Health reform will do a lot of things that most Americans don't realize it will do, and it will not do a lot of things that many Americans mistakenly believe it will do. One of the most recognizable components of health reform that didn't actually become law is the public option. The public option was the lighting rod in the health reform debate. After all, it had a concise name, and was easily talked about -- by both proponents and opponents -- whereas the other minutiae of reform are difficult for most people to understand. It was seemingly at the epicenter of the debate over government's role in our lives and our health care system, despite the fact that it might, some would argue, be the best chance of preserving our private insurance system.
But for all the attention it received, and all the attention it diverted from other aspects of reform, it didn't make it into law. The question is why not? How is it that a major piece of legislation -- one that succeeded where others had failed for decades -- was able to be passed, while a minor piece of that legislation received so much attention and had to be eliminated in the end? The easy answer is Joe Lieberman, but I don't think that's the full story. After all, the legislation wouldn't have cost significantly more with the public option intact, and it would have covered more people and given all Americans more, rather than fewer, choices. Well, perhaps that last point is debatable. Some felt strongly that the public option would have an unfair advantage that would lead to the collapse of the private insurance system and the implementation of a single-payer system. Maybe so. Of course, that ought only to happen if the people chose the public option over private insurance consistently.
What I think the fate of the public option demonstrates is the sharp distinction between policy and politics. You see, as policy, the public option makes a good deal of sense. Granted, it has not been implemented nationally in the United States, and therefore we have no real empirical evidence to demonstrate that it works, but we do have a sound understanding of economic theory, incentives, and markets that go a long way in predicting the outcome(s) of a public option. The public option actually draws on many -- but not all -- conservative principles. So, on policy grounds, at least some Republicans should have supported it.
But, on the other hand, we have politics. In that game, the "enemy" that is the other party cannot be allowed a victory, because even if the results are beneficial for the nation and its people, when the other side wins, you lose. The trick then, becomes to use politics, but make it appear like policy is the focus -- to blur the dividing line between the two. When the opponents of health reform latched onto the public option -- a piece of policy -- they did so for political reasons, and they didn't discuss the merits of the policy, but framed it with negative politics. Thus, the public option was "socialized medicine," a "government takeover," and a "threat to our private insurance system." These labels may evoke a visceral response, but what they don't do is articulate any specifics of the public option--what it would or wouldn't do. It's effective politics, masquerading as policy, and it works. In fact, it works so well that I firmly believe that you could take a cute puppy or newborn baby, call it "socialized medicine" and watch sizable groups of people shun it. It's a label--and while it may go nowhere in describing the content to which it is applied, it matters tremendously in determining how people respond to it.
And so it was with the public option. There were the strong supporters of a single-payer system who saw the public option as a major policy compromise made to navigate the politics of reform, and the strong opponents who painted the public option as the death of American capitalism to engender hostility among their constituents. But here's what I really believe: If the Republicans had been the ones to propose health reform, they could have included the public option without violating their public policy positions -- and they wouldn't have had to put up a nonsensical, albeit quite effective, political fight on that issue, because the Democrats would have welcomed the approach.
Note: This post was inspired by the article "The Origins and Demise of the Public Option" by Helen Halpin and Peter Harbage, which appeared in the June 2010 issue of Health Affairs.
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