By Kip Sullivan
The campaign to create a “public option” ended in failure last March when Congress passed the Patient Protection and Affordable Care Act with no “option” in it.
This failure occurred even though the “option” campaign happily allowed their proposal to be transformed from one that would have taken 130 million customers away from the insurance industry and given the insurance industry no subsidies, to one that took zero to 10 million customers away and gave hundreds of billions of dollars to the insurance industry. Even after “option” advocates had degraded the “option” to a sad little token of a program, Congress refused to incorporate it into PPACA.
There are several useful lessons to be learned from the failure of the “option” campaign. However, you won’t find them in an August 17 article in The American Prospect entitled “Health Reform 2.0” by Jacob Hacker, the most visible scholar in the “option” campaign.
Rather than give us his assessment of what went wrong, Hacker celebrates PPACA and issues recommendations for improving it that are so vague they amount to platitudes. Here are examples:
- “reformers will need to call plainly for a greater government role;”
- “Insurers and providers will be doing everything they can to shape what states do. Reformers… will need to push back;”
- “[reformers should] build on the existing law to fill in its gaps;”
- “progressives [should] rehabilitate American government;” and, of course,
- “reformers should revive the public option.”
Any questions?
The following two sentences are the only ones in Hacker’s article that resemble analysis:
[T]he public-option debate was a case study in why cost control is so hard: Conservative Democrats first effectively stripped out the tools of cost control that would have allowed the public option to compete aggressively with private insurers. Then they complained that the public option wouldn’t control costs!
So why were “conservative Democrats” successful in stripping the “option” of its alleged cost-containment tools? Hacker doesn’t say. We may infer from Hacker’s silence that he would prefer his readers not question the decisions the “option” campaign made.
But the decision by Hacker and the leadership of Health Care for America Now (HCAN, the coalition that led the “option” campaign) to abandon single-payer legislation in favor of the “option” on “political feasibility” grounds ought to be questioned. Over the last five years, Hacker has repeatedly argued that single-payer legislation is not “feasible” because the American public is “stubbornly attached” to the current system. By the same logic, he also argued that “option” legislation could pass because it leaves the current multiple-payer system intact.
Here is a particularly condescending example of Hacker’s argument taken from an article he published in 2007 the New England Journal of Medicine in which Hacker criticizes Michael Moore for supporting a single-payer system:
Moore wants to do away with it all. His “prescription for change,” available on the Sicko Web site, calls for giving every U.S. resident “free, universal health care for life” [and] abolishing “all health insurance companies….” Moore clearly does not think much of the health plans being offered by Democratic presidential candidates Barack Obama and John Edwards. The Sicko site directs us to a new vehicle for “netroots” organizing sponsored by Physicians for a National Health Program … which warns, “Beware of Phony Universal Coverage: Many political candidates say they support ‘universal health care,’ but usually this just means making more Americans insurance company customers. Real universal coverage means evicting insurance companies and establishing a national health program instead.” It is an appealing vision, in many ways…. But it is also unrealistic. Sadly most Americans … can be frightened into believing that changing [the current] entrenched and inadequate system means paying more for less.
(“Healing our Sicko health care system,” New England Journal of Medicine 2007;357:733-735, 734.)
Having criticized Moore for being “unrealistic,” Hacker went on to urge his readers to abandon single-payer and support the version of the “option” he was promoting back then, a version he called the “Health Care for America Plan.”
We all know what happened over the next two years. Single payer was taken “off the table” because it was “unrealistic” and an utterly innocuous version of the “option” was placed on the table. But, alas, even this “option” turned out to be “unrealistic,” and so it was also removed from the table. What remained on the table was the centerpiece of what became PPACA – a mammoth insurance industry bailout. The PNHP warning that Hacker scoffed at in 2007 turned out to be 100 percent accurate.
As PNHP had warned, the legislation Obama supported (and that Hacker now celebrates) turned out to be a scheme to turn even more Americans into “insurance company customers.” Under PPACA, the insurance industry will get 20 million to 25 million new customers (16 million directly, and a few more million through the expansion of privatized state Medicaid programs), and the premiums of most of these customers will be subsidized by the taxpayer.
The net result of Hacker’s strategy: A “reform” bill with no “option” and no cost control which will leave half the uninsured uninsured a decade from now and which enriches the insurance industry.
This outcome begs for analysis. The “option” campaign was one of the most well-funded campaigns for a left-of-center proposal in American history (HCAN alone spent at least $51 million over the past two years). Moreover, the campaign took place at one of the more propitious moments for health reform in American history. And yet it failed completely. (This assessment assumes that Hacker and HCAN weren’t all along promoting an insurance industry bailout under the guise of promoting an “option.” I have questioned this assumption in a previous comment on this blog.)
But Hacker offers no analysis other than to blame “conservative Democrats” for whacking his “option.” If it had been a single-payer bill that conservative Democrats successfully opposed in 2009 and early 2010, we know exactly what Hacker would be saying: He would be saying single-payer advocates are “unrealistic” people who don’t understand Americans as well as he does. He would be saying, “Of course conservative Democrats killed the single-payer bill. They represent mainstream Americans who are stubbornly attached to the current system.”
But, of course, it wasn’t single-payer that got killed last year, it was Hacker’s “option” – the completely gutted version – that got killed.
The lesson that Hacker and all of us who care about universal coverage should draw from the “option” debacle is that the “option” never was the Northwest Passage to universal health insurance in America. It will turn out to be more like the Donner Pass – a path that seemed from afar to lead over a mountain range of obstacles, but which turned out to be a trap.
It is imperative that the American universal coverage movement arrive at an accurate interpretation of the history of PPACA, including the “option” campaign’s criticism of single-payer and its support for an insurance industry bailout. The interpretation I hope we all arrive at some day is that the “option” campaign squandered a golden opportunity to achieve real reform or to at least set the stage for the achievement of real reform in the near future.
The year 2009 was one of those rare windows of opportunity for fundamental reform of our health care system. Two-thirds of Americans supported a single-payer system. The nation’s large and seasoned single-payer movement was chomping at the bit to fight for single-payer legislation.
But the “option” campaign squandered it all for an insurance industry bailout. Hacker’s timid and inaccurate analysis of what was possible played a key role in this tragedy.
Kip Sullivan is a member of the steering committee of the Minnesota chapter of Physicians for a National Health Program (www.pnhp.org).