Dude, write in word or wordperfect or whatever, saving constantly, then cut and paste into movable type. How many blog posts are my favorite bloggers going to have to lose before you realize that writing directly on a web browser is a bad idea?

But even if it is a bargaining chip, it's hard to understand the bargaining theory in which you don't start with it in the plan.

They don't have confidence that they'll win the resulting public perception battle on "government-driven health care" which could sink the whole reform process. They're probably right.

"That said, this isn't a bill, and I'm sure administration spokesfolk would tell you that they're leaving this to Congress."

If by "this" you mean the primary responsibility for the drafting of the details, I do hope you're wrong.

The White House seems to be making the same mistakes they made with ARRA. You need to start big--maybe even bigger than you think you need--and negotiate from there. The weakness of the congressional Democrats means bills will only get more conservative as they move through the legislature, and the White House needs to take that fact into account in pushing its agenda.

Probably the best way to look at this is through the mandated Medicaid HMO versus state-run Medicaid analogy. As you go across the country, various municipalities don’t have a ‘public’ Medicaid option (Tennessee, Philadelphia, other counties here and there) and the only way to get coverage is through one of many private (not to say ‘for profit’, usually non-profit, actually) insurance companies that are administering Medicaid for the state. In those areas there is no public option but, again, these companies are highly regulated and often required to be accredited by the National Committee on Quality Assurance which includes the requirement to submit the laundry list of clinical outcomes that go along with the Healthcare Effectiveness Data and Information Set (HEDIS) data.

I have to say, I’m not sure I care if there’s a public option. In mandated Medicaid HMO areas (as well as managed care/state-run blended areas) patients typically are free to move freely among plans and the only way for the Medicaid HMO’s to make any money is to retain the patients and to keep receiving that patient’s per member/per month payment from the state. That almost always translates into market-driven competition that benefits the consumer, i.e., plans trying to out-do each other with better networks, better added benefits, patient satisfaction (also part of the NCQA process, the Consumer Assessment of Healthcare Providers and Systems Survey - CAHPS). Not to say this model is always super; you often have plans putting together untenable benefits aimed at recruiting members but that crumble after a year or two due to hurried actuarial work.

I think the people supporting a public option are presupposing that the private plans (again, private plans using public funds) are going to suck. And they might. I think that’s a fair concern given the uncertainty of the actuarial models. But since there will most likely be some sort of mandated benefits package, I don’t think there’d be much daylight between the public and private plans.

The way I look at these principles is that these are things Obama is saying are basically non-negotiable. If that's the case, then if a public option is a bargaining chip, it couldn't be part of the principles since those are things that he refuses to bargain with.

Since this is the budget bill, rather than piecemeal legislation, doesn't that mean that Collins and Spector aren't required? Per the rules, the budget bill only needs simply a majority - 50 votes - to pass and it can't be filibustered.

That changes the game entirely, I think.

For those interested in getting health care reformed, this isn't a big deal.

But for those interested in getting Democrats elected, this is a HUGE deal. A public option could "crowd out" regular insurance. In Britain, the existence of this public option gave Labor a generation of voters. People think "wow, free health care, thanks Labor!"

A mandate without a public option will kill Dems in the short run and will kill them in the long run. We need a Democrat-affirming institution to last from one administration to the next, similar to Social Security. Giving people a "public option" does that.

A mandate without a public option is just indefensible. That one is a sure-fire loser in the court of public opinion.

What if Obama doesn't believe in the public option?It isn't a given that if you include the public option it will be removed and it is possible he left it out because he doesn't want it in.

Craig, you make no sense.

I don't care if Obama doesn't believe in the public option, I do. It's not a given it would be removed -- to me, this is the most important part of health care reform.

We've waited forever for health care reform. Democrats have pushed this thing forever. I know it's the right thing to do on the merits, but are we to be punished politically for its passage and then watch as it's incrementally ripped apart by future GOP administrations?

We need significant. public buy-in of the proposal. This begins with the public option. It also ends with a mandate w/o anything to back it up.

This is a budget bill, you only need 51 votes and there is no cloture vote. However, if the bill is not revenue neutral, there is a 60 vote threshold to suspend pay-go. Several posts over the past two days has shown Ezra confused about this.

Is it possible the whole health care plan is not in this bill to keep the cost down ($634 BB in this bill vs. $1 trillion for everything that is needed) and to insure no pay-go violation? Then in next year's budget bill they come up with the other $400BB to cover the public option. Just a scenario.

Your Senate slurping is getting ridiculous, Ezra. You've heard of the other body, right? The one with real liberal leaders?

senatorwho is exactly right.

Your obsession with the senate, while understandable because they are the bottleneck, obscures the very point about bargaining you were trying to make. It is not that Obama starts with a big plan, and then "Congress" waters it down. It is that the house starts with a big plan, and the Senate waters it down. Or the Senate starts with a bad plan and the house strengthens it.

Point being, even if Obama doesn't propose it, the question is not "whether Kennedy and Dodd's people decide to fight for its inclusion." The question is what Nancy does.

This is really sad. A public option was the single most important lever Obama had to make sure that health care reform does not get hijacked by the insurance industry the way Medicare Part D was. And to at least get us started on the very long path to universal single payer, i.e., the path to rationality.

And to think he had it in his primary season proposal.

This guy gives new meaning to bait and switch.

Dodd et al are going to go to the mat over this when they have every reason to think that Obama will pull that mat out from under them when Arlen, Susan, and Olympia pay a visit? Just like he did on the Stimulus bill? Just like he did on using state secrets to hide unconstitutional behavior.

And I respectfully disagree with wisewon that the public would not support a public option. Not the perhaps too radical at this time: "Medicare for all." But certainly the completely defensible "Medicare for those who want it."

Especially in these times when vast numbers of people are quaking in their boots that they are just a pink slip away from not having medical insurance. Not even Specter, Snowe, and Collins would stand in the way of that populist juggernaut. Specter, by the way, was road kill for the 2010 Pennsylvania senatorial race until Obama breathed new life into him by gratuitously making him a "centrist" power broker.

And ThomasEN seems dizzily out of touch with history and reality when he says:

"I think the people supporting a public option are presupposing that the private plans (again, private plans using public funds) are going to suck. And they might. I think that’s a fair concern given the uncertainty of the actuarial models. But since there will most likely be some sort of mandated benefits package, I don’t think there’d be much daylight between the public and private plans."

I'm not presupposing anything. I'm simply looking at the disastrous state of our private health insurance system, both on an absolute and a relative basis. Why will the private sector screw up health reform and saddle us with higher costs and qualitative shenanigans if they are left as the only foxes in the chicken coop? Because they're very experienced at doing just that. Would ThomasEN care to spin for us on why Medicare Part D is being implemented through the private sector in a manner that is optimal for the common good rather than their operations? Would he care to tell us why we should grow to love Medicare Advantage Plans – which mercifully Obama seems to be taking a stand against.

Though having already given up the strongest lever he had in the public option plan, it's at best 50/50 that he won't wilt on Medicare Advantage. The industry certainly thinks he will. Have you seen the explosion of adds on TV trying to get a surge of people signed up for these plans so that they can be used as hostages in the debate as to why Medicare Advantage is nor "too big to wind down"?

Agree with others.

a) This is how he fucked up the stimulus.

b) The public option could have defined the market in ways that regulation can not.

c) It turns the plan, as it stands, into a 634 bill give away to the private sector.

d) This bill does not require 60. It requires 50 plus 1. It's paygo. Obama made that clear.

These are the rules of the game. None of which I expect to see. I have given up on this country and progressives. You are no better than the conservatives. You just don't get it. You never will. These aren't complicated questions or strategies unless you are too weak to do anything.

Dude. You're conflating Part D and Medicare Advantage, which I in no way did. Part D cannot succeed until an unholy wrath of regulatory might crashes down upon every scumbag PBM in this nation. Straight Medicare isn't all that much better than Medicare Advantage and they both have their pros and cons, I'm sure you could go head-to-head on shitty anecdotes regarding service on either side.

And they're not being pushed because they're recruiting hostages, they're being pushed because most of them are dogs that were sloppily underwritten. Most importantly they got solid health outcomes. They also got the service delivery and regulatory mechanisms right, several of them just effed up the capitation formulas.

a) This is how he fucked up the stimulus.

If by "fucked up," you mean "getting exactly what he wanted in the first place." There seems to be some strange idea that Obama made some horrendous mistake with the stimulus, when, basically, he didn't.

This is a bit worrisome, but I'm going to withhold judgment for the moment.

Guys, relax already. Obama won't let us down on this. He loves us like his children.

Looking at the principles, I'm going to say that, in fact, it's not even particularly worrisome.

This isn't a plan. It's a statement of principles. "Having a public plan" is not a principle - it's a detail of implementation. I don't see how this statement of principles tells us much of anything about what actual plan is going to come out of congress.

John

a) Obama's own team and obama says the stimulus they got is not perfect or what they wanted. So, it's funny to read his zealot supporters saying opposite on line. You continue to have mystical powers to read beyond what is plainly there.

b) Your statements on the healthcare issue can be cut verbatim from quotes of zealot supporters prior to the stimulus debate. It will change in Congress, and blah, blah blah. You people got nothing else. Certainly not substantive points to offer. Just your hope and believe in 12 dimensional chess that has yet to materialize. The only one's you are playing are yourselves.

godplay -

a) Perhaps I was a bit hyperbolic, but, really, come on. The stimulus package was very, very close to what they originally proposed. Of course it changed somewhat, and of course they had a few rocky moments in the middle there, but the idea that they faced any kind of serious setback is ridiculous, and has nothing to do with being a "zealot supporter." Can you offer some support for the alleged claims by Obama supporters that the stimulus isn't what they wanted?

b) I don't see you offering any substantive points - just a lot of cynicism. My basic point about the health care issue is that they haven't offered a plan - just a list of pretty general principles. If an actual plan comes out with no public option I'll be disappointed, but that's not what's happened yet.

I'm with John in regards to the stimulus/ recovery bill including most of what Obama's Team wanted, and about the public insurance option in a health reform bill. (But I'll be way more than "disappointed" if public insurance is excluded).

I've been involved with this work as a nurse and as an activist for over 15 years and I'm convinced that most "Progressive" organizations and individuals (quick thought: are they an entirely homogeneous group?) are fighting VERY VERY hard to make sure a public insurance option included.

MoveOn.org started a "HC This Year" petition to Congress yesterday and although it doesn't specify "public insurance option" there's a reason for that and imho it's a smart reason. This is hardball politics to the nth degree.

So don't just complain, do something!!

Sign Petition at http://pol.moveon.org/thisyear/?rc=reg&id=15682-6875543-aXFNKVx&t=2
And Stay Involved at
http://www.HealthCareForAmericaNow.org

The substantive point is the public option plan. There's nothing else to add. The rest of it is just chatter to build on that point. Yes, I am very cynical, and I will continue to be so. For instance, I find it ironic that you expect something more specific from me than you require of Obama. One of us is the President and the other is not. That makes for cynicism.

There is NO real reform without a public option:

If the program gets reformed; Republicans will just slowly chip away at it. Reform absolutely REQUIRES significant middle class participation. Significant middle class participation is possible with the public option. Programs like this strengthen the left.

It is well known that after the Labor Party established the NHS following WWII, tons of low-income who had been Conservatives voted Labor. This is unheard of. People’s political ideologies are usually set early on in life. The public option can change minds.

Especially in America, the middle class sees itself allied with the upper class. In surveys, the middle class frequently says it makes “just under” the upper class, though the upper class is exponentially more rich than the middle class. This type of thing is harmful for the economy and for social change.

The public option allows middle class people to see themselves allied with the lower class. This huge benefit comes IN ADDITION TO protections against the program being torn down, because of its universality (preventing the whole "programs for the poor performing poorly" problem). Universality is a NECESSITY if health care reform is going to last. We need public buy-in. We NEED NEED NEED the public option.

If you know beans about health insurance market dynamics, then you know that including a "public option" - assuming people make rational choices - leads quickly and inevitably to a single payer system.

Why? Well, begin with the competitive advantage in provider reimbursement Medicare has over private insurers - while some insurers are paying hospitals at Medicare levels, in general there will be a 10% to 20% spread between Medicare and the lowest paying insurer. All else being equal, lower input costs translate to lower premiums.

Now, to make a "public option" fair (since it would likely involve guarantee issuance, community rating, and probably income-sensitive premium supports), all else needs to be equal - you have to require private insurers to play by the same rules (or else they take all the young and healthy people and the public option becomes a dumping ground for high risks).

At that point the only basis for choosing between private insurance and the public plan is price (since the public option involves free choice of providers), and the public option has the lowest input costs and the lowest administrative costs.

There may be some committed ideologues who would pay a premium not to hold the same coverage their neighbor is getting through the public option, but again, I am talking about rational choice.

If that is the scenario, and if perceptive legislators understand it, then unless they think their constituents are ready for a single payer system, they will rapidly back away from a public option.

And in the interest of moving the ball down the field, maybe the President sees that too, and doesn't particularly want to see real prospects for health reform deep-sixed immediately by having "single payer" tied to its tail.

Which then leaves you wondering just how the essential ingredients for reform - cost containment, portable coverage, universality, and equitable financing - can be achieved absent a public option.

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