In January of 2009 the Democratic Party, having won big majorities in both Houses of Congress, took over the 111th Congress of the United States. The Democrats had very large majorities in both Houses. In the House, there were 255 representatives caucusing with the Democrats for most of that session. In the Senate there were 59 caucusing with the Democrats for much of the session, and the caucus reached a high water mark of 60 Senators for about 6 months during 2009.
By comparison, in the current 115th Congress, Republicans have 237 members in the House, and 52 members of the Senate. So, in 2009 – 2010 the Democrats could have passed legislation in the House, while taking 37 defections from their caucus on a particular bill, compared to the Republicans 19 defections now. In the Senate, the Democrats could have taken 9 defections from their caucus and still passed the legislation, while the Republicans can now take only 2.
In brief, the Democrats were in a much more dominant position to pass what they wanted in 2009 – 2010 then the Republicans are now, especially when one considers that they had a popular president supposedly on their side, while now the Republicans have an unprecedentedly unpopular president available to support their efforts. Yet in 2009 – 2010 the Democrats were incapable of passing a popular health care reform bill.
Instead, after more than a year of unnecessary struggle, Democrats passed the Affordable Care Act (ACA). In the run-up to the elections of 2010 and afterward, the ACA notoriously fueled the rise of the tea party, as part of a widespread reaction that led to Democrats being swept out of the House in 2010, losing a number of Senate seats as well, and state legislatures and governorships all over the country. The catastrophic loss exposed them to the gerrymander in a decennial year, contributing mightily to House losses in the 2012, 2014, and 2016 elections, and finally to the loss of control of the Senate in 2014 followed by the failure to comeback in 2016, a year when the electoral Senate map greatly favored their party, as well.
So, the grand effort to pass the ACA was one the most egregious examples of political malpractice in the history of the United States. The bill used up an enormous amount of political capital for the Democrats and it has continued to cost them right up to the present.
To add insult to injury, the Act has been a failure. It was supposed to expand coverage to 33 million people; but it only expanded coverage by 20 million, and is now threatened by a bill that would, according to CBO, result in more than that number of people becoming uninsured.
In addition, as a consequence of its failure to end lack of insurance, also left us with 30,000 in avoidable fatalities due to lack of insurance. But because it failed to become popular, its replacement by a new Republican bill, is likely to result in an increase in avoidable fatalities to over 60,000 annually.
Also, though it promised affordability, after an initial period when health insurance prices rose much more slowly than in the past, over the past couple of years, as the insurance companies realized that they would get to insure fewer people than planned, prices are on their way up, with frequent reports of seemingly outrageous jumps in insurance prices and also in pharmaceutical costs.
Even now, Democrats, and those among them who call themselves progressives cannot brag about the achievements of the ACA with any kind of credibility. After 7 years since ACA passage, insurance is still far from affordable for increasing numbers of people, and there is a problem of quality in the services offered by the narrow networks of physicians provided by the insurance companies. As a result, the best the Democrats can say about passing the ACA is that passing it was better than passing nothing at all.
But this point is highly arguable, because it is a really a variant of saying that the ACA world is the best of all possible worlds up to this moment. But that was never true.
The ACA outcome was shaped by the strategy and tactics the Democratic leadership, and the President chose to follow in 2009 – 2010. That strategy was to abandon the bill that nearly 2/3 of voters wanted in 2009 in favor of taking the vague notion of “the public option” as a strategic goal, and then, on the so-called “pragmatic” theory that a bill of any kind was preferable to no bill at all, they met every difficulty the bill encountered with pre-compromises and compromises, finally leading to a bill based on a neoliberal market model of health insurance.
In the negotiation process they gave away even their pet public option trick sparkle pony – the distraction from Medicare for All that prevented their appealing to the public at large for support in getting HR 676 passed early in 2009. Eventually, their herculean negotiation efforts resulted in the ACA and in the 356,000 fatalities due to lack of health insurance that would not have occurred had they passed HR 676, Medicare for All, by using a direct popular appeal/steamroller legislative strategy to pass it by the Spring of 2009.
The Democrats had the votes to do that with strong leadership. But both their President and Congressional Leadership were neoliberal in character and actually preferred a market-based bill to bail out the insurance industry to the type of bill 2/3 of Americans wanted, including most of their own Party.
Enough of this rehearsal of the sad past of 2009 – 2010! Now, in the wake of the Republican failure to pass their own health insurance catfood bill due to a disagreement between those Republicans who wanted the lowest quality of catfood for Americans and those who were satisfied with a bit higher quality, we see a rejuvenated progressive movement.
Awakened by the departure of Obama, the inspiring presidential run of Bernie Sanders, and the reaction to the establishment Democrats rigging the primary in favor of Hillary Clinton and setting the stage for the popular vote-losing President Trump, the new progressive movement is calling for a National Improved Medicare for All Act (NIMA) now. However, there is confusion in the movement. Bernie Sanders, who was a strong clear voice for Medicare for All in 2015 and 2016 is now beginning to mention once again the public option trick sparkle pony as an alternative to it, at least in the short term.
For a short time there was even speculation that he might introduce a public option bill into the Senate on grounds that Medicare for All can’t happen now due to Republican control of both Houses of Congress. However, since then, Bernie has walked backed the talk that Medicare for All cannot happen now, and has confirmed that he will introduce a single payer, Medicare for All bill into the Senate, probably in May. That is good, but it underscores the need for a Medicare for All movement to create a groundswell so powerful that we drown out talk of a public option by Democrats.
We’ve been down this road of “pragmatic” pre-compromise before. We’ve seen that abandoning Medicare for All as the firm goal of progressives leads to a loss of support for our movement, for health care reform during the fight for it, and eventually to lack of faith in progressive movements and their ability to produce good outcomes for people.
It may be true that we will fail to get Medicare for All passed during this Congress and the Trump Administration, but withdrawing from our goal must not be our doing. It must be the clear responsibility of the Republicans.
Most importantly, we cannot allow a bill to pass that retains the structural characteristics of privately – managed, manipulated market health care, and that allows people to keep dying, and going broke, and losing their houses and families due to lack of insurance, or to having insurance that leaves them fighting or experiencing bankruptcy. Such a compromise is simply unacceptable in view of our experiences since 2009, when we might have ended this neoliberal regime in health care.
It is better to lose the fight this year, than to accept a compromise that does not alter the structure of delivery of health care, because if we do accept such a compromise the momentum behind further reform will be sapped while people wait to see how the new law will work out. That is what happened when the ACA was passed and that is what will happen again with a public option as the Republicans negotiate the life out of it with the compromises they extract from Democrats and progressives, while progressives strive for any bill that may provide incremental improvements for the 99% compared to what they have now.
Let us not be fooled again this time. Let us not follow Bernie or anyone else down the public option trick sparkle pony rathole just to see a measure of miniscule progress toward universal health care at any cost. That will not satisfy people who are ill and dying, and also suffering economic collapse and degradation. So, let us hear no more about the false promise of the vague term “public option” whose meaning is hard to know and whose symbol allows for a myriad of marketing campaigns favoring the public option flavor of the week that somehow gets more and more tasteless as the negotiating process in Congress wears on an on.
No, let us not do that. Let us make our maximum effort to pass HR 676, preferably a revised version of it that does not raise taxes over present levels to pay for it, and that just lets the Treasury use the tools provided to it by Congress to get the Federal Reserve to fill its spending account to the degree needed to spend the Congressional appropriation for Medicare for All. If we lose this fight then those who favor Medicare for All can run on that in 2018 and win at that time, contributing to a sweep that can get HR 676 passed over the President’s veto, if necessary, or at least set the opponents of HR 676 up for a crushing loss in 2020.
Think about it. The compromises of 2009 and 2010 have cost hundreds of thousands of lives and many more damaging side effects of various kinds while postponing decent health insurance reform legislation for the better part of a decade. If we fail now, however, we can probably succeed in just two or three more years.
But if we accept a compromise bill with the Republicans, then how many more years will it take to pass a Medicare for All that can end the destruction caused by lack of insurance. Would we have to wait for 2025 to get to Medicare for All; or even later to end the evil of private market-based insurance?
Would we end up having to wait for 16 years of more since the golden opportunity of 2009 was wasted through wonky cynicism, lack of courage and faith, and plain selling out to corporate interests? I believe we would. And that is why I think we need to give it our all now, and then again and again until we get to the only viable place – ending the murders by spreadsheet!
During 2009 I blogged quite a lot in the fight for health care reform. In the course of that blogging, I wrote two posts in particular that make very clear why the political process we will enter if we end up trying to get a public option passed is a failure process for progressives. Below, I’ve reproduced them in full, with some minor changes from the 2009 version.
You need not read these additional posts if you don’t want to. But if you still doubt my conclusion that we ought not to follow any leader down the public option rathole, and if you are still unsure about the kinds of pitfalls that we would face during a PO negotiating process, then I urge you to read these posts. I think they will be well worth your time, and you will understand why I feel that even mentioning the public option is folly for us.
It’s important to sharply distinguish strategy from tactics in health care reform. I think strategy is about your goal and overall orientation toward getting health care reform, while tactics are about the low-level things you do to get from point-to-point in getting the strategy implemented. Tactics are influenced by strategy in the sense that tactics need always to be evaluated from the viewpoint of whether they advance strategy or not. If they don’t they’re counter-productive and need to be put aside in favor of other tactics.
In my view, much of the health care reform movement made a great strategic error in this fight. And that error was to make the strategic goal a Public Option (PO) solution, rather than to make it a Medicare for All solution.
That error has shaped everything else that much of the health care reform movement has done for the last year, and is the one thing primarily responsible for the sorry outcome we have on our hands now in both Houses of Congresses. I think we have to learn from the experience of the past ten months and stop boosting the PO, even a very strong PO, as if it were a strategic goal.
Medicare for All, should be our standard, and we should evaluate our success or failure in political activity by how far we’ve moved the ball toward this goal, not by how far we’ve moved the ball toward getting a PO. The PO, even a Jacob Hacker-type PO, is at best a tactic relative to the overall strategic goal of getting to Medicare for All.
We should never forget that, or let other people forget that. Since it is a tactic, we should be treating it as a tactic that gets us to Medicare for All in a short time, not something we resort to in order to overcome blocking or resistance, not something we pre-compromise on, before even testing the strength of resistance to our efforts to get something better.
I think, also, that treating the PO, as if it were our strategic goal, was a very bad choice. It did not elicit the limited opposition and pragmatic, but useful compromise for our side, that many progressives anticipated, and talked about as a benefit of going the PO route, and its messaging has been, and still is, horribly confusing and disingenuous. It has elicited all kinds of fears from the public that Medicare for All would never have elicited.
Since tactics are not independent of strategy, but are always shaped in the context of it, adopting the PO as a strategic goal shaped our tactics by constraining us from doing some things. We could never call on a mass movement to support us in getting health care reform, because who can really get excited over a PO that won’t produce universal coverage?
We could never develop simple messaging that was honest, because all the simple verities about stopping the fatalities, providing universal coverage, making things really affordable, and really saving money for the country, don’t really apply to the PO plans we’ve been seeing in House and Senate bills. Even now, nearing the end of the current legislative process, we are seeing simple messaging about the great “victory,” a bill with a shrunken PO that is not honest, since it greatly exaggerates the expected positive effects of PO legislation, while ignoring its many downsides.
The kinds of claims we are seeing now from Democrats in Congress would be honest justifications for Medicare for All, if Congress were passing HR 676, but they are dishonest ones for the PO plans we are seeing in HR 3962 and Harry Reid’s new Senate compromise. And who can get excited and fight hard while using messages that you know are not true?
Maybe conservative apparatchiks can do that, but progressives find that very hard. They need to believe in what they are doing, and what they are saying.
I agree with Jane Hamsher that Medicare for All supporters, ought to ask what they could have done differently to have produced more success for their favored alternative, but I think an important related question is what can Medicare for All reform advocates do differently now? What can give a different result that is closer to the strategic goal we’re pursuing?
And I think the answer to that at the level of high-level tactics is that we have to build a mass movement in the background of what we do day-to-day, because without that we aren’t going to get Medicare for All through the Congress. Some groups out there are trying to build that movement, and it may be gaining steam.
This terrible health care reform bill will fuel the movement for Medicare for All, whether or not it passes, but realistically, I don’t think that movement will be a factor for a few years at the earliest. So what do we do now day-to-day?
I think we ought to pressure progressive politicians in the House and the Senate to become movement politicians. Movement politics is different from conventional politics, and movement politicians often have to use different tactics because they are trying to get principles adopted, and so they have to defend those principles, and not easily compromise them except perhaps at the end of a lengthy legislative process, when there is no other alternative, and they can get something very, very valuable in return for the compromise.
It’s important to get people to understand that movement politics is not about not compromising. Instead it’s about not pre-compromising, or abandoning one’s strategic goal, or making compromises that mortgage the future of movement possibilities. One of the worst things about the current House bill is that it risks wholesale rejection by the public of the very idea that support of progressives and Democrats can really help them against the insurance companies, and in getting affordable health care.
That’s why this bill must be killed. It has been oversold, and the backlash from it is very dangerous to the whole health care reform movement.
We need to persuade, cajole, urge, threaten, and organize their constituents to get our Congress people to become movement politicians. We have to call on them to believe again, and rip the hell out of them when they act as if they don’t.
When they produce a piece of crap legislation we need to not be balanced and moderate in cataloging the pros and cons of the legislation in two matching lists. We have to evaluate their legislation from the point of view of the principles and strategic goals of our movement, and we need to call a spade a spade if their legislation gives up core principles, gets us no closer to our strategic goals, and even falls short from a moral point of view.
Progressive politicians in Congress are not acting like movement politicians who are coming from principle. They are acting like politicians trying to get something, anything, done at any cost as long as it carries the health care reform label.
This may seem practical, because “the perfect is the enemy of the good,” and they don’t want to go against their leadership and their President, but in the long run, it’s a tactic that won’t get them and us to Medicare for All, because a) it makes them look like corrupt politicians, and b) no one will take Medicare for All seriously, unless its advocates are willing to make everyone pay a price for trying to marginalize their strategic goal, and laugh at it in the legislative process.
The first thing for Medicare for All advocates in Congress to do is to defeat any other health care reform bill that either 1) doesn’t provide a clear possibility of getting to Medicare for All in a reasonable time, or 2) threatens the political prospects for getting further reforms that will provide that clear possibility. There are currently, 87 co-sponsors of HR 676 in the House. That many representatives would have blocked any health care reform bill that wasn’t Medicare for All the first time around if they were playing movement politics. Unfortunately, they were playing at merely symbolic stuff – kabuki, in their co-sponsorship, not making a real commitment to HR 676.
Had those progressives put themselves on the line and made the leadership and the Administration taste defeat for trying to marginalize HR 676, people wouldn’t laugh at Medicare for All, or progressives anymore. Instead the leadership and the Administration would start to bargain, and the progressives would have had an opportunity to drive a hard one. That bargain could have ensured 1) or 2) above, even if the resulting bill was no more than something like ending all insurance company abuses and stopping there, leaving the future unconstrained for a much more effective health care reform bill than we are contemplating now.
In writing all of this, I’m painfully aware of not answering the question: “yes, but what do we do right now?” I think the answer to this is implied in what I’ve already said. It is to do everything we can to kill the bills now emerging from the House and the Senate.
First in the Senate, and if that fails, then turning again to the House to once again try to get enough of the progressives to stand up to the leadership and vote against it, when it comes out of conference. For health care reform that won’t mortgage the future, we need to kill these bills, and in the process we need to get the Democrats and the progressives to stop being less than honest about what they do and what they don’t do. Then, when the leadership and the Administration goes back to the drawing board, which they certainly would very soon, we would need to go back to HR 676, not compromise until the end of the process when the leadership and the Administration need progressive votes to put it over, and then adhere to principles 1) and 2) above in negotiating any compromise.
If we do these things, I think we’ll get a much better bill than we have now. It won’t be perfect, since “the perfect is the enemy of the good,” and nothing in this whole health care reform debate has been “perfect.” But even though it will fall short of perfection, it will be much closer to being “good” than what we have now.
And the truth is that what we have now is not just “not perfect.” It is not good at all. It leaves too many to enjoy that well-known Republican solution to health care: “Don’t get sick. But if you do, then die quickly.”
Many progressives, even though they’ve been working for a PO-based health care reform bill, have 1) never given up Medicare for All as the goal of their activity, and 2) decided, in the first quarter of 2009, that Medicare for All could not pass the new Congress. They then reacted to their realization by concluding that since Medicare for All couldn’t pass, they would not advocate for it anymore politically, but would transfer their activist commitment to getting a strong public option.
Last Spring, they had in mind a Jacob Hacker-type PO, which they saw as the road to Medicare for All. So, in short, they took Medicare for All off the table as something to push for, and they did so because they thought the impossibility of its passing was “reality.”
In my other life, in the field of Knowledge Management, I sometimes work on the idea of reflexivity, a favorite notion of George Soros’s, and also on complex systems, a field having to do with the rise, maintenance, and fall of various types of systems, including human organizations of various kinds. Both of these notions are closely related to the idea that to some degree at least we make our own realities, or, as some in systems theory put it, we constantly “bring forth our world.”
One of the things we mean by this is that, to some degree, and especially in social contexts, we and others help to make our own reality. Social reality is not given to us, so much as we contribute to making it ourselves. In turn, this means that our futures are not pre-determined for us, and that, in particular, there is no pre-set future social reality, but rather there is only the reality that we, in concert with our fellow humans, make.
Now, getting back to the thinking pattern of a lot of progressives in the Winter and Spring quarters of 2009, we can see that they decided that a social reality in which Medicare for All was feasible by the Summer or Fall of 2009 would never occur, and as a result of that prediction, they decided not to advocate for it anymore in this round of reform, but to advocate, in just as determined a way, for Public Option-based legislation, because they thought that it was the best that progressives could possibly hope for in the short run, and, many of them thought, it might lead to single-payer over 5 – 10 years anyway. They set about creating, in other words, a social reality of reform with a robust PO.
They may well have been right about their prediction of the fate of Medicare for All, but I think they made a mistake when they concluded that just because Medicare for All was unlikely to happen in the short run, they ought to give up pushing for it, and instead concentrate their political activity on pushing for a “robust” PO. I think this because, in deciding to take Medicare for All off the table, and working for a PO instead, they have brought forth a world in which the robust PO that was their pre-compromise position proved hard to communicate, became the left wing of the political spectrum of recognized possibilities, and the focus of attacks from the insurance industry, and so gave way in the legislative/lobbying process to what is likely to be at best a reform with a very, very weak PO, or even a “trigger,” that they must really bite their tongues to continue to support.
By committing to tactics of explicit advocacy of a robust PO, aimed at bringing about legislation, they set themselves on a path where the judgment that they needed as robust a PO as possible, always implied continued explicit advocacy of a robust PO at every stage of the legislative/lobbying process, regardless of the degree of defeat suffered at the preceding stage. When the most liberal House and Senate committees came out with disappointing bills that were quite far from the original idea of a robust PO, and had a completely unacceptable band-aid period, during which the majority of the deaths, bankruptcies, and foreclosures due to lack of health insurance would continue, they believed that they had to react with support of the best of those bills, because they offered the best available PO on the continuum of robustness. When the committees merged their bills, and even though the result fell far short of their original pre-compromise, there was nothing to do, they thought, but support and redouble efforts to prevent further erosion in the PO.
When similar things happened in the Senate, progressives had similar reactions when it came to lobbying activity. In each case where there was disappointment, the progressives revised downward their notions of what was possible, and prepared to bring forth a world with a weaker PO-based reform. Each time they did that, they took action that was part of a more global process that led to an even weaker PO. This process is a classic example of reflexivity: one’s judgment of what is possible leads to one’s choice of action, which impacts a later judgment of what’s possible, which impacts one’s choice of a similar action as before, and so one goes round and round in a deflationary cycle that ends with action defending a PO-based reform that is only a shadow of what one started out to support.
But, going back to the first step, why did progressives conclude that since Medicare wasn’t possible in the short-run, but the public option was, that, in this round of reform, at least, they ought to advocate for the PO explicitly and directly, and push as hard as they can to get as robust a PO as possible? This certainly seems like the commonsensical, and straightforwardly rational thing to do, but it clearly wasn’t, because it drew them into a reflexive downward spiral of decreasing PO robustness within every stage of the legislative process, until now they are facing a PO predicted to enroll only 3 million people, or perhaps even “triggers,” which won’t be operative until 2014, which may allow state opt-outs before the exchange and the PO are operative, and which may even contain the Stupak anti-choice language.
What progressives could have and should have done instead, regardless of what they believed about the ultimate feasibility of getting it passed, was to have taken the seemingly completely irrational course of refusing to take Medicare for All off the table, mobilized the 87 co-sponsors of HR 676, and insisted that they would defeat any reform bill that wasn’t HR 676. Had all progressive movement groups held to that position, and all progressive legislators too, and loudly announced that they would oppose, and vote against, all committee bills that weren’t HR 676, and loudly announced, as well, that Nancy Pelosi’s synthesis bill had better be HR 676 if she wanted their votes, they would have brought forth a completely different world, an entirely different reality this Fall.
Imagine if, at the first stage of this process early in 2009, the progressives had not agreed to take HR 676 off the table in the House and Bernie Sanders’s S 703 in the Senate. The first thing that would have happened is that the MSM and cable news would have talked about Obama’s rebellious Party ideologues who were contradicting all the tenets of pragmatism, who were allowing the perfect to be the enemy of the good, who were insisting on single-payer, and who were refusing to accept his leadership and undermining his newly-elected authority.
Since this opposition in the ranks would have been big news back in January and February, the progressives would have gotten interviews. Single-payer, enhanced Medicare for All, would have been presented to the broader public back then. It, and not the PO, would have been touted as one of the main reform policy positions, even while it was also characterized as the ideologue position.
The support for Medicare for All in Congress, however, whether ideological or not, would have connected to a popular movement for Medicare for All, very early on, and enabled that movement. To avoid a fight with the progressives and lots of press articles about how ineffective he was being as a leader, President Obama might have concluded that the best way to go was to feed this popular movement, to find its leaders, to get them into the White House, and to help them to mobilize the public in favor of Medicare for All.
Why would he do that? Because every good politician knows that when the crowd starts to move, you need to get out in front of it, if you expect to have any control over it at all. The crowd needs to trust you as one of its leaders. And after all, any health care reform bill is a great victory for his Administration, even if it destroys the insurance companies as a viable political force that can’t provide campaign contributions either to Democrats or anyone else.
The insurance companies would have fired on Medicare for All very early, of course, and the pharmaceutical industry too. Both would have attacked it as “socialized medicine.” But everyone knows about Medicare because their grandparents and parents have it, and 86% of them like it.
People know that it’s not socialized medicine; but only Government-funded insurance. It can be easily communicated to them that if Medicare for All is enacted, they won’t lose their providers, but only their insurance companies, which a heavy majority of them hate and mistrust anyway.
What about the polls? Well once the MSM had made the very early progressive insistence on Medicare for All, a popular narrative, they would have included Medicare for All in their polling. In fact, there’s a good chance that their framing would have suppressed polling of the PO entirely, because the progressives would not have had it on the table, as something they were pushing.
Even if that had not happened however, both Medicare for All and a “Medicare-like PO” would most probably have polled 75% together, with Medicare for All itself at around 55-60%. That support probably would have been maintained throughout the Summer, because the tea bag movement would have had a lot more difficult time tagging Medicare with “death panels” and “Government takeover of medical care,” than they had doing that with PO-based bills that no one understood.
What about the blue dog and ConservaDem opposition in the House? With 55-60% supporting Medicare for All and 15-20% supporting the PO, the blue dogs and ConservDems would have had a hard time, proposing anything in opposition to Medicare for All, other than a Jacob Hacker-type PO. How many votes would they have had? Well, that would have depended on the President.
If early progressive stubbornness and the appearance of a popular movement had persuaded him to be friendly to Medicare for All, and get out in front of the movement, then the whole group of Congresspeople who routinely support a president of their own Party would have come over to Medicare for All. Adding that group to the 87 progressive co-sponsors of HR 676, one would probably have been looking at 200 votes in the House. Not enough to pass Medicare for All, but getting close.
In a situation like this, and assuming the same “no” behavior we see now from the Republicans, the result, with some leadership and heavy presidential pressure, would be that either Medicare for All would have passed the House in a close vote, or a compromise with the blue dogs on a strong Hacker-type PO would have emerged behind closed doors as a compromise. In this scenario progressives would have had to compromise only once, at the end of the process, and there would have been no need to sell the PO idea to the public, except as the best alternative possible to Medicare for All itself.
What if the President wouldn’t back Medicare for All, but maintained neutrality from the House proceedings, while saying, in typical Obama fashion, that, in principle, he agreed with it, but . . . . That would still leave the Presidential Party in the House as the arbiter between the blue dogs and the more numerous co-sponsors of HR 676. If the partisans of HR 676 stood very firm, the most likely outcome would again be a very strong PO, much superior to what we have now.
How about the Senate? Well to reasonably project what might have happened there, I think we first have to forget about the political landscape we see now, because an alternative landscape in which the House progressives insisted on HR 676 until the very end of the process, would have been very different from what we see today. One difference would have been that progressives in the Senate would have seen many representatives in the House standing up for Medicare for All, and also an external movement, good polling for Medicare for All, and much better press coverage for it than we see now. Cable news commentators like Chris Mathews, Ed Schultz, Keith, Olbermann, Rachel Maddow, and Dylan Ratigan would be covering it far more than they are now, as would various commentators on CNN, and Fox, though in a much less complimentary way. Finally, netroots commentary would have been much more frequent and much more complimentary than it has been.
If the President aligned with the House progressives and the movement, then Senate progressives, and presidential followers in the Senate would have been much emboldened to follow the House progressives, and most probably more than 40 Senators would have fallen in line in back of Medicare for All; not enough to pass the bill, even through reconciliation, or through using the nuclear option. Nevertheless, those votes would have been enough to guarantee a much better compromise bill emerging from Senate negotiations, especially if Harry Reid made it clear that health care reform would not be subject to the regular order in the Senate, and that extraordinary measures would be used to pass a reform bill.
With only 10 Senators, none of whom were the most extreme blue dogs and Conservadems left to bring over, I think the likelihood would have been very good, if the progressives held very firm, that a compromise on a Jacob Hacker-type PO would have been negotiated in the Senate too, and one without a band-aid period before implementation.
What if Obama stayed above the fray, beyond endorsing Medicare for All in principle, to accommodate the movement? In that case, there would still be roughly 20 votes for Medicare for All. With the House progressives standing firm for HR 676, and a Medicare for All movement ongoing, these Senators would have done the same, and no health care reform bill could pass without accommodating them.
On the other hand, their hand would be weaker than in the first scenario, because the Senators who primarily support the President, would be less supportive, more neutral to Medicare for All, and more interested brokering a compromise deal with the remaining Senators needed to get to 50 votes so that reconciliation, or the nuclear option, could be used to pass a health care reform bill.
Nevertheless, stubbornness, on the part of Medicare for All supporters would still have worked to get other Democrats to move toward at least a strong PO-based bill, without a band-aid period, because the alternative is no bill at all, and blue dogs and the White House cannot abide that. The result would have been a much stronger PO-based bill coming out of the Senate.
With a Jacob Hacker-type PO bill coming out of the House and a weaker, but still very strong PO, coming out of the Senate, the Conference Committee would have produced a bill very close to Jacob Hacker’s original design. That’s still not Medicare for All, and progressives whose goal is such legislation would still have had work to do in the future. But the result would have been far better than we are looking at now; both for those who prefer Medicare for All, and for those relatively few who prefer the PO in principle.
Finally, why have I constructed this narrative of what might have been, if only the progressives had concluded that the likely eventual defeat of Medicare for All, did not entail that they should stop advocating for it, and pressure only for a public option based reform?
First, because I wanted to make it clear that whether or not Medicare for All is possible to pass in a given legislative session, doesn’t determine whether we ought to do all we can to advocate for it or seek it. What does determine that, or at least should, is an accurate assessment of what the consequences of continued advocacy and pressuring for it are likely to be.
Nor, is the seeking in such a situation merely just symbolic. It can have a variety of practical effects including: a) educating people about what Medicare for All might mean; b) influencing the context of the legislative process producing health care reform; and c) influencing and shaping the actual negotiations affecting that process.
Second, I wanted to sketch out the reflexivity trap progressives had gotten themselves into when they adopted the PO-based strategy for getting health care reform. Since a PO-based reform is a vague and ambiguous concept, that represents a moving target for reform, many different positions on the continuum of robustness of PO – based plans exist, and this reality of many choices that might fit the idea of the PO, fits perfectly with the many stages a bill goes through in our legislative system, to produce a de-generative spiral of gradual weakening of the PO as the process moves through its successive stages. The PO concept was tailor-made for gradual watering down in the crucible of legislative conflict, and commitment to it in the abstract by progressives, condemned them to a reflexive process that resulted in this gradual weakening of the PO, until the possibilities we see today were created by the progressives’ own PO advocacy-guided interaction with other parties in the process.
Third, I wanted to make it clear that progressives contributed vitally to the outcome we have now, by their choice to enter the reflexive process of getting the PO through the legislative process, while accepting as their goal trying to get the best PO-based plan they could at each stage of the process. As soon as they committed themselves in this way, they committed themselves to defeat and failure. They could have created a different social reality by just insisting on Medicare for All and refusing to enter negotiations on the type of PO that would be accepted as a compromise until the very last stages of the process. But they didn’t try this, because they were afraid of working against their new President, or of being marginalized as ideologues, or of engaging in a protracted conflict with their fellow Democrats.
And fourth, and last, of course, I wanted to try to prevent the lesson of the process we are currently still engaged in from being misconstrued. That lesson is not that the United States is not ready for a robust PO-based plan right now, and that we must keep trying to fight for one in the coming years and educating the public about what the PO is.
That is the wrong lesson, because it is a trap. It is a trap that results in 2000 page compromises full of loopholes. It is a trap because it involves endless negotiations about the precise variation of the PO idea that will be enacted. It is a trap because it opens legislation up to band-aid periods in which we fail to end deaths, bankruptcies, and foreclosures due to lack of insurance coverage, and to endless negotiations about which parts of the population can enter the exchange and have access to the PO, and which cannot. It is a trap for countless other reasons as well.
The right lesson for progressives to learn now is that the present bill must be killed, because it is a terrible bill which makes the future worse, as I’ve argued here, here, here, and here. And, once it is killed, progressives also need to forget about advocating for the PO. The PO is not a goal, it is not something that can stand alone as an ideal that will excite people. It is a second-best tactical solution that we can accept only as an outcome that emerges at the end point of the legislative process, and only if Medicare for All, after all of our most intense efforts, can’t get through that process.
We cannot seek the PO in the context of an incremental legislative process, and expect to be successful. We must seek and work for, and move heaven and earth for, only Medicare for All, whether we believe we can pass it or not, and then, if we do fail to pass it, we must be prepared to use the desire of others for any reform bill, to compromise just once on a Jacob Hacker-type public option, without entering a multi-stage de-generative reflexive process that will kill the PO as an instrument for getting to Medicare for All.