After Public-Option: What (Could Be) Next

As someone who believes in the cause of universal health care, reading the news these days is an emotional and mental roller coaster. I read one article – Kennedy releases his health care bill! – and experience exhilaration, I read on – Blue Dogs come out against public plan, AMA opposes bill – and I plunge into sudden fear, I refresh the page – Blue Dogs now say they will back the public plan, AMA backtracks on their public statement – and I ascend on wings of hope. It’s tiring, and I can only feel sympathy for those staffers, bureaucrats, activists, and reporters who are on the front-lines of this political struggle in D.C.

Yet I take hope from the fact that opposition has not been able to build up momentum – every announcement of opposition has been followed by a sudden reversal, no doubt the product of much invisible, underground, behind-doors political work. The rise of discontent that accompanied the Clinton plan has yet to emerge. Make no mistake – given how often expressions by industry that they’ll cut 1.5% of health care cost growth are followed up by hedging and weasel words, the situation remains in flux, uncertain, and unstable.

In the end, I feel increasingly confident that a health care bill, likely creating a public option, will pass sometime this year. I don’t know how good it will be, but I think it will pass.

But this will be only the beginning, not the end. The bill on the table, even in its most progressive form, will not completely solve our health crisis. We will still have a health care industry that is too expensive, and that provides poorer outcomes than most other industrialized nations. However, the passage of a bill will make possible the transformation and creation of a national health care movement, which is the subject of this post.

As I have suggested elsewhere, one of the advantages of the public option plan is that people have to choose to join the public plan – which means that it is possible for a social movement to actually shape the American health care system, not through solely pressuring the government to act, but by directly contacting people and convincing them to join the public plan.  After passage, this provides an option to unite public option advocates,  single-payer advocates, unions, social movements, communities of the poor and of color, the feminist and gay rights movements into a national crusade for public health care.

So what would this movement do, and how would it organize?

1. A Door-To-Door Crusade For Public Insurance

The first, and the center-piece of the movement would be a national grassroots movement to sell the public plan to individuals and groups in our communities, focusing on the bluest areas, the poorest areas, the most uninsured areas, to wipe out un-insurance and under-insurance, and to create a majority constituency for the public plan.

This would accomplish several objectives. First, it would unite the progressive movement behind a cause where concrete success is both visible and attainable, beginning to rebuild the institutional capacity for grassroots political movements above and beyond election-year mobilization;  second, it would serve to mobilize and progressivize vast swathes of the U.S population and the electorate through contact with the movement; third, it would create large majorities of voters in Democratic states with a vested interest in the success of the public plan, and thus a vital constituency to pressure Democratic Congressmen, Senators, and the White House to protect and improve the system; fourth, by growing the size of the public plan, it would make the plan more fiscally sound and bring down prices through improved capacity to negotiate in bulk.

Fifth, it would create an instant and powerful tool for progressive social movements in their organizing. Imagine what it would mean for the U.S labor movement if it could offer, at one and the same time as organizers are going around trying to get people to sign up for the union, a cheaper, better, public union health care plan that the boss could never take away from you – imagine the ability to defuse threats of loss of benefits if you vote union. Imagine the aid that being able to sign people up for health insurance would help HIV/AIDS activists working with at-risk populations, or feminist organizations working on women’s health and access to contraception, or anti-poverty organizations working to deal with asthma, diabetes, and other diseases of poor people.

Finally, through democratic collective activism, we could create single-payer within a few years at the very most – without having to go through Congress, deal with lobbyists, or any other institutional barrier to change. 177 million people have health insurance, mostly through their employers – a campaign targeting large employers could yield dividends quickly, especially if the plan is affordable and good quality.

2. A Movement To Shift the Labor Movement Wholesale to Save Industry

At the same time that the labor movement’s organizing can be a key vehicle for shifting people onto the public plan, the first and biggest low-hanging fruit (still 12.4% of the workforce) is the American labor movement itself. More than 16 million workers are members of unions, to which number should be added millions of dependents and retirees who draw their health care through a union health care plan. Probably all together, we’re looking at 30-40 million people.

And yet, ironically, the union movement is the one organized groups of workers in private health care plans who want to get rid of their plans. Because more than anything else, it is the sheer built-up costs of health care and especially retiree health care that has made corporations like GM, Ford, Chrysler “uncompetitive.” It is the fear of losing their expensive benefits, found nowhere else in the American workforce, that drives unions to agree to painful and devastating concessions and weakens strike efforts. Getting rid of their dependence on their employers for health care would free one hand of the unions in their efforts to win in collective bargaining, organizing, and strikes. In addition, shifting health care costs off the sole back of the core industrial employers will make a huge difference in terms of how much of our industry we’ll be able to preserve through this recession and out the other side.

Even more importantly, the union movement is a major group of well-paid workers who can switch almost instantly – all it takes is one round of union contracts, and all of the sudden, the percentage of people in private employer health care plans dips below 50%, and the public plan becomes a major health care player, at the very smallest one-third the size of Medicare’s beneficiary health care pool.

3. A Health Care Quality Watchdog

One of the most successful government interventions into the private sector market in American history was the Office of Price Administration in WWII, which successfully brought inflation to a standstill. One of the secrets of the OPA’s success was the 188,000 people (mostly housewives) who served on or volunteered for their local War Price and Rationing Boards (better known as “little OPAs”) who kept tabs on local merchants and stores, reported price violations, held businesses accountable for the quality of their products, made sure that people were obeying rationing regulations, and so forth.

If this health care reform is going to be a success, the government can’t do it alone. No matter how efficient the new Health Insurance Exchanges, MedPAC or similar institutions, and the new bureau that oversees the public plan may be, they will still need the help and the pressure of citizen activists to do their job. This is a job that the health care reform movement is highly qualified and well placed to do – keeping tabs on who’s accepting the public plan and who isn’t, whether insurance companies are obeying regulations on pre-existing conditions, community rating, and % spent on health care, keeping track of where health care costs are unusually high and investigating why that’s the case, and a million other tasks.

In this effort, the health care reform movement works as both insider and outside, both an ally to the government in ensuring that regulations and laws are obeyed and as a goad in pushing the government to hold itself to promises and standards, to improving its performance, and to expanding and improving its programs.

4, Future Legislation

It is virtually never the case that universal health care happens all in one go, or that the passage even of a single-payer program ends the need for health care reform legislation. Even if the most liberal version of the current legislation passes, there will be ways for progressives to “nudge” the system in the direction of single-payer universality and affordability and quality. First, expansion of single-payer systems – this includes lowering the entry age of Medicare, increasing the cutoff age for SCHIP, increasing the income cutoff and standardizing eligibility for Medicaid. Second, improvement of the program currently under discussion – a big ticket here will be improving and expanding the income subsidy, which if it passes will be a very popular entitlement, and a way for progressives to push towards “free at the point of service” and redistribute income in a progressive direction. Other improvements might be improving the public plan’s reimbursement rate or coverage, changing the public option to opt-out instead of opt-in. Third, long-term cost control programs necessary for the success of single-payer – as many of you have probably been reading, there’s a lot of talk about empowering MedPAC to do cost-effectiveness studies and to recommend best-practices, a crucial step towards establishing a system-wide cost control mechanism; we’ll need more, like policies switching from fee-for-service to capitation (plus an outcomes bonus, like in the NHS) to reduce incentives for doctors to over-medicate their patients to earn money, more emphasis on public health and preventive services, and so on.

Eventually, as the public option grows by leaps and bounds, and as hospitals and doctors and pharmaceutical companies become dependent on government programs, and as private insurers dwindle, there will be the big push to shift from public-option to single-payer. In the current bill, the key will be providing an option for states to experiment with single-payer – and then pushing single-payer through in liberal states like California and New York. Next, there will probably be a state-by-state effort to establish single-payer, and then a push for regional compacts to spread costs over a large pool of insurees. Ultimately, once a majority of Americans (probably just a majority of Americans in a majority of states) are living with and comfortable with single-payer, we flip the switch.

I truly believe that despite what differences currently exist between single-payer advocates and public option advocates, that this is the way to go. If we look at countries with single-payer systems, it always, always took long-term activism to transform their medical systems, and there are still activist movements to put pressure on the government to improve outcomes, control costs, resist privatization, and provide more and better services. And after all, isn’t that what we’d rather be doing? Looking to extend life expectancy and reduce child mortality rather than fighting over how to finance health care? Fighting to enhance quality of care instead of arguing over who and how to provide coverage?

– Steven Attewell