|"...The reform package, as drafted by the Obama administration
and the House leadership, is dubious legislation even
with the inclusion of a public option."
The Policy That Dare Not Speak Its Name
Co-Founder and Co-Editor of The American Prospect
I'M SURE I'M not the only reader who noticed the
juxtaposition of two front page stories in Sunday's New
York Times dealing with health care. The first article
cited a new Times-CBS poll showing that 72 percent of
Americans favored a government run health plan
comparable to Medicare, which would be available to
The second reported on a rogue radiologist at a
Philadelphia VA hospital who botched 92 prostate
The right will doubtless go to town on that one, as
what we can expect of government-sponsored medicine.
I'll have more to say about the VA in a moment, but
first let's consider the poll findings.
The poll is relevant because Congress will soon decide
whether to include the so-called "public option" in the
Obama health reform bill. As drafted by three House
leaders and unveiled last Wednesday, the 852-page bill
would include a government-sponsored, Medicare-like
Republicans and the health industry have been kicking
and screaming that this is socialistic. But the poll
suggests that defenders of the public plan have nothing
to fear politically, and that Republicans are in danger
of getting on the wrong side of a popular issue.
However, that's only the beginning of the story. The
reform package, as drafted by the Obama administration
and the House leadership, is dubious legislation even
with the inclusion of a public option. Basically, it
leaves the two worst aspects of the system intact.
First, private insurers will continue to dominate.
Second, most people will continue to get their
insurance through their employers. Given these two
bedrock realities, there is no way that the bill can
make serious inroads on cost without cutting back on
care. The high cost of the approach is already causing
key legislators to back off. The current system wastes
huge sums, but because it is so fragmented the money
flows to profit opportunities and not to the most
cost-effective forms of health care.
Also, as my American Prospect colleague Paul Starr
warns, a mixed system with a public option effectively
invites the most expensive and hard-to-treat people to
opt for the public plan, while private insurers will
seek to insure the young and the healthy. This is a
familiar problem known as adverse selection. The
private insurers will then smugly point out that the
public plan is less "efficient," when in fact it simply
will have a more costly population. The only way to
avoid this problem is to have everyone in the same
universal plan--what's otherwise known as a
The public option is a not-very-good second best--
because our leading liberal politicians lack the nerve
to embrace the one reform that simultaneously solves
the problem of cost, quality, and universal inclusion.
The policy that dare not speak its name is of course
comprehensive national health insurance, or Medicare-
for-All. I try to avoid using the term "single payer,"
because a technical, policy-wonk phrase not understood
by most civilians has become insider shorthand for
national health insurance. Let's call the thing by its
rightful name. Medicare-for-All is something regular
The Times-CBS poll is evidence that this is what more
than two Americans in three really want. Most voters
have not followed the nuances of how the public option
in the Obama plan would compete with private insurance.
The poll simply indicates that voters want access to a
straight-up, Medicare-style plan to be available to one
and all. In past polls, when Times-CBS pollsters ask
whether people favor national health insurance,
responses generally favor Medicare-for-All by margins
of about two-to-one.
In the current debate, liberals find themselves
fighting to keep the public option alive, so that some
form of efficient, publicly-run health insurance will
stay in the mix--but knowing that it is embedded in a
reform package that is far more costly and inefficient
than it should have been. Instead of validating the
common sense and reformist demands of ordinary
Americans and identifying the insurance, drug, and
corporate elites as the obstacles to real reform, too
many of our liberal leaders from President Obama on
down hope to co-opt business elites with a convoluted
scheme that undermines the efficiencies of a
comprehensive and universal system. And just wait until
it gets watered down further in order to retain the
support of these same elites. A plan that all of these
groups would endorse would not be worth having.
So what's the matter with our politicians? Why are the
people so far ahead of their elected leaders on this
one? One reason, as usual, is money. The combination of
the insurance industry, the drug industry, the American
Medical Association, the hospital lobby--all of whom
oppose Medicare-for-All--represents a huge amount of
political spending. It takes a brave politician to face
down all of these industries, even though the people
are on the side of real reform. The AMA's position is
especially shameful, since the professional societies
that represent most actual physicians favor national
The second reason that liberal politicians wimp out on
single payer is that the self-styled realists in this
debate have decided that Medicare-for-All, even if it's
the first-best system, is too hard politically. But
think about it. Has the administration picked up one
Republican vote by supporting the present system plus a
public option? Hardly. The current House leadership
bill, offering a mixed system, with a robust public
option, a requirement that employers provide good
insurance or pay a tax, and that insurers not
discriminate against pre-existing conditions, is just
as heavy a political lift as national health
insurance--and far inferior policy. So why not just go
for the first- best?
The advocates of Medicare-for-All have become something
of an embarrassment to the liberals. The White House
forum on health reform on March 5th, which boasted a
diverse range of viewpoints, including representatives
of the Business Roundtable, the health insurance
industry, the drug lobby, as well as a broad spectrum
of business, labor and Congressional leaders, left
advocates of Medicare-for-All banging on the door. None
were included, despite requests for invitations.
When Sen. Bernie Sanders recently arranged for five
prominent advocates of national health insurance to
have a courtesy meeting with Senate Finance Committee
Chair Max Baucus, the story was newsworthy because the
political elite usually pretends that this viewpoint
doesn't exist, much less that it represents the desires
of two Americans in three. The mainstream media have
also colluded in the general effort to keep the single-
payer option out of the limelight. The organization
FAIR recently published an important study in its
heroic magazine, "Extra", titled "Media Blackout on
Single- Payer Healthcare."
Indeed, the Sunday New York Times-CBS poll didn't even
offer Medicare-for-All as a free-standing option. It
took the Obama position as the left edge of the debate.
As for that rogue doctor at the Philadelphia veterans'
hospital, quality control is not what it should be
throughout our fragmented system. And the oases of
public medicine are particularly starved for resources.
Yet studies consistently find that on average, the VA
does more with less than its private sector
competitors. Phil Longman has written the definitive
book on the subject, "Best Care Anywhere." Here is a
In this case, the offending radiologist, Dr. Gary D.
Kao, was actually a contract employee and not a VA
Only by having a comprehensive system can we marry
quality, cost-effective care, and universal access. One
of these days, a national leader will have the nerve to
embrace national health insurance and fight for it.
Until then, we will keep paying more money for less
care, and liberals will defend reforms they themselves
scarcely believe in.
Robert Kuttner is co-editor of The American Prospect,
and senior fellow at Demos. His recent book is "Obama's