Drawing a Line for Liberty in the Legislative Sand: Enhancing Choice with the Public Option

The American health reform initiative of 2009 has provoked the debate that couldn’t shoot straight. The issues and subjects have been wildly misdirected. In so many ways, these past few months of health reform controversy have shown the immaturity and ignorance of American politics. And I don’t just mean the “death squads.” A serious hallmark of the debate has been over the so-called public option—a government run non-profit health insurance plan that will compete in exchanges with other private plans and offer coverage to those seeking coverage as individuals or families outside existing insurance groups. In most other developed nations of the world, this aspect of the American health reform debate would seem crazy and upside down. They have debated whether there should be any private insurance options allowed.

Nothing but a pale and partial shadow of a serious form of universal health insurance and a right to health care, the public option idea in American rhetoric has been quickly branded as socialism. If anything, it is actually a bolster for liberty and consumer choice.

In addition to my scholarly work in bioethics and health policy studies, I am an elected trustee in the Village of Hastings-on-Hudson, NY, and I am a Democrat. I view the public option as only a stepping stone to more thoroughgoing reform that will be needed as a long term project after the current legislation is enacted in some form. Still, it has both potential practical and symbolic importance. Politics, as they say, is the art of the possible, and it is also the domain of appearances.

Under the leadership of the late Senator Edward Kennedy and others over many decades, the Democratic Party has made a commitment to the American people to repair a damaged health care system marred by both inefficiency and inequity. Those of us who serve in local government, close to the grassroots problems and hopes of our constituents, look to those Democrats who hold federal office as stewards of that commitment.

Without the innovation of a public option in the health insurance marketplace, health reform package now under consideration in Congress will be incomplete and will fall short of its promise. Many see it as an element to promote greater equity and social justice. I am not so sure about that, but I do think that it is an important element of health reform that will promote the value of liberty. This may seem like a paradox, because many of the Republicans and conservative Democrats who oppose the public option do so because they oppose a larger role of government in health insurance, and this they do seemingly because they believe that government diminishes individual liberty and choice.

I suggest that the opponents of the public option have the logic of liberty upside down. The public option will enhance consumer choice, not diminish it. The public option will build into market competition itself powerful incentives to provide better affordability, value, and quality health care. The entire burden of protecting consumers (when they are purchasing insurance) and patients (when they are making claims on their insurance for coverage of needed services, a moment when they are quite vulnerable) should not fall to government regulation alone. But it will without a competitive public insurance option. The public option, working in tandem with important regulatory requirements on insurance carriers, will put a new accountability into the health care marketplace. The public option is an interesting kind of policy innovation, one that offers something to both progressives and centrists. It uses market competition, not administrative sanction or other subsidies and incentives, to achieve goals that otherwise would have to be addressed by more direct, and more intrusive, regulation.

Opponents of the public option have offered a compromise approach that “triggers” a public option if the private insurance market fails to perform well. However, this is not a true compromise. It is a political strategy of misdirection. It will distract attention from an important innovation and shunt it aside until a tomorrow that will never come, a tomorrow when anything like the public insurance option can be neutralized bureaucratically and quietly. I venture the guess that the trigger will never be pulled, for the public option will be buried in a cloud of data and spurious disagreement about how well private insurance is actually performing.

According to a recent article by Elizabeth Drew, Washington insiders say that the public option has no chance of surviving the coming floor votes and reconciliation process in Congress. In this legislative end game, however, the public option is worth fighting for, both because insiders might be wrong and votes could shift and because it should be at least used as a bargaining chip by progressive Democrats to improve other parts of the bill. Beyond that, this little fight over the public option may be a symbolic moment of considerable significance for the remainder of the Obama presidency.

President Obama’s resounding election arouse a large contingent of citizens who rejected the public philosophy of the Bush years and who sought a new kind of pragmatism and healing reasonableness. I among them. Where have we all gone? It is time for progressives to show some backbone; to draw some lines of value and principle in the sand; and, in the final hours of health reform legislation 2009, to play a skillful and winning game of chicken.

Bruce Jennings is senior consultant and Fellow of The Hastings Center and director of the Center for Humans and Nature. brucejennings@humansandnature.org