Amy Smoucha has worked on health care issues for Jobs with Justice for three years now. That’s dozens of months, hundreds of weeks, and thousands of hours. And that makes her expertise on the subject worth listening to. So I did. When the e-mail below arrived in my inbox, I paid attention–especially to her fourth point.

In fact, within a few days, I will write in more detail about the “national, non-profit, publicly accountable option for health insurance coverage” contained in the Senate bill. Suffice it for now to say that rather than fight the screaming mob about the public option, the Senate did an end run: it eliminated that program and substituted a plan that has the potential–minus the right wing hysteria–to achieve the same thing. An analysis of how useful (or less than) those two programs may turn out to be will be part of my upcoming posting.

But for now, see what Amy thinks of the progress Democrats have made so far:

An open letter to progressives:  ideology kills people

I have been amazed at the rancor and deceit that many politically “right wing” and conservative leaders have demonstrated during the long, heated struggle to pass health reform legislation.  I’m amazed that for political, partisan and ideological reasons, Republicans and Libertarians are willing to lie to their own voters.  I’m awestruck at the monumental steps people are taking to protect corporations, defend outrageous profits and protect a status quo that working people in any political party cannot afford much longer.

Of course, we expect that sort of vitriol and cynicism from the right wing and from conservative political operatives who have lost ground in the last election and are bitterly losing the health care fight.

I am having a much harder time understanding the fierce attack by some folks who are thoughtful, independently-minded and progressive.  Like any significant human and civil rights struggle, we are in a place where we’ve won a lot, we’ve lost some of our demands, and there’s more work to be done to get a final bill out of conference.  Both the House and Senate health care bills represent an incredible step toward real, affordable, quality health care for every person in our country.   Neither of them accomplish everything we need.

I hope we all evaluate the bills and what they accomplish based on the ambitious reforms they include and an understanding of the context in which the measures are proposed. The bils do many things for our communities–like funding clinics and doctors.   It’s important to consider the flaws in the bills alongside a balanced understanding of just a few examples of what we are gaining and winning:

1. The Senate bill delivers health coverage to 94% of Americans –31 million uninsured people will gain access to affordable health coverage.  (The House bill would cover 36 million-95%.)

2. The proposed expansion of Medicaid will provide a lifeline to 15 million low-income and disabled Americans.  Congress is about to enact a significant expansion of Medicaid for both individuals and families up to 133% of the federal poverty level.   Currently in Missouri a family of three is eligible for the state health insurance program if their income is less than $292 a month.  Both House and Senate bills lift the income rules for the whole country to about $2029 a month for that same family of three.  For the first time adults without dependent children will get this coverage.  These 15 million uninsured, low income individuals will gain insurance through a public health insurance program that is affordable and has very nominal out of pocket costs.  This provision will help laid-off workers and part-time workers.  This expansion will revolutionize life for people with disabilities and people living with mental illnesses.  For many of us, when disability strikes, we will no longer have to prove that we are “permanently and totally disabled” and unable to work just to have access to the public option of Medicaid.  We won’t have to stop working just to get health care.

3. Corporate abuses are curtailed and health Insurance companies have been significantly pushed back in both bills. The Senate bill went much farther than we imagined in reining in insurance company abuses.  What’s really in the Senate bill?  Insurance companies will not be able to turn us down or charge us more if we have pre-existing medical conditions. Insurers will be required to spend 85 cents out of every dollar they receive in premiums on health care rather than profits and administrative costs. If not, people would receive rebates from their insurance companies for the difference.  Insurance companies will be banned from issuing policies that have lifetime or annual limits on benefits.  Consumers gain the right to an independent appeal of any decision by an insurer to deny coverage.

4. Both the House and Senate bills bill create a national, non-profit, publicly accountable option for health insurance coverage.  The House bill contains a national public insurance option.  However, even in the Senate bill, people purchasing insurance in the Exchange will be able to choose from national plans, including at least one non-profit plan, supervised by the same department of the federal government that selects health insurance plans for federal employees.  Before the recent invention of a “public plan” demand, progressive health care activists were asking Congress to either open up Medicare for all or allow people to buy into the plans administered by the Office of Professional Management-the same plans that Congress and Federal employees have.  We just won a long-standing demand.

5. We cannot “start over” and get more progressive reform through Congress any time soon.  Getting landmark legislation passed is a treacherous, long chess game, especially when that legislation has powerful corporate enemies or extends significant civil and human rights.  Unprecedented political capital and economic capital have been spent-the years spent making health reform a key issue in the last election, the storybanks, the canvasses, the phone calling.  We all put our best game on the field.  It’s time for a final push to improve the legislation in conference committee and to plan on how we will take this momentum and build and expand on our victory.  Many leaders in the health reform movement predict that if health reform fails now, we will not have another meaningful effort for 15 to 20 years, if at all.  If health reform fails now, the insurance companies and for profit health care corporations will laugh (at us) all the way to the board room.

This fight has been long and vicious because Congress is creating federal rules that make insurance companies behave.  Insurance companies are going to be regulated, and they don’t like it.  So much is at stake.  It is very dangerous to forgo these incredible victories because they are not far enough, especially since losing means millions of struggling Americans will have to continue in the health care system as it is for many, many years.  I’ve spent the last three years talking to hard working people throughout Missouri who will get real, measurable, concrete help from these legislative changes.  For some of them, their lives literally hang in the balance.  We have a responsibility to stand beside and for the uninsured working people who will gain much from these bills.

As a few progressive groups send emails around to “kill the bill” (along with the tea party) or “a bad bill is worse than no bill,” insurance companies and right wing political operatives throw fuel on that fire. All of us should deeply consider the consequences of
squandering this opportunity to move our health care system several strides forward.  Kill the bill, and insurance companies win.   I believe we are better than that.

Writing about the “ersatz public option”, Robert Reich pointed out that private insurers, Big Pharma, Republicans and “centrists” wouldn’t hear of Medicare for all 300 million of us–too much like Canada.

So the compromise was to give all Americans the option of buying into a “Medicare-like plan” that competed with private insurers. Who could be against freedom of choice? Fully 70 percent of Americans polled supported the idea. Open to all Americans, such a plan would have the scale and authority to negotiate low prices with drug companies and other providers, and force private insurers to provide better service at lower costs. But private insurers and Big Pharma wouldn’t hear of it, and Republicans and “centrists” thought it would end up too much like what they have up in Canada.

So the compromise was to give the public option only to Americans who wouldn’t be covered either by their employers or by Medicaid. And give them coverage pegged to Medicare rates. But private insurers and … you know the rest.

He covers each succeeding compromise, concluding with this description:

It’s a token public option, an ersatz public option, a fleeting gesture toward the idea of a public option, so small and desiccated as to be barely worth mentioning except for the fact that it still (gasp) contains the word “public.”

Sunday evening, I participated in a conference call with Jon Walker of Firedoglake. If you’ve been reading any of the FDL health care updates posted here daily for the last several weeks, you know the name. Walker knows the health care turf. And various remarks he made about the public option indicated that, although he might not go as far as Reich did, he’s well aware of how anemic the public option is. So I asked him whether he thought having it in the bill was of any account and whether the weak cost controls in the bill would end up costing the Democrats in future elections. He said that a strong public option would have saved the government $110 billion and consumers $200 billion over the next ten years. So Walker is bemused by the fact that conservatives and “moderates” keep insisting on cost control but refusing to support the one obvious means for that–a robust public option. He hasn’t seen a senator yet step up with actual proposals for serious cost controls. Mark Warner of Virginia says he plans several such amendments. We’ll see whether he, or any other senator, proposes real measures.

As far as what dramatic steps are needed, he points out that in every country that isn’t single payer, a single rate setting agency exists. Either the government decides what a given MRI will cost or a coalition of insurance providers and health care providers decides. Procedures in this country cost 30 percent to 100 percent more than they do elsewhere, partly because of the incredible waste of having a thousand different health care providers negotiating with dozens or hundreds of different insurance companies.

Another big improvement we need is risk adjustment.

Risk adjustment means transferring money from insurers whose clients are healthier than average to insurers whose clients are less healthy, enough to neutralize the effect of varying health status. If it worked perfectly, insurers would have no incentive to seek out the healthy and drive away the sick because they would receive the same amount for each.

Obviously, Walker assumes the bill is worth passing, flawed though it is. I asked him what argument he would make in favor of the bill, even though it lacks adequate cost controls.

His answer:

The important thing, I feel, in health care, is to be moving in the right direction as opposed to moving in the wrong direction, to make a commitment to insure people. You’re never gonna get quality health insurance in a market system without a strong risk adjuster, because there will always be … unless you make it impossible to make money by trying to drop sick people or you make it just not profitable to drop sick people, it’s always going to be the go-to for insurance companies. They’re not going to figure out how to make things cheaper, they’re just going to figure out how to have better people to insure.

That’s the problem with the public option right now in the current bill. (Inaudible) will actually be five percent cheaper. It’ll actually do a five percent better job than private insurance, but since it will be the only insurance company not gaming the system, it will have to charge a four percent higher premium.

If insurance companies weren’t intent on merely gaming the system, they could be saving all of us and themselves a pile of money. They could, for example, get together and create standardized information systems. As it is, doctors often have to devote a third of the costs of their practice to dealing with insurance companies. Those costs would plummet if every insurance company required the same set of information in the same form. And anything that saves the doctors money enables them to charge less so that insurance premiums could be lowered. Right now, however, WellPoint and Aetna have no incentive to set about such a reform.

Jon Walker knows that they’ll expend their energies, under the coming plan, finding ways to reject the sickest people.

So that is very critical, having that [public option] as a big component. Having the public option there, if you can get the risk adjusters working right, I really think the public option will get a lot of customers. I think it will expand. Having it in place, even if it’s relatively small and only somewhat cheaper, it will be a good go-to tool when we actually get to the cost containment battle down the road.

My biggest fear is that we might not have the beginnings of a progressive solution in the reform bill so that cost containment solutions going down the road will be less generous care, less things being covered, you know, that kind of pathway.

I asked Walker if he had any feeling for when further reform might begin.

The second stage … well,our current system–it’s funny you should keep talking about strengthening it–the current system is headed for a collapse of some type. You know. It might even bring down the whole economy with it, it might not. But you can’t have health care costs grow at, whatever it is, eight percent a year. You know, we can’t, as a nation, have 35 percent of all our money being spent on health care. That just can’t happen, especially when all the other industrialized countries are spending half that amount. So something will have to be done and my hope is that progressives will try hard to get the things in place that will be, when we actually have the fight for the cost containment, we’ll have the progressive infrastructure in place to (inaudible) progressive solutions (inaudible). And that’s why I think it’s great to have a public option in there. If you have a public option with very little overhead and all these private insurance companies with much more overhead, that helps make a strong argument for a minimum medical loss ratio as a cost containment move.

So, yeah, you know, I don’t know how that next fight’s going to happen. Hopefully it’ll go our way. But if the progressives don’t win this current “health care battle”, including the public option, I don’t see them having any political power moving forward.

I emphasized that last sentence with boldface because it’s the culmination of his logic. Robert Reich thinks the compromise has gone so far that the public option is worthless:

But what more can possibly be compromised? Take away the word “public?” M
ake it available to only twelve people?

Walker, on the other hand, considers that, though the public option is weak, it is, paradoxically, huge. And we must have it.

Update: Firedoglake is pushing a petition to tell Reid we want that public option:

“The power to pass a public option is yours alone.  Don’t let corrupt Democratic senators owned by insurance industry lobbyists kill the public option and majority rule.  Get them in line, or use reconciliation to pass a public option with a majority vote.”

Go ahead and sign it.

Joe Lieberman assumes everyone is stupid. His assumption is correct when it comes to our useless old media. It’s too bad for Joe Lieberman that Al Gore (you remember him Joe?) had a hand in the development of the Internet. We can now easily search for all kinds of information.

Lieberman Repeats Claim That Public Option Not Part Of 2008 Presidential Campaign

Brian Beutler | November 21, 2009, 9:15PM

….”This is a kind[ ]of 11th hour addition to a debate that’s gone on for decades,” Lieberman told reporters tonight. “Nobody’s ever talked about a public option before. Not even in the presidential campaign last year.”

I asked in response, “How do you reconcile your contention that the public option wasn’t part of the presidential campaign given that all three of the [leading Democratic] candidates had something along the lines of the public option in their white papers?’

“Not really, not from what I’ve seen. There was a little–there was a line about the possibility of it in an Obama health care policy paper,” Lieberman said….

[emphasis added]

Disingenuous putz.

From the Obama campaign, September, 2007 (pdf):

….If you do not have insurance you can choose to enroll in the new public plan, which will offer benefits similar to what every federal employee and member of Congress gets. Or you can choose private plan options through the national health exchange…

[emphasis added]

Uh, Joe, the Internets are forever. Or until some narcissistic group of putzes does something to pull the plug.

By they way, thanks for nothing, Claire.

Claire McCaskill twittering earlier today about the public option:

All sound and no fury. CBO estimate in: 2% of Americans would potentially use public option.

In case you don’t know what she’s talking about, she links to this article in the St. Louis Post-Dispatch which discusses the Congressional Budget Office (CBO) estimates that few would use the public plan, those who did would be sicker than the average and, as a result, premiums would be higher.  

Perhaps McCaskill should stop gloating and take into consideration the fact that the public option makes such an anemic showing in the CBO analysis because folks like her have worked so hard to handcuff it.  As Jon Walker of FDL notes:

This illustrates a serious, reform-crippling problem with the House’s bill. It has an insufficient “risk adjustment” procedure. The risk adjustment mechanism should be a re-insurance program that redistributes a large amount of money among the plans on the exchange based on the health of their different customer bases. Without a strong risk adjustment mechanism you are literally guaranteeing it will be impossible to get high-quality, low-hassle insurance on the new exchange.

Seems like McCaskill, who likes to strut her financial skills stuff, should be able to figure this out.  So why doesn’t she have the honesty to come out and confirm what many have suspected for some time now: our Democratic senator would sooner support a plague of locusts than an effective public option – and her smug twitter means that she thinks she may be off the hook at last.  

First Claire McCaskill wanted to handcuff the public option; now she wants to trigger it or let states opt out, anything to sideline it.  After all, she says, it isn’t the main course when it comes to health care reform, just one of the little vegetables on the side.  

Remember when McCaskill told the unruly teapartiers at one of her town hall meetings that she didn’t want to have to use her “mom” voice?  Perhaps she needs to call on some more generalized mom skills now and recollect that it is just as important to eat your vegetables as anything else. Otherwise, she could get a lesson in nutrition next election when some of her erstwhile supporters decline to feed the campaign kitty.

Update:  If you want to get an idea about the harm done to health care reform by those quibblers and ditherers like McCaskill whose lack of support weakened the public option, you might be interested in this TPM report.

Right wingnuts aside, people want a public option as a part of health care reform. They understand what it will do – cover people who can’t get health insurance now at a cost they can afford and at the same time holding down overall health care costs. That’s considered a good thing by people who aren’t batshit crazy.

Poll: Majority Want Public Option More Than They Want Bipartisan Bill

And in Warrensburg, Missouri the local paper is conducting an online “poll” (it’s not scientific):

Should health care reform include a public option versus only private coverage?

As of this writing “Yes” is getting 62% of the responses.

Uh, Claire, the teabaggers of August have run their course. They have never voted for you and they never will. And they’re in a very small minority.

Senator Claire McCaskill (D) yesterday via Twitter:

I’m confident that we will have plenty of time to examine bill before Senate debate. It will be posted on internet too. about 9 hours ago from web

I’m for a public option, as I have said here many times. @msstagabout 9 hours ago from web

I’m not sure that everyone understands that a public option will only be available to those who don’t have insurance coverage, not everyone. about 9 hours ago from web

Is that so insurance companies continue to price gouge everyone else?

And there has to be a limit on federal $ to public option, with same rules as private companies that will be available to choose from. about 9 hours ago from web

I’m waiting for the proviso that any public option must have a 30% overhead cost so as not to put insurance companies at any disadvantage.

We’re all just hoping that Claire’s legislative impact on health care reform doesn’t cause a similar result to her legislative impact on cutting back the stimulus. And we’ll be watching those votes.

We are getting close to the final stretch on health care reform, and the coming weeks may well be the acid test for the Missouri Democratic Congressional delegation. Who will stand up for Democratic principles, and who will cave to what is perceived to be political expediency?

As of today, one Missouri Democrat has already fallen by the wayside. Ike Skelton has announced that he will vote against health care reform legislation, and, in particular, against the public option. To justify this betrayal, he regurgitates a few lines from the same lame script Republicans have been using; he claims that the public option “could drive private insurers out of business,” adding that:

…he also is concerned that the House proposals could make large cuts to Medicare and hurt rural health care providers.

These objections are balderdash, and it is a sure bet that Skelton knows that fact very well.  Could it be that he is really worried because NRCC thinks he’s vulnerable and has targeted him with an ad claiming that he wants to cut $50 billion dollars from Medicare?  

Somebody should warn weak-kneed Missouri Democrats like Skelton that, no matter how abjectly they try to appear “moderate,” they may not be doing themselves much good in the long run. As Michael Tomasky convincingly argues, failing to enact health care reform is likely to hurt Democrats in red or purple states far more than those in blue states:

Imagine that Obama loses on healthcare. His approval rating sags to 42%. The Republicans stand to make gains in 2010. Where are they going to make them? Not in the navy-blue districts represented by the solons who are certainly going to vote for whatever plan emerges. They’re going to make their gains in the marginal, gettable districts and states.

That describes Missouri as far as I am concerned, and I would argue that the same factors will come into play even if a weak reform package is passed and the public comes to believe that more effective health care reform was sabotaged by corrupt and/or weak congress members. Skelton, like all the timid little Democrats cowering in fear that their constituents might discover that they stand for something, might well be shooting himself in the proverbial foot.

Is Claire McCaskill taking her cues from Jay Nixon now?  It seems, according to a DailyKos report, that she shares Jay’s graphophobia when it comes to putting pen to paper and signing a letter to Harry Reid demanding a public option. Thirty of her Democratic colleagues have no such fear, including even a straight down the center moderate like  Dianne Feinstein and Republican-at-heart Arlen Specter, but McCaskill, who claimed to support a public option earlier this summer, has evidently declined to make her support public in a meaningful way.  

Perhaps the  bipartisan “gang” McCaskill began hanging out with in September, Joe Lieberman, Kent Conrad, et al., have been a bad influence on her always somewhat mushy convictions. That would explain the tone of  this tweet from yesterday:

CBO says HC bill from Finance is deficit nuetral [sic] and will reduce the deficit over time. Good news. Still needs work(public option or coop)

A bit cryptic, admittedly, but sounds to me like McCaskill would be perfectly satisfied with the pathetic Senate Finance Bill if it were enhanced with provisions to create the equally miserable coops rather than a real public option.    

If there’s no public option:

Unpopular

From the few tea leaves I get to see, I’m getting the sense that people on The Hill are not even having the conversation about just how unpopular forcing people to buy shitty insurance they don’t want is going to be.

Mandate + No Public Option = Unpopular taxpayer bailout of private insurance

…The Baucus bill is a mandate with no price controls, because it lacks a public health insurance option to increase competition with private insurance…

May 27, 2009:

Senator Claire McCaskill in Sedalia – May 27, 2009 – part 4

….Question: Thank you for coming today. And  many people whine about taxes., but my family, we’re paying like over seven thousand dollars a year in health premiums. And I’d much rather trade that in for a national health care system. And I appreciate what my taxes buy. [applause]

Senator McCaskill: Well, thank, thank you for that. Does anybody mind if I read another. [laughter] You know, I, I do not think we’ll do a, the President doesn’t support, and I don’t support a single payer system. I think competition in the marketplace and choices is very, very important in health care. Now, if we enact these reforms and , but I have a feeling that this is gonna work, because I think we’re gonna have the kind of competition that will drive down costs. And, we gotta make sure that the government run health program is fair, because we don’t want it to be so overwhelming that it stamps out all the private insurance. ‘Cause we want that healthy friction in competition, between the two. We certainly have had competition as it’s related to the, the, some of my friends on the other side of the aisle want to do with health care what we did with Medicare D. Which is a government sponsored but completely private program. Well, you know, yeah, there’s competition there. Sometimes there’s so much competition it’s confusing, seniors don’t know whether they’re going or coming, whether drugs are covered or not, whether they’re getting a good deal or a bad deal. But the problem with that is, we built into that program six billion dollars worth of profit on taxpayers for the pharmaceutical industry. Well that doesn’t seem right to me. They actually put in the bill that we couldn’t buy bulk to get down prices. Well that’s the silliest thing I’ve ever heard of. So I don’t think we want to emulate Medicare D because I don’t think we can afford it. I don’t think we can afford to plus up certain silos of profit in the health care industry.  I think we can figure out ways to provide competition and choices and to bring down costs. And that are the three goals. Competition, choices, and bring down costs. And I’m kind of excited. I think we’re actually gonna get a bill this year. I feel pretty good about it. [applause]…

December 15, 2008:

Claire McCaskill (D): “Kitchen Table Talk” in Kansas City, part 3

…Question: On the issue of health care, this is a great opportunity to jump right in there, you know there’s a lot of [inaudible] thought, you know, early in the campaign health care was really being talked about by the group of [inaudible] candidates, by Barack Obama, by John McCain, so we thought this, the stars were aligned, health care is actually going to get dealt with, but then we had this little economic problem kind of creep up towards in there and everybody said, “It’s never going to happen!” But I was wondering if you had any insight, from the outset he picked Daschle, given the appointments that he did, that perhaps the impetus for reform now actually exist than the whole possibility of stimulus, in terms of the economic problems that may actually help push health reform along. So I just kind of wanted your insight on that.

Claire McCaskill: Well, I think Daschle’s going to be a very strong – he clearly, I mean I’d recommend his book on health care reform to anybody who hasn’t read it. He’s really knowledgeable in this area and this was what he really wanted to do because he is driven in terms of wanting to work on health care reform in this country. I think we will get at some serious health care reform within the first, hopefully the first of two terms, but the first Barack Obama administration. I think they’ll be some nibbling around the edges on some health care reform, possibly even in the stimulus. Expansion of the ability to stay on COBRA for example. Some, some additional funding for children’s health insurance. Potentially some tweaking of the Medicare rates. I think all of those are within the realm of possibility in the stimulus. But nobody is backing off at really taking a whack at the silos of profit in the health care industry and reconfiguring health care so it’s more efficient, effective and certainly more preventative. Yes?…

“…I don’t think we can afford to plus up certain silos of profit in the health care industry.  I think we can figure out ways to provide competition and choices and to bring down costs. And that are the three goals. Competition, choices, and bring down costs…”

“…But nobody is backing off at really taking a whack at the silos of profit in the health care industry…”

We’re waiting.

I was recently visiting in the San Francisco Bay area where I came across this op-ed about the “evils” of the public option in the San Francisco Chronicle.  All I can say is when you are at a loss for words at the stupidity of the wingers, just reduce ad absurdam. One could, of course, try this exercise and substitute fire departments, etc. for libraries.