Monday, January 16, 2012

More on the Future of the Public Option

David Dayen has an interesting response to my post from last week about the future of the public option, in which I noted that it's very early, but so far there doesn't seem to be much visible support for adding a health insurance public option to ACA among 2012 Democratic Senate candidates.

Dayen argues that the public option fight "fundamentally transformed the tactics and strategies of whatever is left of a progressive movement." He continues:
[T]he trust of the base to use the normal mechanisms of politics to advance goals simply crumbled. That’s why you’re seeing a dearth of promises from candidates about the public option. Base voters have become increasingly cynical that those promises mean anything. So why bother making the promise in the first place? The progressive movement is undergoing a transformation where they no longer see engagement with candidates as the best or only strategy to advance goals. Those not hopelessly alienated by the entire political process prefer outsider strategies that force political pressure from the bottom up, rather than relying on the promises of those politicians to carry the day. That’s the new reality...
Is Dayen right about what "the progressive movement" believes? I don't know. It's easy to forget that most liberals supported ACA and support Barack Obama, but I'm not aware of any solid evidence about what activists believe or how they're acting. I'm sure he's correct about some, but I have no idea how significant that is in practice.

If he's right, however, than that's too bad for liberals, and it's a fundamental misreading of the 2009-2010 ACA battle. After all, the truth back then was that Democratic candidates in 2008, and certainly Barack Obama, placed very little emphasis on the public option as a key campaign promise. It was certainly mentioned, but it was presented as a minor component during the campaign. So in view, it's a major misreading of the ACA fight to read it as showing that liberal politicians can't be trusted to keep their promises. Instead, what ACA showed that promises matter a lot, but that there's a lot of complexity involved -- higher profile promises matter more than those on which the candidate places less emphasis, and sometimes it's Members of Congress who matter as much or more than the president.

That doesn't mean, by the way, that political action outside of basic electoral politics is pointless. My general guess is that people gravitate and should gravitate to where they're most comfortable. But in purely instrumental terms, one of the best investments that I can think of in politics is in getting politicians who want to be seen as sympathetic to your point of view to actually support the issues you care most about.

My prediction had been that activists would make it clear to liberal candidates that the public option was now a high priority, which would translate into quick action whenever the next chance happens for fulfilling the liberal agenda (just as family leave passed quickly in 1993 and the Lilly Ledbetter Act passed quickly in 2009. For liberals to react to ACA passage instead as fundamentally a betrayal would be a mistake; for them to react by giving up on forcing politicians to make future promises would basically be an excellent way for liberals to lose all influence in Washington.


  1. Nothing wrong with keeping it on the front burner, but I think the case for a "public option" will become self-evident as the ACA is implemented, and we get into the part with actual exchanges. Plenty of people will work out what a "Medicare for All" plan for pre-seniors would cost, and how that compares to other plans available from the "for profit" crowd.

    I'd say better for liberals to push their allied politicians to pursue immigration reform and renewable energy solutions. There was really only political room for Obama to tackle one of the three, and it would be wise to be in position to act if conservatism's fever breaks.

  2. I've made this point before--I'm not sure if it was here--but I've repeatedly encountered progressives who simply don't understand what the public option is, and who assume it is equivalent to single-payer. (One of TNC's commenters actually referred to the "single-payer public option"!) I've become increasingly curious how widespread this misconception is, and how it may have even influenced the ACA fight on the left in the first place. Maybe the really committed activists get it, but my sense is that a lot of casual left-leaning voters are unclear about the details of the ACA (and I don't blame 'em) and had an exaggerated picture of the role the public option played in the bill (it was actually pretty peripheral, even from the start).

    This ties into a more general point about liberal disillusionment with Obama (I haven't read Sullivan's piece yet, but I've been thinking about this for some time), which is that many progressives never paid close attention to what Obama was promising and tended to read into his rhetoric what they wanted to hear. That wasn't because his campaign rhetoric actually consisted of nothing but vague hopey-changey unicorn talk--that's one of the big myths about his campaign, where he actually went into considerable detail about his policy intentions--but because some supporters just weren't paying attention, too chilled from euphoric excitement, I guess. So they ignored or dismissed his repeated declarations to increase troops in Afghanistan, and they somehow got the impression that he was calling for single-payer, something none of the Democrats were backing--or had backed in over a generation. If anything, Obama's health-care proposal during the campaign was generally recognized as to the right of Hillary's and Edwards'. It did go further to the right after he entered office, but it never was some progressive dream vision of reforming the health-care system.

    How widespread this level of misunderstanding was is hard to say, and I agree with you, JB, that I sense it's overstated on the blogs and in the press, because Obama's liberal critics are vocal enough that they sometimes seem to be a larger group than they actually are (and they like to flatter themselves by thinking so). Chait's essay from a couple of months ago on liberal disenchantment with Obama (a good if imperfect piece) seemed to take for granted that most liberals were in fact disenchanted with Obama, and that Chait somehow represented a minority of liberals who defended the president's record. This assumption doesn't fit what the polls have been showing. That's why (you knew this had to tie into your post somehow) I suspect David Dayen's point probably exaggerates how bruising the public-option fight was to the morale of the left. Nevertheless, there undoubtedly are liberals out there who saw the discarding of the public option as some massive betrayal of progressive priorities, and confusion between the public option and single-payer may have contributed to this feeling; how much so I can't say.

    1. Fun fact: "Shibboleth" is actually the old Hebrew word for "public option."

    2. I think this is spot on. Many liberals cruised on the genuinely exhilarating sense of self-confidence and assertiveness in Obama's (not totally meaningless) rhetoric. Obama didn't dissimulate, but many liberals seemed to miss that he was pretty concrete about his actual policy proposals too, and those liberals also shouldn't have deluded themselves about the composition of the Democratic caucus, which never has been uniformly liberal. What liberal Obama supporters scanned as betrayal by 2010 was actually simply the centrist/conservative Democratic pivot points of the legislature winning out in an intra-Democratic battle.

    3. I agree with much of what you say, but what I find strangest is that progressives never acknowledge how few their numbers are. They also don't take the temperature of the general public on their issues, so they don't realize how far out of the mainstream they are.

      Maybe they saw conservatives punching above their weight in the Bush administration, and thought they could do it too. If so, they didn't realize how important it is to shape the public message, because it was just dismal on ACA.

  3. "[T]o react by giving up on forcing politicians to make future promises would basically be an excellent way for liberals to lose all influence in Washington"

    Liberals have influence in Washington?

  4. @JS

    Why would ACA implementation make people more aware of the public option's potential cost savings? Various sources, most notably the CBO, have published those kind of estimates and they didn't seem to have much influence on people who weren't already on board. And the ACA exchanges won't be providing public option info at all.

    One thing I could imagine is that the exchanges could generally include Medicare, Medicaid, and VA info alongside the private plans, to provide info to those who are eligible for those programs but are considering buying private insurance anyway. This would of course be cost to the patient, not total cost. Then anyone looking at the plans would say, hey, Medicare's way cheaper (and the VA's practically free)! I could definitely see that leading to people demanding access to Medicare. That's really a different scenario than what you said, though. What they would be seeing and presumably demanding access to in my scenario is not a Medicare buy-in/public option (where the patient covers the full cost) but straight up mostly-gov't-funded Medicare.

    For this reason I expect insurance companies, hospitals, and Republicans will push hard for the exchanges to only provide info on the private plans.

  5. I think Dayen is getting at is that whatever progressives really really want, they won't get. The "system" will find a way, either through holy joe or Ben Nelson, or somebody else, to pull the football at the last minute. If we telegraph what we want in the normal game of horse trading to pass legislation, then whatever that is, can't be part of the final bill. Maybe that's unique to the Holy Joe situation, but who knew that Ben Nelson had such an axe to grind with liberals? Dayen is saying maybe in the future, we shouldn't try to get what we want by hoping that politicians will just have our back when the horse trading goes down. Outside pressure and flexing our organizing muscles will be better tools down the road. Not saying i agree with it, but I think that's the view.

  6. First of all, I understand 'the base' and activists to be two distinct groups. The base is the large number of ordinary voters who, if not disaffected, will show up and vote Dem.

    Activists are a far smaller group - insignificant in purely electoral terms, but important in shaping dynamics - who either behave as party actors or consciously reject that role in favor of being 'outside the party' actors.

    And, as I remarked belatedly on the earlier public-option thread, my impression is that most current-era liberal activists were not all that deeply engaged in the health care issue at all. Once ACA passed, they mostly moved on, either pleased that something got through, or disgusted by the process and its compromises. For this latter group, 'public option' became a symbolic term, having little to do with policy details.

    Most liberal activists of the recent era have seemed more concerned with social issues, such as varied aspects of gender politics; civil liberties; and foreign policy - the latter two entangled.

    Notice that even economic stratification and the Occupy movement came out of left field - so to speak - rather than out of the existing activist movement.

  7. Hi Jonathan:

    Dave here, thanks for replying. I should add that I don't necessarily endorse this mentality, but it's what I see from my vantage point. And while the public option wasn't a fixture of the 2008 campaign trail, something generally described as "universal health care" was - and a non-trivial portion of the base feels that's not what they got out of it. Polling generally backs up this point, showing up to a quarter of respondents saying that the ACA wasn't liberal enough. I'd put almost all of those people in the base activist category, not the casual observer of politics category. And rightly or wrongly, they felt betrayed.

    And the public option acts as a straw-that-broke-the-camel's-back kind of incident in this story. It fits on a continuum with things like not ending the war in Iraq in 2007, and giving telecom immunity in 2008. Maybe these weren't realistic goals, but they contributed to a growing disconnect, a credibility gap between Democratic politicians and a strain of Democratic activists. It's something I encounter every day. Maybe I exaggerate the size of this disaffected group, but I tend to think their presence is undeniable, and I find it in surprising corners of my interactions with liberals, not just in echo-chamber environs.

    The other problem is that at the other end of the spectrum, the group of those satisfied with ACA in particular and the first term in general are not making these demands either, perhaps in the self-protective way that people de-emphasize faults in politicians they want to get re-elected.

    1. Hi Dave, and welcome!

      I agree with that last paragraph completely. Pro-ACA Dems, almost all of whom wanted a public option but differed with the anti-ACA left (or the larger group of frustrated-but-accepting-ACA Dems) on the practical strategy questions, absolutely should be pressing 2012 candidates on the issue, IMO.

      And as I hope I said, I'm not really disagreeing with your reporting/interpretation on where Dem voters and activists are - and certainly there are at least some who are there. Just saying that in my view, even if you take a fairly extreme view of what happened during ACA, they're still shooting themselves in the foot by giving up.

  8. @ Chaz

    I agree with your last paragraph, absolutely the insurance industry will try to prevent comparisons to current government-managed health care programs. But I really don't see many Medicare/Medicaid/VA care patients looking to move out of those programs and into private insurance.

    What I'm getting at is that once ACA is up and running, and Americans are actually looking through the exchanges.. people like Ezra Klein and Jon Chait are going to be working on stories that tell people what a "public option"-like program would cost, compared to the private, for-profit insurance companies available.

    Possibly Vermont and some other states will have their own "public option" choices in their exchanges. Maybe some conservative-leaning states will attempt to set up a bare-bones version, and get rejected by HHS for not meeting minimum care requirements.

    But to make at least a minimalist point here, I don't see profit-based insurance comparing favorably to current government care programs. I never thought getting the 'public option' into the original bill was all that important because the experience is going to naturally lead people to want something like it. The key was to get coverage for all.

  9. I think there's a basically unbridgeable divide between two types of groups with some power within the Democratic Party coalition. And in my experience, the people on the economic left basically understand this whereas the centrists do not, which is a true irony because the centrist types tend to have a huge self-image invested in the idea that they are the politically savvy smart ones and the left is a bunch of naive dreamers who don't understand political realities.

    The public option is not what the left wanted. It isn't what the left thinks is a proper solution to the health care problem. It's the compromise.

    The left basically has the proper critique of the health care system. Health care is a public good and the health care systems that work the best involve the public provision of that good. In other words, socialism is a superior system to capitalism when it comes to health care. Under socialism, more people get more care and costs get controlled. Under capitalism, poor people die of preventable conditions or live in misery.

    Sorry for the Marxist rhetoric, but this is the truth.

    In contrast, the centrists/wonk/technocrat types started for a different place. They asked what was politically possible, and came up with Romneycare, because that funnels more business to the insurance companies which are the cause of the health care crisis. Then, after coming up with it, they convince themselves that it will solve the problem.

    The public option was simply the price that the left demanded to support something that they don't think will work. And it's not simply that they don't think it will work-- there's a significant concern that the health care debate will set a horrible precedent, by confirming that the ONLY way we can ever provide social services to solve public problems is to do it through the private sector, even if it results in the failure of the program. That's a principle that could destroy the government's ability to solve America's problems.

    So when the public option was taken out of the bill, a lot of the left bailed. Because they don't, in principle, support mandating that every American deal with corporations that the left believes are basically evil (or to put it another way, have a profit incentive that basically requires them to be evil for the benefit of their shareholders, as the way you make money as an insurance company is by denying as many claims as possible).

    Any analysis of the importance of the public option fight that treats it as nothing more than a sop to the left misses the whole point. The public option was the compromise to obtain the support of people who actually understand that for-profit health insurance companies are incompatible with the public provision of health care. (And by the way, all those European companies that have "private" national health systems also strictly forbid any insurance company from making a profit.)

  10. The "left" (in all its fragmentations & permutations) shares a common problem with many conservatives and centrists: the subconscious desire that the President be a "father figure" who has both the emotionally-needed cultural cues desired by the base (needs that may often also be subsconcious and that will shift with situations, to be bolstered in difficult situations and to be cheered in times of triumph, to be perceived as fighting against strong opponents, etc.). And the father figure must, of course, have the proper mix of policies that can be discussed out loud and defended rationally.

    In all segments of the population, this makes the Presidency overly-fascinating to the information consumer, while allowing congresspersons and other governmental actors to escape the scrutiny they should deserve. In my experience of trying to run campaigns and build parties, most everyone who's interested in politics has a list of favorite Presidential candidates and a list of hated Presidential candidates, while in most cirucmstances activists on both sides find it difficult to build interest and enthusiasm for Congressional candidates. State legislators? Forget it, nobody cares about them.

    Presidents are thus given undeserved compliments for governmental actions perceived as positive, and given undeserved demerits for governmental actions perceived as negative. Actors lower down on the political food chain get the opposite effect, they don't get compliments they deserve for good work and escape blame for poor work (again, all in the eye of the political consumer). I think this is at least half of what is going on in the situation with liberals and the public option. We/they fell in love with a father figure for emotional reasons, and then fell out of love somewhat, also for emotional reasons. It requires the expertise of psychologists and relationship counselors, more than that of policy wonks.

    And for the record, I do believe the public could and would respond to the right female politician as a "mother figure" to be followed and appreciated/blamed just as male father figures are, yet of course a female politician has to be twice as good at doing twice as much to get the same attention from an subconsciously-prejudiced population & media as a male politician.



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