The three co-founders of The American Prospect, each of them -- Robert Kuttner, Robert Reich, and Paul Starr -- considering himself a good progressive, square off in an article titled Debating the Public Option.

You would think from the title that the three of them are debating the merits of a public option, or how a public option ought to be structured, but what it really is is Kuttner, staunch single payer advocate, calling out Starr and Reich, apologists for parasites, on their stupidity. So ok, Kuttner doesn't actually call them stoopid. Allow me...

Paul Starr starts it off:

According to last week's Washington Post, the public option is the "crux" of the health-reform debate and the "greatest challenge" for Senate negotiators to overcome. That's an accurate description of the current political scene, but it's true only because so many people, including members of Congress, are responding ideologically to the idea of government involvement.

The public option is not the biggest question in reform. Under the proposals being considered, it would be offered only within insurance exchanges at the state and regional level. The far bigger question is how those exchanges work:

He lays out a few questions of design, and points out some of the possible pitfalls, in a health insurance exchange[s], then winds up with a very smart statement:

In other words, we could get a public plan that instead of "disciplining" private insurers, as the president said last week, actually buttresses their dominance of the system. Watch what you wish for.

Okay, so the fact that he's seriously discussing something designed to keep a bunch of parasites around [don't they have worm medicine for that?] is a black mark against him, but he's right that the public plan is unlikely to "discipline" private insurers.

Robert Kuttner thinks Starr is an optimist:

The public option, as it is evolving, is even more dubious than Paul Starr's apt critique suggests. Under the House leadership bill, people who have coverage through their employers are ineligible. So the proposed, head-to-head competition between the public plan and private competitors is left to employers, not individuals.

So, that bit about if you like your insurance, you can keep it is a lie, because only your employer can keep or dump that plan, whether you like it or not, and the bit about if you want to buy into the public plan instead, you can is a lie too, at least for the 160 million or so who have that oh-so-desirable employer-sponsored insurance. He goes on:

What's distressing is that progressives have put all their eggs in this leaky basket. It's clear that Jacob Hacker's original inspiration -- that over time the superior efficiencies of a true public plan would crowd out private alternatives -- is being undermined by the politics of compromise.

Now, quite possibly Hacker's heart is in the right place, but only someone living and working in an ivory tower could write this:

According to opinion polling, most Americans want public and private insurance competing side by side so that they can choose the best option for themselves and their families. Both should have a chance to prove their strengths and improve their weaknesses in a competitive partnership.

Um, no. Most Americans just want to be able to take their kids to the doctor when they get sick, but if you stick something about "competition" into a poll and ask them about it, a lot of them will parrot it back to you because that's what they've been told will solve all their problems for the last 30 years. They don't give a flying fuck about "competition", they want their problems taken care of.

But I digress.

Back to Kuttner, who will tell you the truth when no one else will:

In public opinion polls and in liberal advocacy, the badly flawed public option has become a kind of proxy for what most Americans really want -- national health insurance. That's the true public option. It would be far more cost-effective, because it would eliminate so many industry middlemen and would remove the incentive to put health dollars into profit centers. Politically, protecting the public option from industry mischief is no less a heavy lift than single-payer. It's a pity that all the progressive energy that's gone into defending the public option hasn't gone to advocate national health insurance.

Robert Reich, an otherwise smart dude, whips this out:

Paul Starr worries that the public plan would end up a dumping ground for the sicker and more expensive. If that were the likely outcome, private insurers, the pharmaceutical lobby, and the American Medical Association would be all in favor of it. But they're apoplectic about a public option [...] will further erode their margins.

Yo, Rob, those people are going to wax apoplectic about everything. This is how they get what they want, by throwing tantrums. Also, unlike Democrats, they seem to believe that successful negotiations begin with asking for more, far more, than they're willing to settle for.

I'd prefer a single-payer, but it's got no skin in the game. The only practical hope we have for expanding coverage and taming health-care costs lies with the public option.

How can so many things be so wrong in so few words? He'd prefer single payer, but... at least he said practical, instead of pragmatic. Skin in the game?! Wha? That's just gratuitous blather here, about which you could even say I don't think that [phrase] means what you think it means. Expanding coverage? Haven't we been "expanding coverage" since about 1912? That's worked out well [not]. And a public option is as likely to tame health care costs as my putting a bird feeder on my front porch is going to tame the pair of hawks that are nesting in my neighborhood.

Oh, and then he goes on to scold those of us who are holding out for single payer for blowing the country's one chance at real reform [yes, I hyperbolized there a bit, but not a lot].

Starr is back with:

I don't agree with Robert Kuttner that progressives should be insisting on single-payer (Medicare for All), which would provoke an overwhelming political backlash not just from the health-care industry but from the large number of Americans who are satisfied with what they have. Moreover, I am leery of putting all our expenditures for health care on the public budget, which might have the effect of crowding out other desirable public needs. And I am skeptical about the wisdom of (one-sixth and growing).

Crowd out is another one of those buzzword thingies so beloved by the Libertarians. Libertarians are not going to bring us meaningful health care reform, don't use their words, or their ideas. And the wisdom of permanently centralizing decisions about so large a share of the economy? Dude, this centralization that you decry is how all those other countries have kept the health care parasites from taking over huge portions of their economies. It's hard to get good enough data to separate it all out, but probably we're only spending 10-12% of our economy on actual care, with the other 5% or more being skimmed off by useless leeches. Far better for all of us if that 5+% were going to renewable energy, affordable housing, better schools....

But a few paragraphs later, the public option, instead of centralizing a huge portion of our economy, is going to crash a huge portion of our economy instead:

The industry is genuinely scared of a public plan that would pay doctors and hospitals Medicare rates, which run 20 to 30 percent below what private insurers now pay providers for the under-65 population. According to the most widely cited estimate [that would be the infamous report by the Lewin group, why can't these people ever cite their sources?], a public plan on those lines, if offered to all employee groups and individuals, could enroll more than 100 million people who now have private insurance.

But what would happen in that event? The resulting sudden drop in the flow of funds to the health-care sector would cause a monumental financial crisis throughout the system.

So that drop in in the flow of funds to the health care sector back in the 90s caused a monumental financial crisis throughout the system? And a little math for ya, the $350 billion or so that full-blown Medicare for All would save in the first year is about 15% of the $2.4 triliion we're going to spend this year on health care and all its related leeches. Weren't you the one who was worried just now that we weren't spending this money on other important stuff?

He goes on to tell us more about how to design a proper health insurance exchange, which is w-a-a-a-a-y more important than having a public option:

The public option has gotten all the political attention, but the real "crux" of reform is the system of rules that govern all competing plans. If the Democrats can't get a strong public plan through the Senate but can get a strong design of the exchanges by trading off a weak public plan, they should take that deal and pass the bill.

So the really important thing is for the government to properly design an insurance market [Ezra Klein likes designing exchanges too... whatever happened to the "respectable liberal" blogger?]. I guess health care will just naturally flow our way after that.

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Finally, Kuttner comes back with his wrap-up, starting off slowly:

Reich says that single-player has "no skin in the game." Well, let's put some there, rather than being apologists for a threadbare cloak of a public option.

Where Starr and I disagree is on both his diagnosis of Medicare for All, and on his optimism that "exchanges" could be designed in a way that would meet his hopes (the exchanges sound a lot like the purchasing pools of the Bill Clinton plan that Paul Starr helped devise).

And finishes up by including The Prez himself:

The regulatory and political nightmare of doing everything that Starr insists is necessary to get a system of insurance exchanges to work efficiency is actually far more of a daunting challenge than having a single system under direct public control. And the odds are that the Obama administration, by the time it is done reassuring Max Baucus, the health insurance industry, the drug companies, and the Blue Dogs, will settle for far less than Starr's formula.

Reich may say that if we just work hard enough, we can prevent that fate and still get a good program. But Obama began with less than what we need, and he has not painted this as a battle of the people against the interests. The bill gets weaker with each succeeding round. I suspect that by the time there is finally legislation for him to sign, Reich and Starr will both feel that it falls way short. It is high time for progressives to stop settling for badly flawed second bests and to throw their energy into a first best that could rally popular support and produce a system that serves everyone.

Yo, Progressives! What part of Medicare for All do you not understand?