What's So "Public" About the Public Option?

In a rhetorical gambit destined to sew confusion and frustration among supporters of  health care reform, Democrats in the House seem poised to take the widely supported idea of health insurance "public option" and transform it into something that seems neither "public" nor, in the near future, "optional." 

This shifting definition of "public option" came to light at a town hall meeting hosted by Yvette Clark (D-NY) in Crown Heights, Brooklyn, last night.    During the meeting, Clark emphasized her emphatic support for a "robust public option," drawing standing ovations from the crowd. At other points in the town hall meeting, however,  Clark's definition of what she meant by "public option" left the crowd confused and uneasy. 

In her PowerPoint presentation, for example, Clark announced that a "public option" if passed would not be available until 2013.  In response to this time line, many in the audience who had cheered Clark's declaration of support for a "public option" yelled out "What'll we do for four years?"and "Why so long?"

Even more peculiar than the long time line, when asked directly by an attendee "What is it exactly that will make the public option public?" Clark responded, "It will be public because it will be nonprofit."  This answer elicited furled brows and silence from the room.

In other words, according to one of the most vocal advocates of a single-payer system--a Congresswoman deservedly lauded as a champion of health care reform--the "public option" did not mean a government administered program like Medicare, but a "nonprofit" entity established by a government grant, run independently, and not ready until after the next Presidential election--at least.

While it is impossible to know what most Americans imagine when they hear the phrase "public option" in the context of the health care reform debate, I can say for certain what I imagined and it was not a non-profit entity with a 4-year time line.  What I imagined--or thought I imagined before last night's town hall--was a "public option" that would be unrolled similarly to Medicare.

Just after the signing of the Social Security Act of 1965 that created the program, President Lyndon Johnson held a second public ceremony to sign up the very first American for Medicare:  Harry S. Truman.

In the videotape of the event, Johnson explains that Truman is getting preferential treatment by getting his card right away, because "the rest of the sign up cards would not go out until the end of the month."  That is to say:  one month after Medicare was signed into law, the Medicare enrollment cards arrived in mailboxes.

A time line similar to Johnson's Medicare roll out was pretty much what I had imagined whenever I heard members of Congress declare their support for "public option." I expected that a public option would become available for Americans within a few months of the law being signed. Apparently, I was wrong.

According to a recent article on Politico, the shifting definition of "public option" is not accidental, but is emerging from the perception by Democrats in the House that the August recess caused them great damage from which they need to come back:

The comeback for Democrats -- if there is one -- will begin in an all-important closed-door caucus meeting next week in the basement of the Capitol, where House Speaker Nancy Pelosi (D-Calif.) and her top lieutenants will try to undo the damage of the August recess and convince their wobbly members that a vote for health care reform will not cost them their jobs in 2010.

Leaders say their strategy is to convince members that nothing is set in stone and that they are more than open to negotiations. And they're engaging in a softer sell, prioritizing health insurance reforms while pitching the public option as something that's way, way down the road. (link)

If the Politico account is accurate, the strategy of shifting the frame on the "public option" is bound to create more and more frustration among current supporters of a public option.  The more Americans who understand that the Congress wants the public option to unfold slowly and in a not-very-public way, the more people will feel Democrats are betraying the principles of reform they claim to be supporting in their rhetoric.

Adding insult to injury, the fact that House Democrats plan to launch this strategy at a closed-door meeting has the potential to set in motion a perfect storm of suspicion among supporters of a truly public and ready-to-go "public option."

All of this means that the real debate to keep the "public" in a "public option," and to make it available sooner, rather than later, has not even begun.  If that is the case, September could be a long month, indeed.  And it is hard to see how Democrats will benefit if they shift the debate from demands for a "public option" to concerns as to whether the public option is still public and optional.

Follow Jeffrey Feldman on Twitter: www.twitter.com/JeffreyFeldman

Comments

[rad21]

Medicare overhead cost is 3% of premiums; other insurance 13-25%. Extra-costs due to corporate structure, management compensation with padded perks; advertisin­g/marketin­g; actuaries, lawyers etc. There are investments, takeovers, mergers, campaign-c­ontributio­ns and lobbying, outside consultants, bankers, lawyers, etc. - ALL Paid by healthcare premiums. With administrative costs of hospitals, nursing-homes and doctors at 24%, 19% and 12%, only half the premium is spent on care.

Cost-drivers are health-insurance, pharmaceutical, bio-engineering companies, led by management interested in bottom-line; hospital and nursing home administrators; medico-legal system, healthcare economists and consultants. Cost-drivers contribute to steep cost-curve. Complex formulary of insurance and funding makes the system cumbersome and inefficient, adding further irrationalities and alien motivations within the system. Goal of good patient care is lost in the shuffle.

WH should negotiate with the Insurance companies. Insure all, no denial of coverage and permit portability. Immediate 30% reduction in premiums and another 20% reduction over next two years. Half the savings to come from Insurance and the other half from the delivery of care. This will reduce healthcare cost from 17% GDP to 11%; making American business competitive in the world. With such a deal, all sides should be on board to sign off on a bill. If the insurance companies do not deliver, the Public Option should deliver by 2012.

[RZoroaster]

With all due respect to the author its clear that you, and most of the people commenting here, have severely misunderstood what the public option was intended to be. It was never meant to be a medicare style plan or an unrolled plan. It was always supposed to be a non-profit that people have to buy into, whose only public feature was that its administrators are appointed by the government and that it has special permission to compete nationally. This misunderstanding is exactly what's killing healthcare reform right now!!!

If it was a medicare style plan then it validates all the anti-reform arguments about it killing private insurance! We can debate single-payer another day but that's not what this reform is about and it won't be about single payer this cycle. Single payer has no chance right now. Give it up. Support the real public option and stop spreading misinformation that feeds into republican arguments!

[djstar]

The debate is making me ill. I believe I, like many others, keep looking for information to make the BEST decisions and get as much information as possible. The thought of no public option makes me literally queasy as I type.

One issue I keep hearing every so briefly and usually from doctors in scrubs is Tort reform. It DOES seem that one of the reasons our doctors are not doing THEIR best work is the fear of litigation. Everyone knows over testing and over treatment is costly. Over and over, I hear that young doctors can no longer hang up a shingle, start a practice and establish that sort of personal interaction with their patients from the fear or cost of malpractice.

As an element of a public option, can we subsidize or ease the burden (if we don't want to put lawyers out of work) for private practices that are willing to participate in a public program? I have heard repeatedly doctors supporting public option, but a huge obstacle is the up front (much as MY high payments and deductibles are) operating costs before we start getting to health CARE.

With the streams of professionals running to the protected plan, they will have to compete for their participation. Lowering costs of coverage after signing practitioners, helps the doctors, allows more operating budget for equipment and hospital maintenance, DISCOURAGING over building and profit for hospitals, moving funds to the DOCTOR, the primary care individual.

[PunditBasher]

I am fairly skeptical of this healthcare plan the democrats are putting forward

When you listen to their pundits, they claim that they are going to set up a not for profit insurance company. This would be fine, not really progress towards the kind of healthcare reform the left wants, but whatever, its not a terrible idea
But for some reason, they say its going to cost lots and lots of money. And that doesn't add up

If all they are doing is setting up a public insurance company, then that would be basically free. They should spend approx. what they take in. There will be start-up costs but it really shouldn't cost a lot of money. So that means that the money they are spending is on something else. But what?
They even say they might take out the public option part of the plan. But as far as I am being told that was the whole plan, the public option. So If they take that out what exactly are they passing?

[dogdiva]

I agree. When a pundit or a pol is faced with an R saying how costly the whole program is going to be, I NEVER hear the response that it will be designed to pay for itself. Why? What am I not getting?
I would think they are talking about the subsidies that will go to those who can't even afford the public option (which I think will be legion) except that the R's keep making noises that we should give people subsidies to pay for private insurance. What's missing here is the TRUTH. Republican's have no intention of giving 30 or 40 million people a MEANINGFUL subsidy so they could afford private insurance. NONE! Or they will say "First, you buy the insurance and then we'll give you some kind of credit at the end of the year". Nobody in this fight seems to understand what "no money" means.

Why doesn't one of these so-called journalists pin down this very basic point. When a Republican says in their plan they would help people buy insurance, is it so difficult to say "How much would you give them?" Who would receive 'help'? "What good will 10% of a premium do anyone with NO discretionary income"? "Where are YOUR numbers?"

[RZoroaster]

This is a very good point. that is indeed where the cost comes from. Not from the public plan but from the subsidies. And while republicans complain about the cost they support subsidies. Its the cost-free public plan they're revolting against. There is definitely a disconnect there and someone needs to bring it to light.

[SHADETREE]

YES DEMOCRATS ALL YOU HAD TO DO IS EXPAND MEDICARE AND YOU WOULD HAVE BEEN SMART, THIS IS NOT THE DEMOCRATIC PARTY OF F.D.R., HARRY S. TRUMAN, OR L.B.J. THIS IS THE GOLDMAN SACHS PARTY NOW

[WinterParkMom]

The basis for any public option should be:
Coverage for EVERYONE who applies
Structured premium payments of not more than 100 per individual, 300 per family
Deductibles capped at $2000 and based on income (means testing every year like the va)
No mandates forcing people to purchase insurance (a windfall for private carriers)
No triggers (also a windfall to private carriers)
No subsidies to private insurance carriers
No taxes on employer provided benefits
If someone has private insurance and wants the public option, they can drop private with no problem and be covered immediately under public.
No mandates on employers to buy into the public option to cover employees. Has to be free choice.
Everyone with coverage gets treated for new or pre-existing conditions.
Fairly negotiated reimbursement to private pracitce, specialty doctors and hospitals
Fairly negotiated prices for medications, even on name brand stuff which has no generic equivalent.
AND MUST BE EFFECTIVE IMMEDIATELY. Within 1 month of the above bill passing, Americans must be able to start buying and using it.
It must be administered by an autonomous federal agency. Monies paid in must not be co-mingled with any other money, does not go into the general fund so it can be looted.
The ONLY payouts from this fund will be for: payments to practicioners, pharmacies and admin. In 5 years if we see significant overages, those overages will only be used to suplement medicare and fund medical research and maybe scholarships.
See next post on funding

[vanmungo]

You keep recycling the same ignorant, uninformed proposals.

You obviously have read nothing about the history of the public option and how it has evolved.

No one has ever proposed the kind of public option you are talking about. Certainly there is nothing even remotely like that in the bills being peddled by the mainstream Democrats.

even WITH the lobbyist-approved, shrunken public option being peddled by the Democrats, we will have no reform.

The shriveled version of the public option is nothing like Medicare. Unlike Medicare, it will be self-sustaining, not publicly funded; unlike Medicare, it will charge premiums and impose deductibles, making it unaffordable for the tens of millions most in need of help; unlike Medicare, it will have to negotiate provider fees on the same footing as HMOs--so no cost saving there, no cost savings of the single risk pool of single payer--according to the CBO, no cost savings period.

And no significant expansion of coverage, because it will be open only to those not already covered by employers, and even for them not until 2013! This is a gift to the HMO lobby, pure consumer fraud-- a public option that is neither really public nor an option for most people!

See "Bait and Switch: How the Public Option Was Sold"

http://www.pnhp.org/blog/2009/07/20/bait-and-switch-how-the-%E2%80%9Cpublic-option%E2%80%9D-was-sold/

[abmabardy]

I would think the very fact that it will be NOT-FOR-PROFIT will provide cost savings and therefore lower premiums.

I buy health insurance as an individual. ZERO bargaining power. My rates have doubled in tha last eight years, and that includes downgrading to a lesser policy three times.

I am willing to pay $300, even $400 per month. Over the last two years, I have been paying $550 and $650 respectively. I just received a letter saying my new rate, if I choose to renew, will be $800 per month. I honestly don't care who "runs" the public option, just as long as the rates come down.

[slowtono]

Close but no banana. No company or employer may buy public option until all of their employees have PERSONALLY opted out. Employee choice not company. Colleges already requiring freshman have insurance. No written control on allotted increases? 5%, 8% 22%, once established raise it all you want? Who pays lawsuits? Who pays lawyer fees? Who pays for schooling of doctors? There is not a single business in America that the government dictates price and salary over, how are you going to ratify this in the courts? It's unconstitutional! There has not even been a cap on tort law payments. The administration actually sees the 35% profits of insurance companies as a way to siphon money. So good luck with that. Government wants to run this, then use it to take over all insurance, then leverage that into regulations and enforcement over all business and of course eventually dictate of FEDERAL LAWS for who gets to do what.

[WinterParkMom]

47 million un insured
20 million under insured
Subtract 10 million poor/indig­ent/mental­ly ill, etc, who are uninsured and will have to get free care = 37 mill un-insured who can pay.
18.5 million can pay $50/mo = 925,000,000
18.5 mill can pay $100 = $1,850,000,000
20 mill under insured will switch and can pay $100 = 2,000,000,000
That is a grand total of $4,775,000,000
That is FOUR BILLION, SEVEN HUNDRED SEVENTY FIVE MILLION DOLLARS IN PREMIUM PAYMENTS PER MONTH. FIFTY SEVEN BILLION THREE HUNDRED THIRTY MILLION PER YEAR IN PREMIUMS FOR ONE SET OF PEOPLE.
That does'nt count the millions who'll switch from private companies if they can pay $100 or 200 per month and have their entire family covered even with pre-existing conditions. Repeal bush tax cuts asap another 700 billion.
After thinking about it more, institute a 1 penny federal sales tax on EVERY item. I can hear the opponents shouting about making the poor poorer, but my statement is 1 cent on each item NOT on every dollar or hundred dollars. From candy bars to big screen tv's to your house. 1 cent on everything. If your grocery bill was $100. for 53 items, your bill would be $100.53. That's not putting people in the poorhouse especially when we've been dealing with price increases. Also, if you're saving 300-500 per month on insurance, you have that money to spend and put back in the economy, save, or invest

[LaurenMarie984]

But, gee. That might ruin those poor corporate insurers and we wouldn't want to see the little guy get the shizz end of deal.......

*faved*

[jmpurser]

This has been the game all along. The "public option" was not designed to deliver health care reform. It exists solely to give cover to the people who want to kill single payer. The "public option" is not funded by the government (beyond the start up cost) nor is it available to the public. If it were it could become single payer and everyone involved has sworn that will never happen. Beyond that it won't really be "optional" either since everyone will be forced to buy insurance. That's right, the "public option" is neither.

So even the robust, strong, super powered, cuter than a puppy, minty fresh breath, whiter than white, zippity do dah, "public option" with a cherry on top is going to be a pale, sickly little thing designed to sneak a giant corporate welfare plan through congress.

That's all it has ever been and all it will ever be.

If you want real health care reform I suggest you start yelling for single payer as so far a national health service plan isn't even being talked about.

[TXfemmom]

I am disgusted with the Dems. I sent a bunch e-mails and told them to stick to their guns, grow a spine, and to come up with some way to SCARE the Blue Dogs and enough to put an effective public option into play which would be effective in six to nine months.

Said the same thing to the President. There are many ways to intimidate these Blue Dogs. First, tell them if they do not at least go along with blocking a filibuster, that the Dems shall introduce a bill which makes it impossible for any State to receive back from the Federal Government any assistance which exceeds the amount they send to the Federal Treasury. Since virtually all the Blue Dogs and many Republicans come from those states which are, in essence, WELFARE STATES, and receive back far more than they send, this WOULD HIM THEM WHERE IT HURTS.

They have to fight, be willing to dig in and HURT THESE PEOPLE IF THEY ARE WILLING TO HURT THE COUNTRY.

[vanmungo]

What do you mean by an "effective" public option"? Who is proposing such an option? Which bill? Please be specific, and don't let yourself be bamboozled by this empty marketing phrase who meaning seems to be different for each person who uses it.

The sad reality is that even WITH the lobbyist-approved, shrunken public option being peddled by the Democrats in HR3200 and the Senate HELP bill, we will have no reform.

Their shriveled version of the public option is nothing like Medicare. Unlike Medicare, it will be self-sustaining, not publicly funded; unlike Medicare, it will charge premiums and impose deductibles, making it unaffordable for the tens of millions most in need of help; unlike Medicare, it will have to negotiate provider fees on the same footing as HMOs--so no cost saving there, no cost savings of the single risk pool of single payer--according to the CBO, no cost savings period.

And no significant expansion of coverage, because it will be open only to those not already covered by employers, and even for them not until 2013! This is a gift to the HMO lobby, pure consumer fraud-- a public option that is neither really public nor an option for most people!

See "Bait and Switch: How the Public Option Was Sold"

http://www.pnhp.org/blog/2009/07/20/bait-and-switch-how-the-%E2%80%9Cpublic-option%E2%80%9D-was-sold/

[Chironomid]

Time to kill the whole idea, let the misery build and boil for another 5-10 years until it reaches the point where people are 1) ready to DEMAND something substantive and 2) ready to stop believing 5th grade lies about something so fundamental and obvious.

Sorry to 90-180,000 people who will die unnecessarily over that time. And sorry, too, to the Democratic Party who, if they don't pull their butts out of this fire and get this done right and right now, will never see my vote again and, I suspect, many millions of others.

[jmpurser]

I hate to say it but I think you might be right. What a horrific price to pay for a lack of human decency and common sense.

[JDM73]

Good Lord! Are people just waking up to this *now*? The text of HR3200 was made public in...what, early or mid-July? Yes, it's true. The public option would not take effect until 2013; it would not be made available to everyone; it would pay Medicare rates only for the first three years.
This is what you get for being so easily distracted and so uninterested in specifics, America. And this is what you get when you settle for less than single payer, universal care.

[vanmungo]

There is no excuse for Dr. Feldman to have been so uninformed about what's behind this slick marketing phrase "public option." All he needed to do was read the relevant portions of the bills.

As Dr. Feldman has belatedly discovered, even WITH the lobbyist-approved, shrunken public option being peddled by the Democrats, we will have no reform.

The shriveled version of the public option is nothing like Medicare. Unlike Medicare, it will be self-sustaining, not publicly funded; unlike Medicare, it will charge premiums and impose deductibles, making it unaffordable for the tens of millions most in need of help; unlike Medicare, it will have to negotiate provider fees on the same footing as HMOs--so no cost saving there, no cost savings of the single risk pool of single payer--according to the CBO, no cost savings period.

And no significant expansion of coverage, because it will be open only to those not already covered by employers, and even for them not until 2013! This is a gift to the HMO lobby, pure consumer fraud-- a public option that is neither really public nor an option for most people!

Dr. David Scheiner — a single-payer advocate and Obama’s personal physician for 22 years — said, “It’s a bad bill. No bill is better than this bill."

See "Bait and Switch: How the Public Option Was Sold"

http://www.pnhp.org/blog/2009/07/20/bait-and-switch-how-the-%E2%80%9Cpublic-option%E2%80%9D-was-sold/

[mcmchugh99]

They are fumbling on this in a way LBJ, FDR and Truman would never have allowed. They must be rolling in their graves at what the Democratic Party has become under the Clintonite generation.

They could have made life much simpler for themselves if they had just said they were going to expand Medicaid and open up Medicare to anyone under 65 who needed it.

And yes, the August recess damaged them, as the Republicans intended all along that it should. Let that be a lesson to them in any future efforts to pass "bipartisan" reforms. There will never be any bipartisan reforms in this decade.

[calirighty]

Public option or no public option, 2013 is when everyone would be insured. According to H.R. 3200, only those without insurance now would be initially covered. The rest would have to wait until 2013. Libs keep blasting conservatives for "blocking healthcare". To date I have not seen one single proposal from the Democrats that is reasonable. 2013 is unacceptable.

[vanmungo]

Sorry, you are wrong about this. NO ONE would be eligible for the so-called public option (neither really public nor an option for most people) until 2013, and then only those who are not already covered by private insurers, Medicare, or Medicaid would be eligible.

So it's even worse than you portray it to be.

People need to shed their illusions about the corporate-owned Democrats and join up with some of the independent organizations fighting for Medicare for all:

http://www­.1payer.ne­t/
www.singlepayeraction.org
http://www.healthcare-now.org
http://www.guaranteedhealthcare.org/

[ouroborous]

One word: HR676.

Medicare for ALL.