The Take

New life for the public option

By Dan Balz
Sunday, October 25, 2009

The resurrection of the public option is the latest and one of the most surprising turns in the long battle over legislation to overhaul the nation's health-care system. Under assault for months, and declared on life support repeatedly in recent weeks, the provision for a public insurance option is unexpectedly alive as House and Senate leaders prepare to send their bills to the floor.

That doesn't mean it's a done deal. Whether it survives the final battles, and in what form, are still the unanswerable questions. Multiple versions of a public option are on the table. Liberal and moderate Democrats are still at odds and are drawing lines in the sand in hopes of exercising maximum influence on the outcome.

Senate Majority Leader Harry M. Reid (D-Nev.) and House Speaker Nancy Pelosi (D-Calif.) are still scratching for the votes to pass bills with a public option included. But by next week, both hope to have bills ready either for unveiling or to send to the Congressional Budget Office for analysis and scoring.

What encourages some of those who have followed this debate closely from the inside is the degree to which Democrats are in sight of a compromise on the public option and other remaining differences -- though many may have to accept some disappointment to get a bill to President Obama's desk.

What brought the public option back to life?

Conservative opposition nearly sank the public option over the summer. Many Republicans called it a government takeover of health care. Some conservatives see it as the first step toward a single-payer system (as do some liberals). At the height of the town hall and Tea Party activity, the White House appeared to be running for cover. Officials worried that the public option had become a proxy for more pervasive concerns about the amount of government intervention Obama was calling for in his economic and domestic policies.

Administration officials sent equivocating signals. White House Chief of Staff Rahm Emanuel, driven by a pragmatic desire to get a bill through Congress, appeared willing to sacrifice the public option, if necessary, to reach the larger goal. The president maintained that he still preferred to see a public option in the legislation, but he told one town hall audience that this was merely "a sliver" of the overall health-care debate. In other words, if it sank into obscurity, he wouldn't weep long over its disappearance.

The conservative opposition and the administration's apparent wobbliness prompted a counterattack by liberal advocates of the public option, who saw it as the holy grail of the debate. Few experts see it that way, and there are no doubt far more important provisions that would have a more direct effect on coverage, on how individuals are treated by their insurance companies and in controlling costs (still the weakest element of bills under consideration). But the grass-roots support had an effect.

When Congress returned to Washington in September, the debate's focus shifted to the dynamics of the Senate Finance Committee, where Chairman Max Baucus (D-Mont.) had labored for months to produce a bipartisan consensus. To that end, he joined several other Democrats in opposing two versions of a public option in the committee's bill, saying he saw no way to get 60 votes in the full Senate.

That seemed to spell the end for the public option. Baucus, however, managed to get one Republican, Sen. Olympia Snowe (Maine), to join with Democrats in approving the legislation. Snowe opposes a public option, but she has advocated the use of a trigger mechanism that would allow a government insurance plan if private competition proves inadequate. Snowe's future votes remain conditioned on what is in the final bill.

With virtually unanimous Republican opposition likely, Democrats reevaluated the politics of the public option. Two recent events contributed to their renewed push to include it. One was the insurance industry's decision to attack the legislation and issue a report warning of higher premiums. The report triggered a backlash among liberal Democrats, who decided to push even harder for a public option.

Then last week, new polls, one from The Washington Post and ABC News and the other from the Henry J. Kaiser Family Foundation, found clear majority support (57 percent) for a public option. The Post-ABC News poll showed support had risen five percentage points since August. The new numbers emboldened public-option supporters to press harder, even though the same polls continued to show the public divided over the overall shape of health-care legislation.

National polls are one thing. But getting the votes in the House and Senate is quite another. For red-state senators or House Democrats from marginal districts, perceptions of public opinion at home are another, which is why rounding up the votes for a bill with a public option remains a challenge.

Pelosi has long been a determined advocate for the public option. The most robust version, which would pay on the basis of Medicare rates, appears not to have enough votes to get through the House. As of this weekend, Pelosi's fallback appears to be a provision that pays on the basis of negotiated rates, still a relatively robust approach.

Reid is trying to attract 60 votes for a bill with a more qualified public option, one that would let states opt out of the system. Even if he is a few votes short, Reid is inclined to include the option in the bill that goes to the floor. Snowe's trigger mechanism may be the fallback position in the Senate if there aren't 60 votes for an opt-out plan.

On Friday, Pelosi signaled her receptivity to the opt-out approach as a possible compromise between the House and Senate, a sign that despite her advocacy for a robust public option she doesn't want to jeopardize reelection prospects for the moderate-conservative members of her caucus.

Much negotiating and posturing lie ahead. Obama told Senate leaders late last week he still sees value in trying to keep Snowe in the coalition. But liberal Democrats will be unhappy if the Senate bill includes her trigger mechanism rather than something stronger.

That will then test Democrats' cohesiveness, and Obama's leadership and persuasiveness. That battle could be weeks away. The fact that the House and Senate now appear likely to receive health-care bills with a public-option provision is surprise enough.

© 2009 The Washington Post Company