’t accurately forecast costs based on previous trends. CBO forecasts, nonetheless, are important political factors these days, and a CBO score for single payer showing that it’s less expensive than HR 3200 would have placed a lot of pressure on the health insurance companies and their allies, to compromise on a strong public option that itself would have done a lot better in CBO scoring than HR 3200 has done.

You’re right about the public option not expanding very much in the first 5 years under HR 3200. So let’s see if I understand you: it starts in 2013, and it will remain small for five years guaranteeing that it will have very little impact in lowering health insurance company prices. So now, it’s 2018 and it looks like the public option has been a failure because it hasn’t had much impact, and you also think that supporting HR 3200 and its non-impactful public option, is not wonkish, but political realism, and that the single payer people are the wonks.

Forgive me, once again, but such a public option will drive the Democrats from office way before it’s time to expand it in 2018. If the Republicans take over in 2012, the public option is gone because no one will be there to defend it. If they take over in 2016, the public option is gone again for the same reason. For the public option to be institutionalized it has to help people. It has to have worked. It has to be viewed by people as “my Medicare.” And it has to have worked way before 2012 or 2016, or 2018, or it’s not practical.

Moving on to your counterexamples using Social Security and Medicare and your question asking why the public option won’t expand in the same way they did, I think your examples are not apt for a number of reasons. Social security immediately delivered what it promised to people. It worked from Day 1. Medicare was fully implemented as a working program in 11 months, and a large proportion of those eligible immediately enrolled in it. The public option in HR3200 only applies to a relatively small group of eligibles. On Day 1 it will have no network of providers, and no way of competing vigorously with private insurance companies.

Sullivan treats the start up conditions of the public option very well. I think that to counter what he says you have to consider his arguments. It isn’t enough to say that Social Security did it and Medicare did it, so why shouldn’t the public option expand as well? Sullivan tells us why it won’t expand in the same way as these earlier programs. I think that you need to provide an alternative scenario for how things are likely to work, if you expect others to accept your view that the under-powered public option in HR 3200 will expand enough in any appreciable time frame, to make any impact in competing with private insurers and getting them to slow down accelerating costs. I haven’t seen that alternative scenario in your replies, so far. Also, I’ve noticed that other public option bloggers at Firedog Lake, who’ve been supporting HR 3200, have been distressingly vague about saying why they think its public option provision will work. It is almost as if public option supporters expect the rest of us to forget that the public option in HR 3200 is but a pale shadow of Jacob Hacker’s original idea; and where it may be plausible that the original public option would perhaps civilize private insurers’ rapacious pricing practices, it is rather incredible that the public option in HR 3200 would do so.

Finally, I want to say something about the way the ongoing discussion about health care is going down among progressives themselves. From the beginning, public option proponents in 2009 have labeled people who prefer single payer as wonkish and politically unrealistic compared to themselves. This is the same view the Clinton Administration took in 1993 when they proposed “HillaryCare” rather than single payer. They were the practical ones; the single payer people were the unrealistic idealists, who should just shut up and support the people who really understood politics.

Of course, the self-styled Clinton “realists” then failed miserably in getting health care past the Congress. So much for their claims of “realism.” So far, I don’t see that the record of progressive public option proponents in 2009 is noticeably better than the Clinton “realists” of 1993, and I don’t see that public option proponents have any greater claim to realism and political savvy than any other progressives. This effort at health care reform is about to produce a bill that will fall far short of what is necessary to bring health insurance inflation under control. If the Bill goes down as HR 3200 is structured now, or if the final Bill is even more conservative due to attempts to conciliate the Senate and its Blue Dogs, then that will surely discredit President Obama and the Democratic Party.

All this doesn’t speak very well for the view that the public option proponents are the ones who really understand American Politics, and the single payer proponents are just idealists or wonks who don’t know what can be passed and what is beyond the pale. In fact, it suggests that public option partisans have been guilty, from the beginning, of an unjustified arrogance about the soundness of their own views on the politics of the matter of health care reform that hasn’t served anyone in the progressive movement well.

The preference for the public option as a political strategy has, at least partly, been based on the conventional wisdom that single payer has been defeated by its opponents again and again in American history. However, the truth is that we haven’t seen an effort to pass single payer backed by a President of the United States since Harry Truman. That old defeat of a relatively unpopular president, provides absolutely no basis for opining about what would have happened in 2009, if single payer had been pushed by a progressive president this time around. So, based on an assumption, and perhaps some questionable polling, public option proponents decided it was politically more astute to propose a compromise with the industry right out of the gate, even though there is absolutely no history at all about how public option plans work on a large scale, while there are many nations, where single payer is working well, compared to what we have now. In other words, single payer is something that has worked many times before; but public option is, as yet, only a theory.

In any event, in future discussions here between public option and single payer proponents, I hope I will see not only more civility, and no further mention of “trolls,” but also serious exchanges of views that avoid labeling people as “wonks” or “unrealistic,” or “naive” or similar labels, and instead focus on the views that people are advancing with a mind open enough to see that those views may be more correct than one’s own. I think that is the kind of spirit of debate and discussion that should apply at Firedog Lake.