The Public Option Dialectic

by publius

I'm not sure what the public option's current odds are.  But regardless of the final result, the public option debate itself has been a beneficial and clarifying one for progressives.

Generally speaking, political and intellectual coalitions often benefit from schisms that clarify and strengthen the coalition's ultimate positions.  Sometimes, of course, these divisions can be debilitating.  But to the extent the coalition shares the same broad goals and values, debate is a good thing.

With that in mind, the most interesting "conversation" going on right now in progressive online circles is between two camps I'll broadly call the "wonks" and the "activists."  I recognize that these camps can't be neatly separated, but hopefully most of you have a rough idea of what I'm talking about.

Notably, this divide has nothing to do with "liberal" versus "centrist."  Frankly, I don't think that conservative Democrats have given us much to think about lately.  The "policies" of people like Nelson and Lincoln have more to do with demographic realities and corporate money than intellectual disagreements.

The wonk and activist camps, by contrast, are both pretty liberal.  But they differ in important ways.  Both camps seek to persuade, but the wonks are more focused on explaining, while the activists are more committed to inspiring action. 

The camps also differ in their relative willingness to accept the political realities of the status quo (or in their definition of what those realities actually are).  For this reason, the wonks tend to be more comfortable with legislative compromise, while the activists are (relatively speaking) more resistant.

The public option debate has illustrated some of these intra-progressive divides.  Interestingly, though, I think the debate has strengthened both camps' ultimate positions—and furthered the progressive cause more generally.

In my opinion, the wonks have been less passionate about the public option because they feel that (1) it's not the key to the bill; and (2) it's not politically possible to pass.  The wonks agree that the public option is good policy, but disagree that it's worth going to the mat for.  For what it's worth, this has been my position too.

This worldview, however, rests on certain assumptions about what is politically possible.  The wonks are only right if they are correct about where the boundaries of "the possible" fall.  If they're wrong—if reality is more fluid than they're acknowledging—then they have to rethink some basic positions.

And here is where the collision with the activists has paid off.  The activists have challenged the wonks' notion of where the boundaries of the possible are.  In short, they've blurred these lines in a positive way. 

In doing so, they've helped convinced skeptics like me that I've been far too stingy in imagining what is in fact politically possible.  Indeed, the public option would have been dead a long time ago but for the committed efforts of the activists.  Frankly, I thought it was dead, which is a testament to my lack of vision on this issue.

The wonks, however, have also helped the activists.  Again, this is all personal observation, but my sense is that the wonks have helped clarify the larger stakes.  Reform really does have many important features beyond the public option.  It would therefore be tragic to scuttle the bill solely because it lacked a public option.

But the intra-progressive debate is helping generate the best of all possible worlds.  It's far more likely now that a public option of some kind will be fought for and included.  At the same time, it's more likely that activist liberals will support a bill that ultimately includes a modified public option plan such as an "opt-out," rather than refusing to budge an inch.

Obviously, I'm simplifying things, possibly to a fatal degree.  But that said, I think that the wonk/activist debate has had a beneficial impact on all parties involved—and (hopefully) on the final policy.  Even better, it's the type of ongoing conversation that can be applied in other areas as well.

Comments

[wonkie]

The Overton window is moving.

I thinnk that you are saying that the gates have been crashed and that the activists are now part of the conversation. I'm glad that you did not characterize the activists as leftist. The people I think of as the activists--the Daily Kos crowd and Kos himself,are good examples--atre pretty mainstream in their ideas, just a lot more blunt spoken in their discourse than Democrats have been and a lot less willing to give way when it isn't necessary.

[willf]

I agree with your overall point that the two camps, as defined, can be seen as having a positive effect on each other.

The disagreement comes with your last two paragraphs:

Reform really does have many important features beyond the public option. It would therefore be tragic to scuttle the bill solely because it lacked a public option.

The wonks have not yet made the case for passing a reform bill without a public option. The benefits of the proposed exchange, and the new regulations on insurers (no recission, no exclusion based on preexisting condition) can be circumvented simply by raising premiums to price the poor and ill out of the market. The other worry is that employers will shunt them from employee healthcare rolls so that they are left to find policies on the exchange that are overpriced and provide insufficient coverage. This is a gaping hole in the bill that is not discussed enough.

As well, the idea that a few regulations on insurers will be sufficient to prompt good behavior from health related corporations seems to be based something other than experience with these corporations. Regulatory capture and the inevitable loopholes that result require any real reform to have a non-regulatory component to exert downward pressure on the cost of premiums and deductibles, I have yet to see a convincing argument that this downward pressure can be achieved through regulation alone.

At the same time, it's more likely that activist liberals will support a bill that ultimately includes a modified public option plan such as an "opt-out," rather than refusing to budge an inch.

I wish I could disagree with you more strongly on this point. The "opt out" clause does seem popular and yet it is offered only to weaken the bill and play "divide and conquer" with democratic supporters of health insurance reform.

That some liberals will support a bill with an opt-out clause more strongly than a bill with a robust P.O. -- at the expense of those who live in states dominated by republican governors and legislatures -- speaks to the ease with which those in power can divide us, and make sure that the benefits of any reform bill passed are more easily negated

In order to be a viable force to exert pressure on insurance companies to keep costs (to the now captive consumers) down, any public option has to be open to as many people as possible. It needs the widest risk pool available. Eliminating some states, either because you think that it is the only way to get a bill passed, or because (and I do not say that you advocate this) it is some form of tough love practiced on red states -- that the citizens of those states will demand public insurance once things get bad enough -- only makes the public option that much weaker when it has to compete against enormous private insurance companies.

Those two issues are only the most current sticking points that keep activists wary of compromise.

[John Miller]

I have little doubt that there will be a public option in the final bill. A also think it will have reimbursement based upon a Medicare plus 5 or 10% which, for many doctors and hospitals would be more than they are collecting from some private insurance companies.

Although I would prefer not to see a opt-out public option, if that is what it takes (I don't think it will be) then go for it.

It is interesting that you say Nelson and Lincoln ave to deal with demographic realities. The public option is supported by majorities in both of their states, as it is nationa wide. I find this interesting considering all the lies spread about what the public option would result in.

If there were an honest discussion of the public option, the overall support would rise significantly.

One thing that is absent from most discussions, but which is an important point concerning your view of wonks versus activists (and why can't an activist also be a wonk?) is that if a public option were not included in the final bill is that the Republicans, even as currently constituted, would probably have a major string of victories over the next couple years because a lot of the newer "activists" who came out and voted last year would become disillusioned and not come out to vote in the future.

[bobbyp]

Unfortunately, your paradigm breaks down when it comes to foreign policy, a policy area where the wonks, for all their wonkishness, have been utterly wrongheaded for decades.

For a distinctly minority party, the GOP gets a lot of political milage out of catering to its base. The dems...not so much.

[brent]

I am not one to note typos but

support a bill that ultimately includes a modified public option plan such as an "opt-out," rather than refusing to bulge an inch.

that is a pretty distracting one. I am pretty sure you want to change that to "budge."

[Brien Jackson]

"The benefits of the proposed exchange, and the new regulations on insurers (no recission, no exclusion based on preexisting condition) can be circumvented simply by raising premiums to price the poor and ill out of the market."

http://en.wikipedia.org/wiki/Community_rating

[Brien Jackson]

I think you've got a decent outline of the competing progressive narratives here, but I'd quibble with this part just a bit:

"In my opinion, the wonks have been less passionate about the public option because they feel that (1) it's not the key to the bill; and (2) it's not politically possible to pass. The wonks agree that the public option is good policy, but disagree that it's worth going to the mat for. "

On the one hand, I'm not sure how many people are genuinely of the opinion that a public option absolutely can't pass, so much as they think it's possible that a public option won't be able to pass. That's certainly my take on it; I think some form of public option will probably pass, but it's possible that I'm wrong.

Moreover, it's not that the public option isn't worth fighting for, it's that it's not worth dying over. I think most of your wonks would agree that it's certainly worth going to bat for the public option in the Senate or in conference, I think where they split from the activists is that the activists increasingly seem to want to walk away altogether if they lose that fight, whereas the wonks don't think losing the public option is worth giving up on an otherwise good bill over.

[Ben Alpers]

I'm not sure what the public option's current odds are. But regardless of the final result, the public option debate itself has been a beneficial and clarifying one for progressives.

...and good news for John McCain!

This post seems seriously panglossian to me (heck, you even declare that this is the "best of all possible worlds"!). The focus on the public option in the "debate" on healthcare reform is a reflection on how extraordinarily narrow this debate has been. For example: both single-payer (which I like) and Wyden-Bennett (which I don't like, but which has its serious supporters on this blog and elsewhere) have been essentially shut out of the conversation. And much of the discussion of the public option has involved parrying ridiculous wingnut claims about it, not seriously discussing its merits, either in general or in its specific implementation.

In my opinion, the wonks have been less passionate about the public option because they feel that (1) it's not the key to the bill; and (2) it's not politically possible to pass. The wonks agree that the public option is good policy, but disagree that it's worth going to the mat for. For what it's worth, this has been my position too.

This worldview, however, rests on certain assumptions about what is politically possible. The wonks are only right if they are correct about where the boundaries of "the possible" fall. If they're wrong—if reality is more fluid than they're acknowledging—then they have to rethink some basic positions.

This analysis ignores the extent to which the wonks are themselves responsible for defining the politically possible. Wonk declarations that the public option is not possible raise barriers to the public option and create talking points for its sworn enemies, thus making work for (actual) progressives who have insisted on it. I fail to see how this process is helpful for activists or for wonks who actually support the public option (though I understand all too well how it's helpful for wonks engaged in concern trolling the public option to death).

The "policies" of people like Nelson and Lincoln have more to do with demographic realities and corporate money than intellectual disagreements.

Fixed.

Voters in Arkansas, in particular, are pro-public option, as are voters in Maine and many other states whose Senators are working to kill a public option. This has little to nothing to do with demographics and everything to do with corporate money. This whole "debate" has been largely insulated from public opinion, as are most political conversations when real money is on the line (see last year's Wall Street bailout, for example).

And unless this "discussion" results in a concerted effort to reform our political system so that corporate money has less of a say, it has truly been a waste of time.

[Ben Alpers]

willf: The "opt out" clause does seem popular and yet it is offered only to weaken the bill and play "divide and conquer" with democratic supporters of health insurance reform.

This.

And the success of this strategy in wooing the "Netroots" in the Blue States has been truly disturbing for those of us in deep Red States. It has, however, been an interesting political psychological reminder of how the Democratic Party was able to spend a few decades as the party of both the New Deal and Jim Crow without the cognitive dissonance creating too many problems for its Northern, liberal wing.

If we get "opt out," maybe y'all will eventually, in thirty years or so, consider insisting that people in the South not be treated as second-class citizens by the federal government.

[Brien Jackson]

On the other hand, it's extremely annoying when "activists" both try to play "wonk" and get all pissy that "wonks" don't act like "activists."

[Noise Machine]

So publius acknowledges that the wonks (read:smart liberals) know that the public option won't have any real world effect. But the activists (read:dumb liberals) want the public option anyway because (1) it antagonizes the right and rubs big government in their noses and (2) it's a camels nose under the tent intended to lead to full-blown socialized medicine. But the smart liberals ... I mean wonks... can't say that because of political pressure from the dumb liberals... I mean activists.

[AIMAI]

Yes, this is a conversation that we've been having over and over again. The terrain "politically possible" keeps shifting--in fact, shifting it is what politics is all about. We see this happen on a micro level in question of what any given Senator will do. Specter was once an actual R. He changed political parties and was planning to still run and vote as an R but with D protection. The addition of Sestak to the race fundamentally altered his personal political calculations and, presumably, his voting style for some of the foreseeable future.

There is no such thing as a given set of political parameters that absolutely dictate your political goals in the long term. In the short term you might not have time, or money, or a good public strategy to force vote X to change to vote Y. But in the long term you do. But you have to be willing to act agressively to push the votes, or sculpt the terrain, in the way that is most advantageous to your goals.

I guess you could say that I'm not a wonk. I'm an activist. But I'm not an activist because I believe in expressive politics, or political action as a form of psychotherapy. I believe in having people in politics do their damn jobs of getting good policy through a broken field by practicing good technique in broken field running.

aimai

[scott]

I agree with aimai. All this dithering about the politically possible covers up a lot of intellectual and moral cowardice. The simple point is that you often don't know what you'll get until you actually make the effort. Movement conservatives are, well, nuts, but in the late 50's and early 60's they decided to ignore the model of "consensus politics" that commentators had pronounced The Only Way and push their views. They had their asses handed to them a lot over the years and suffered many defeats but in doing so got their ideas into the conversation and eventually made them seem "mainstream" (although they were still nuts). Why can't we do that? When the GOP wanted confirmation votes for SC justices and needed to defeat the filibuster, they pushed the nuclear option and didn't whine about how we needed 60, 70, or 80 votes to pass anything meaningful. They took a dubiously elected President and rammed massive tax cuts and a drug-company giveaway down our throats. Maybe we could accomplish something like that, or maybe we couldn't, but I see precious little desire on the part of our liberal "leaders" or even A-list blogger types to even give it a shot.

[UserGoogol]

willf: The public plan can be rendered worthless if private insurers are able to risk select in such a way that they dump the sick onto the public plan (thus making the public plan more expensive) and keep the healthy for themselves. The regulatory structure is what makes or breaks this either way.

[ckc (not kc)]

...full-blown socialized medicine...

you say that like it's a bad thing.

[willf]

UserGoogol, agreed.

Looking at the various bills it seems that some of them have public plans designed to fail, and I'd guess that any public plan which passes will have to be strengthened and expanded, again and again (a la Waxman with medicare) before it's truly viable.

Brien Jackson. Community pricing is a good idea, and one little spoken of during the debate. But how big are the communities, and how are they affected by monopolizing behavior of corporations like BC/BS? I realize that this isn't the best argument, but if community pricing would really work as advertised, wouldn't the big insurance co.s be making more noise about it?

Not to mention that an "opt-out" provision will chop the communities into bite-sized bits, as states that have insurance monopolies, like Arkansas, will almost certainly opt-out if the decision is left up to the governor and legislature. despite the wishes of it's voters.

[Tom]

If we get "opt out," maybe y'all will eventually, in thirty years or so, consider insisting that people in the South not be treated as second-class citizens by the federal government.

Maybe people in the South will eventually consider electing some better state governments. Until then, I don't think it's entirely fair to say that letting them voluntarily opt out of something amounts to treating them as second-class citizens.

Besides: if we end up with a situation where blue states have a public option and red states don't, and if the public option works well like we hope it does, then things may get to a point where Southern state governments decide to be pragmatic rather than ideological and accept the public option (while continuing to hypocritically rail against socialism, of course).

[Point]

"In my opinion, the wonks have been less passionate about the public option because they feel that (1) it's not the key to the bill; and (2) it's not politically possible to pass."

I've been keeping up with the wonks* since the start of the debate. I've read plenty on the former, a lot less on the later. (In fact, to my memory, I don't think either ever said a public option was "dead".)

*particularly Cohn and Ezra

[Bruce Webb]

Well let me put in a plug for the wonks in response to this:

The wonks have not yet made the case for passing a reform bill without a public option. The benefits of the proposed exchange, and the new regulations on insurers (no recission, no exclusion based on preexisting condition) can be circumvented simply by raising premiums to price the poor and ill out of the market. The other worry is that employers will shunt them from employee healthcare rolls so that they are left to find policies on the exchange that are overpriced and provide insufficient coverage. This is a gaping hole in the bill that is not discussed enough.

I would counter that it has been discussed plenty, it is just that the activists get bored by the wonkery and don't engage in the details. If we take the only complete piece of legislation we have, which is to say HR3200, we would see on examination that this "gaping hole" does not exist. There are provisions in this bill that prevent insurers from "raising premiums to price out the poor and the ill". There are also rules that prevent employers from "shunt(ing) them from employee health care rules" (in fact this rule is one that disturbs the Wyden folk, us wonks can't win). Plus the minimum Acceptable Benefits Coverage outlined in Sec 122 and paralleled in the HELP Bill are not at all "insufficient". On my reading your premises are themselves simply incorrect, issues you think have not been discussed enough were in large part engaged with back with the bill release and dismissed.

Do you think the profit and premium controls included in Sec 116 of the House Bill are inadequate? And if so why?
Do you think the benefits package outlined in Sec 122 are inadequate? If so why?
Activists by and large don't engage sufficiently with the question of "Why did Dingell, Waxman and Kennedy sell us out by not addressing these obvious holes?" Well the answer is that by and large those holes were obvious and were addressed and for wonks the question is whether they were sufficiently addressed. Yet activists just seem to assume that they can work from second and third hand characterizations of the bills from other activists who seem equal degrees of separation from the bill language.

I know it is not very satisfying to activists to have wonks simply dismiss their objections, but mostly it is not because we just are ignoring them, some of us have concluded they have been sufficiently addressed.

I don't know how to resolve this except by wonkishly plugging away citing bill sections and langauge in hopes that someone will actually check their assumptions.

HR3200 is an excellent work product, as was the original version of the HELP Bill. HR3200 got through Ed/Labor and Ways and Means just fine only to run into some Blue Dogs in Energy/Commerce. How Pelosi and the Tri-Committee resolve that is a somewhat open question but the basic protections are intact in all three and should survive. The HELP Bill was watered down to meet the objections of Centrists over cost but retains the outlines of HR3200 and is a good place to start. While the Baucus Bill can be seen as an attempt to strip all the good features out of HR3200 and needs to be move a long way towards it. But getting this means getting right down into the weeds of the language and not just working at the conceptual level of 'Strong Public Option' or 'Single Payer Now'. Everything is better with a strong PO. But there is a path to a good bill that doesn't include it, And until activists start dismissing wonks as traitors to the cause we are not going to get to the common ground needed to get the best bill possible out of the sausage maker.