Whatever happened to the public option?

March 22, 2013

This weekend marks the third anniversary of the Patient Protection and Affordable Care Act, better known as "Obamacare." And for those of us who covered that rollicking debate, most of it seemed to be about one central question: Would there be a public option?

Remember the public option? It was, for many Democrats, their absolute top priority during the health-care reform debate. But they didn't get it. A handful of conservative Democrats, led by Sen. Ben Nelson of Nebraska, made clear that if there was a public option, they would filibuster the final bill. And so it died.


Ex-Sen. Ben Nelson helped kill the public option in 2009. Why hasn't it come back? (Chip Somodevilla/Getty)

But among the Democratic base, the public option was extraordinarily popular. Many liberals turned on the entire bill when that element was cast aside. And it wasn't just liberals. The option commanded substantial public support. Poll after poll showed it to be one of the more popular elements of health-care reform.

The benefits of a public option were often overstated. In particular, there was a lot of confusion about the differences between a public option that shared Medicare's pricing power, which really could save money but was never politically feasible, and a public option that was just a government-run health insurer, which would save much less money but genuinely had a chance to pass Congress.

But even the weaker public option could've played an important role in the reforms. Many experts thought it could serve as a "benchmark" in in the health-insurance marketplace. As the Urban Institute put it:

The arguments around the public plan too often ignore what we believe is the central reason for including a public plan as a component of reform: that health insurance markets today, by and large, are simply not competitive. And as such, these markets are not providing the benefits one would expect from competition, including efficient operations and consequent control over health care costs. We believe that the concentration in the insurance and hospital industries that has taken place over the past several years has been a significant contributor to this problem. The role of the government plan is to counter the adverse impacts of market concentration and, in doing so, slow the growth in health care costs.

Given the intensity of Democratic support for the public option in 2009 and 2010, it's something of a mystery why there's barely any discussion of it in Democratic politics today. Although it's still true that a public option can't get the votes, nor can Medicare vouchers, a repeal of the health care or making Medicaid a block grant program. But Republicans spend enormous amounts of time and political capital pushing all those ideas. Their theory is that if any of them have the potential to win approval in the future, they need to start pushing them now.

But there's no ongoing Democratic push for a public option. It pops up every so often -- in the House Progressive Budget, for instance -- but it has few champions who seem to be pursuing a long-term strategy to get it into the health-care law.

So its absence in the political discussion is a bit curious. And since the strong version of the policy was estimated by Congressional Budget Office to save more than $100 billion over 10 years, it would be a natural talking point in the budget debate. It would seem like savvy politics for eager Democrats to take up the public option again: Just as Republicans are going to need bills that respond to the problems that will crop up amidst the implementation of Obamacare, Democrats are going to want to be able to promote their own answers to the problems that will crop up in the first year.

So that's the question: Recalling the intensity of the support for the public option in 2009 and 2010, how has it so totally disappeared from the Democratic landscape?

Further reading:

Obamacare's most popular provisions are also its least well known.

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Brad Plumer · March 22, 2013