Thursday, August 20, 2009

Pssst! My Negotiating Position Is Not My Real Position

I know I’m not supposed to say this. I’m supposed to say “the public option is non-negotiable! No public option, no health reform!”

I realize why I’m not supposed to say what I’m going to say. The people who are willing to walk away from a deal are the ones who have the negotiating leverage. I know this. But even though I really want to see the health care reform bill include the public option, I have this thing… I can’t help but blurt out the truth sometimes. And the truth is I wouldn’t dream of letting health care reform die just because public option wasn’t included. Why? Well, isn’t it obvious?

What would happen if health care reform failed?

  • Barack Obama’s presidency would be crippled. Any hopes of passing cap-and-trade, financial reform, or an immigration bill on our terms would be dimmed dramatically.

  • The Democrats would likely be punished in 2010. The last time a popular Democratic President failed to pass health care reform the Dems lost 54 seats in the House. A swing of that magnitude would give the Republicans the lower chamber again.

  • Health insurance companies would be able to continue to dump sick patients from their rosters.

  • Coverage would continue to be out of reach for those with prior conditions.

  • Lifetime caps and high out-of-pocket requirements would ensure that the endless march of healthcare bankruptcies continued.

  • We likely would not see another attempt to reform health care for a generation, if ever. 18,000 people die from lack of health coverage every year; extend that number over two or three decades and perhaps half a million people might die unnecessarily if we fail to gain universal coverage.

I’m not willing to pay this price. All these items could be avoided and reversed, even with a plan that did not contain a public option. Would a true progressive put an ideal bill above the pressing interests of 47 million uninsured? No, of course not. But we have to say we will!

Pretending that we are willing to kill health reform forces us to use unconvincing arguments sometimes. For instance, we say that if we don’t get the bill right this time, we’ll never get it right. This is baloney. Comprehensive health reform is extremely hard to pass: Truman, Johnson, Carter, and Clinton all failed at this challenge. There’s simply no evidence that tweaking health programs once they are law is nearly as difficult. S-CHIP has been repeatedly amplified and refocused, Medicare grew a prescription benefit, and Medicaid has been tweaked many times over the years, sometimes for the better and sometimes for the worse.

We also say that if we don’t pass the public option health care expenses will grow out of control and the Dems will be blamed for it, allowing the Republicans to roll back our reforms. Of course, the other side will try to blame us for growing expenses (and they will likely grow anyway, with or without the public option.) But what would happen with no bill at all? Many significant measures that would lower cost and improve quality – like comparative effectiveness research, more power to MedPAC, and health care IT expansion – would be lost. As for the idea that the Republicans would roll back universal coverage, I say this: Will. Never. Happen. No industrialized nation that has achieved universal coverage has ever gone back. Even Margaret Thatcher, a political giant who privatized every damn thing she touched, didn’t dare touch the British health service.

We have to over-sell the public option. CBO says it will save the government $150 billion over 10 years; a whole lot of money, but we have to pretend the fate of the trillion dollar plan depends on these savings. And we have to exaggerate the scope, even though it’s likely that only 10 million people will be covered by the public option.

Finally, in order to make sure that Obama puts maximum pressure on the Senate centrists, we have to pretend that he has the magical ability to buckle Senators from states where he lost by 15 points. Even though we’re a ways from getting even 50 votes in the Senate, we have to pretend that 60 is a cinch. As they say, the squeaky wheel gets the grease.

I know I sound like I’m being ironic. The thing is I’m not. Yes, the public option is an uphill battle, but it’s definitely not a lost cause. That’s why Steve Pearlstein is wrong in saying we should give it up. Intrade lists the public option’s odds at 35%. We are still in the game, and not letting on to our bottom line is a big part of the game.

So maybe someone in comments is going to “disagree” with me. You’re going to call me a sell-out and a weak-kneed accommodator. You’re going to say of course we should ditch the health care bill if it doesn’t have the public option… it would be worthless without it! That's exactly what you should say, thank you. Sorry we “disagree” (wink, wink.)

Others of you (not many I hope) are going to share my lack of discipline and surfeit of honesty and tell me you agree with me. All I can say is… shame on you.

Okay, maybe now I’m being ironic.

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