The Policy That Dare Not Speak Its Name

By Robert Kuttner for Huffington-Post

I’m sure I’m not the only reader who noticed the juxtaposition of two front page stories in Sunday’s New York Times dealing with health care. The first article cited a new Times-CBS poll showing that 72 percent of Americans favored a government run health plan comparable to Medicare, which would be available to everyone.

The second reported on a rogue radiologist at a Philadelphia VA hospital who botched 92 prostate procedures.

The right will doubtless go to town on that one, as what we can expect of government-sponsored medicine. I’ll have more to say about the VA in a moment, but first let’s consider the poll findings.

The poll is relevant because Congress will soon decide whether to include the so-called “public option” in the Obama health reform bill. As drafted by three House leaders and unveiled last Wednesday, the 852-page bill would include a government-sponsored, Medicare-like public plan.

Republicans and the health industry have been kicking and screaming that this is socialistic. But the poll suggests that defenders of the public plan have nothing to fear politically, and that Republicans are in danger of getting on the wrong side of a popular issue.

However, that’s only the beginning of the story. The reform package, as drafted by the Obama administration and the House leadership, is dubious legislation even with the inclusion of a public option. Basically, it leaves the two worst aspects of the system intact. First, private insurers will continue to dominate. Second, most people will continue to get their insurance through their employers. Given these two bedrock realities, there is no way that the bill can make serious inroads on cost without cutting back on care. The high cost of the approach is already causing key legislators to back off. The current system wastes huge sums, but because it is so fragmented the money flows to profit opportunities and not to the most cost-effective forms of health care.

Also, as my American Prospect colleague Paul Starr warns, a mixed system with a public option effectively invites the most expensive and hard-to-treat people to opt for the public plan, while private insurers will seek to insure the young and the healthy. This is a familiar problem known as adverse selection. The private insurers will then smugly point out that the public plan is less “efficient,” when in fact it simply will have a more costly population. The only way to avoid this problem is to have everyone in the same universal plan–what’s otherwise known as a single-payer plan.

The public option is a not-very-good second best–because our leading liberal politicians lack the nerve to embrace the one reform that simultaneously solves the problem of cost, quality, and universal inclusion. The policy that dare not speak its name is of course comprehensive national health insurance, or Medicare-for-All. I try to avoid using the term “single payer,” because a technical, policy-wonk phrase not understood by most civilians has become insider shorthand for national health insurance. Let’s call the thing by its rightful name. Medicare-for-All is something regular people understand.

The Times-CBS poll is evidence that this is what more than two Americans in three really want. Most voters have not followed the nuances of how the public option in the Obama plan would compete with private insurance. The poll simply indicates that voters want access to a straight-up, Medicare-style plan to be available to one and all. In past polls, when Times-CBS pollsters ask whether people favor national health insurance, responses generally favor Medicare-for-All by margins of about two-to-one.

In the current debate, liberals find themselves fighting to keep the public option alive, so that some form of efficient, publicly-run health insurance will stay in the mix–but knowing that it is embedded in a reform package that is far more costly and inefficient than it should have been. Instead of validating the common sense and reformist demands of ordinary Americans and identifying the insurance, drug, and corporate elites as the obstacles to real reform, too many of our liberal leaders from President Obama on down hope to co-opt business elites with a convoluted scheme that undermines the efficiencies of a comprehensive and universal system. And just wait until it gets watered down further in order to retain the support of these same elites. A plan that all of these groups would endorse would not be worth having.

So what’s the matter with our politicians? Why are the people so far ahead of their elected leaders on this one? One reason, as usual, is money. The combination of the insurance industry, the drug industry, the American Medical Association, the hospital lobby–all of whom oppose Medicare-for-All–represents a huge amount of political spending. It takes a brave politician to face down all of these industries, even though the people are on the side of real reform. The AMA’s position is especially shameful, since the professional societies that represent most actual physicians favor national health insurance.

The second reason that liberal politicians wimp out on single payer is that the self-styled realists in this debate have decided that Medicare-for-All, even if it’s the first-best system, is too hard politically. But think about it. Has the administration picked up one Republican vote by supporting the present system plus a public option? Hardly. The current House leadership bill, offering a mixed system, with a robust public option, a requirement that employers provide good insurance or pay a tax, and that insurers not discriminate against pre-existing conditions, is just as heavy a political lift as national health insurance–and far inferior policy. So why not just go for the first-best?

The advocates of Medicare-for-All have become something of an embarrassment to the liberals. The White House forum on health reform on March 5th, which boasted a diverse range of viewpoints, including representatives of the Business Roundtable, the health insurance industry, the drug lobby, as well as a broad spectrum of business, labor and Congressional leaders, left advocates of Medicare-for-All banging on the door. None were included, despite requests for invitations.

When Sen. Bernie Sanders recently arranged for five prominent advocates of national health insurance to have a courtesy meeting with Senate Finance Committee Chair Max Baucus, the story was newsworthy because the political elite usually pretends that this viewpoint doesn’t exist, much less that it represents the desires of two Americans in three. The mainstream media have also colluded in the general effort to keep the single-payer option out of the limelight. The organization FAIR recently published an important study in its heroic magazine, “Extra”, titled “Media Blackout on Single-Payer Healthcare.”

Indeed, the Sunday New York Times-CBS poll didn’t even offer Medicare-for-All as a free-standing option. It took the Obama position as the left edge of the debate.

As for that rogue doctor at the Philadelphia veterans’ hospital, quality control is not what it should be throughout our fragmented system. And the oases of public medicine are particularly starved for resources. Yet studies consistently find that on average, the VA does more with less than its private sector competitors. Phil Longman has written the definitive book on the subject, “Best Care Anywhere.” Here is a summary.

In this case, the offending radiologist, Dr. Gary D. Kao, was actually a contract employee and not a VA physician.

Only by having a comprehensive system can we marry quality, cost-effective care, and universal access. One of these days, a national leader will have the nerve to embrace national health insurance and fight for it. Until then, we will keep paying more money for less care, and liberals will defend reforms they themselves scarcely believe in.

Robert Kuttner is co-editor of The American Prospect, and senior fellow at Demos. His recent book is “Obama’s Challenge”.


  1. Vashti Winterburg on June 22, 2009 at 4:43 pm

    Thank you Mr. Kuttner. It’s been maddening to have an economical program that takes care of everyone for almost everything not get the time of day. In the mean time we have to watch various Obama/Kennedy/Baucus permutations of the failed Massachusetts plan get lionized. Nevermind that theses plans are uniformly too complicated, too expensive and ineffective. H.R.676’s time will come, we just need to hang in there. I also think that if one of these disasters is actually passed that the backlash will be severe on the Democrats.

  2. Vashti Winterburg on June 22, 2009 at 4:45 pm

    Mr. Kuttner – It is fascinating to read the online letters to the editor about any health care issue and see a load of single payer supporters writing in, especially in the NY Times.

  3. Marc on June 23, 2009 at 5:30 pm

    You provide an accurate description of the problem with the “public option” plan: the insurance companies will simply make membership and benefit costs for those needing benefits so expensive that they will be forced to “The Option.” This, in turn will crush The Option with costs, etc….

    Another problem that you cite is the corruption of our government, as so noted by Thomas Jefferson in 1812,

    “I hope we shall crush in its birth the aristocracy of our moneyed
    corporations, which dare already to challenge our government to a
    trial of strength and bid defiance to the laws of our country.”

    We have advanced since those times: corporations are not only defying laws, but they are now writing them.

    We need to have the single-payer system, or “Medicare-for-All” so that we do not experience adverse selection. The private insurance companies can then be optional for those that desire more coverage, and these companies can deny, charge, and rescind whomever and whatever they like.

    Another requirement of our health care reform would be to require all of our government to be members of The Option, or whatever is created. This is the only way to assure that there is some element of quality created. Currently, their lifetime health plan is quite the deal, while we suffer at the hands of the HMOs.