So now it seems that, even as one-time "wets" on the issue in the Senate are turning around to accept a public option, and the leadership is finally coming around to doing this by reconciliation, so that the votes of the wets might not even be needed, just now, Obama comes out with his plan, and it doesn't have a public option. Early on, the man is on record saying that the seemingly more radical Single Payer would be the best solution, were it not for the exigencies of practical politics, and now, just as the politics of the thing swings around to seemingly make at least the public option possible, he won't support even that.
What gives? Just as the ice starts to break, and Democrats finally seem to have noticed that, gee, maybe an actually popular bill, with popular provisions, like a public option, might actually be politically more doable, more popular, than one that is completely opaque to all but the wonks among us -- our progressive president gets cold feet.
Of course, start down that road of looking for a popular bill to do HCR, and we'll end with Single Payer. This would happen either right away, as the political debate over the bill pushes it to Single Payer before it is finalized, or it would happen more gradually, as a public option gradually outcompetes the private insurers, and we soon have Single Payer de facto, even if we started out with just the public option de jure.
What would be so bad about that? The president, after all, has said that Single Payer would perhaps be what you would do if we were not saddled with that path dependence thing that got us to where we are today via private insurance. But I'm convinced that -- whether because he's changed his mind since, or made some devil's bargain with Big Pharma or whoever that he doesn't think he can withdraw from, or whether that shout out to Single Payer was pure lip service of something he never believed was a good idea but dind't think he'ld ever be called on to make good on, so it was a freebie -- whatever the reason, Obama now believes that Single Payer is a bad idea in itself, not just because of a supposed political non-viability.
Why would that be? I mean, why would that be, outside of all the bad reasons disappointed progressives advance, that he's been bought, or never was anything but just another corporate stooge, etc. , etc. All of this may be true, but even if it is, I don't think it explains anything. Dishonest politicians don't stay bought, and now would be an excellent time for a politician who had only served the industry's interests because he was paid to do so, to jump ship, sell his former patrons down the river, and find new industries to exploit for campaign cash. It's a pattern almost as old as the bribery of public officials, for them to take the bribes for years and years, then get religion, and cred for being a reformer, by crusading against the malefactors of great wealth just as their particular scam of the moment was collapsing anyway. Obama, if he were such a dishonest politician, clearly has the intelligence and flexibility to execute such a strategy, and the health care insurance industry is clearly ripe for betrayal. They're in their death spiral, forced to raise rates further, when they've already passed the point at which their healthy, young, profitable beneficiaries have started to desert them and risk going naked. It would be euthanasia to just get rid of the private industry with Single Payer.
I would argue that Obama's position only makes sense if you assume that he has valid, if mistaken, public policy reasons to not want the industry to die the natural death it is already in the throes of. And the only set of reasons I can come up with, is that Obama and the technocratic centrists around him are convinced that any hope of bending the cost curve downward rests on something like managed care, the payer using the power of its position to control how health care is delivered, and that only the private industry can be free enough of public opinion to be ruthless enough to do this with any effectiveness.
To reduce the argument to a rather wonkish and inside-ball catch-phrase, where most of us hear Medicare For All, there are academic health care finance experts who can only hear Fee-for-Service for All, and fee-for-service is, to a certain set of such well-intentioned academics, the Original Sin of health care financing. The idea is that, if we go with Single Payer, it will be all-too popular because it will be identified with Medicare for All, and that identification will make it impossible for payment in the new Medicare for All to be on any basis but fee-for-service. Medicare as it stands is bad enough, in its payment structure, to these people, but at least its fee schedule, the limit of what it will pay for services, is provided some sort of restraint in its otherwise inexorable upward climb, by the segment of the market still under private industry, managed care, negotiated fee, discipline. Take away that anchor, and these academics fear that the fee schedule will only be able to adjust by bureaucratic fiat, and will thus be completely free to rise uncontrollably in response to the political pressure that the providers can bring to bear on the bureaucracy and their Congresscritter and administration masters.
These are not foolish concerns, even if the conclusion, that we keep the industry alive because only it can provide market discipline, is foolish. The providers, at least the big providers, the hospital chains and Big Pharma are as monopoly and cartel ridden as the insurers, and they will indeed need to be handled with ruthlessness, trust-busted down to the water line, to control costs. It is not foolish to doubt that this will happen, that our gummint, as presently constituted, has the stuff in its shorts to bust the trusts. But it is really, really foolish to imagine that the insurance monopolies and cartels will do any better, at all, than the gummint at controlling their brother monopolies and cartels in the provider sector. No one really knows the full extent of just how much they are, in fact, one and the same set of monopolies and cartels, because we simply do nothing to restrain vertical as well as horizontal integration in this whole sector, but even what we do know (e.g., Humana) makes it pretty clear why we have a cost spiral. It has nothing to do with the family physician down the street not practicing cost-effective medicine, and everything to do with the big insurers and the big providers being in bed together, playing footsie with each other rather than holding each other's feet to the fire.
When we do get Single Payer (Not "if", "when". The industry is in its death throes, and no one involved, least of all its most faithful slaves in Congress, is smart enough to revive it, much as they might want to.), it will indeed need a mechanism to set prices to replace the dependence Medicare now has for that function on the portion of the market that now gets its prices negotiated by the insurance industry. Fiat pricing would be a bad, very bad, idea. But the obvious alternative would be for the Single Payer to run a market, really many geographical markets, because medical services are inherently geographically limited, and let supply and demand run free to set prices within that market. Of course these markets won't work unless the provider cartels and monopolies are destroyed, and trade in those markets is freed of those restraints on trade. No one, not even people who think they want Single Payer, seems ready to face that set of entailments of Single Payer, and that is my best explanation of why it is not necessarily dishonest or dishonorable to not be for Single Payer, or interim arrangements, such as the public option, that would swiftly lead to Single Payer.
If you can't explain how the Single Payer is going to arrive at the prices that providers will be allowed to charge, you shouldn't be calling the president a sell-out or a coward. If you are still trying to maintain the pleasant fiction that a robust public option will not rather quickly kill off an industry that is on its deathbed already, leaving us with a Single Payer that will have the responsibility to figure out some scheme for setting prices to fill in for the deceased industry, perhaps you need to ackowledge paternity and face your responsbilities. Maybe the president is getting a bit squirrelly about now because he sees a difficulty you are free to feel brave about only because you can't see it yourself, and won't take responsibility for addressing.