Volume 9: The Public Option Outlives Joe Lieberman; The Persisting Russian Election Threat
Mark examines the state of a public option for the American health care system; Jack discusses Lev Parnas's explosive testimony before the House Oversight Committee.
Policy Spotlight
The Public Option Has Outlived Joe Lieberman, Its Most Notorious Opponent
By Mark McKibbin
Over two decades ago, a graduate student named Jacob Hacker had an idea: what if the United States health care system could get to universal coverage by finding a middle ground between private and public health care insurance? In 2001, Hacker published a twenty-eight-page white paper introducing this idea, which became known as the public option. Hacker’s public option would have automatically enrolled uninsured Americans into a public Medicare-like health insurance program, established an individual mandate for purchasing care, and implemented a play-or-pay employment mandate requiring employers to either provide care through a private plan or help finance the cost of a public health care plan for their workers.
The idea of a public option had ample political upsides. Politically, it seemed less likely to spark backlash than moving to a single-payer health care system, as those with existing health care plans would not be forced to give up their coverage in favor of a new, untested insurance scheme. By contrast, those without insurance who would benefit from a public option would have nothing to lose and everything to gain.
In 2009, the public option seemed to finally be having its moment. President Barack Obama included the policy as the centerpiece of his health care reform proposal, the Affordable Care Act. Hacker, who was by that time a political science professor at Yale University, testified in favor of his public option brainchild at a US House Policy and Steering Committee hearing.
Then, Connecticut Senator Joe Lieberman, who passed away last Wednesday, demanded lawmakers remove the public option to receive his crucial sixtieth vote needed to overcome the Senate filibuster. In March 2010, President Obama signed the ACA, which no longer included a public option, into law.
Last year, I wrote a long piece on my personal Substack explaining the history of the American health care system through Taylor Swift songs. I called the public option the “red scarf” of American health care policy. Like the red scarf Swift sings about leaving behind at her ex’s house in “All Too Well,” the Democrats left behind the public option in 2009. Its one-time existence still serves as a bitter reminder of what the Democrats thought they had and then lost.
As part of my master’s thesis project on health care, I had the chance to interview Professor Hacker in the spring of 2022 about health care and the public option. With Lieberman’s passing last week, it felt like an apt time to revisit that interview and examine the status of the public option in 2024 and its future prospects in the policymaking arena.
The Public Option’s Catch-22
As a policy idea, the public option did not disappear after 2009. Joe Biden promised to re-introduce a public option during his 2020 presidential campaign. A public option was in the 2020 DNC platform. Yet once Democrats won the White House and gained united control of Congress for the first time in over a decade, the public option faded from their agenda. Other than a single mention in a fact sheet for the American Families Plan, Biden’s White House underwent public option amnesia. In Congress, there was little appetite for reviving it, with policymakers preferring to focus on expanding Medicare and ACA subsidies instead. In fact, there were reports that Democratic aides had quietly admitted before the general election that they expected the public option would be dead on arrival after the 2020 campaign ended.
Nevertheless, the public option still refused to die. In the past four years, as the public option has been de-prioritized by federal policymakers, it has found itself on the policymaking agenda in several states. As of 2021, Nevada, Colorado, and Washington have enacted public option programs.
It has been incredibly difficult, however, for these three states to mould the public option into a workable model for universal coverage. Lanhee Chen recently called Washington and Colorado "cautionary tales" about attempting to implement a public option at the state level. In a 2021 article, Hacker wrote that a public option would be “very hard to do at the state level.” He echoed this sentiment in our 2022 interview.
The public option is thus in a bind of federalism. A federal public option is operationally doable and politically fraught, while a state public option is operationally fraught and politically doable. This bind is different from the one facing single-payer health care, which at the state level is both operationally and politically fraught and at the national level is operationally doable but politically fraught.
With the public option facing a seeming political-operational Catch-22 at whatever level of government it is implemented, what exactly does the future of the public option look like?
Despite the various obstacles the public option has faced, it did not die with Joe Lieberman. There are three reasons to be optimistic about its future. First, state-level public option programs could still lead to upstream policy diffusion through the mechanism of a presidential campaign. Second, the emergence of health care as a winning issue for Democrats will give the public option more swings at the plate in future Democratic-controlled sessions of Congress. Third, viable proposals have been offered for a gaps-focused approach to implementing a modified public option.
Upstream Policy Diffusion
While state public option programs are experiencing their share of operational difficulties, it is still too early to know whether any one of the three states that have implemented a public option will be able to work out the program’s problems and demonstrate that a state-based public option is feasible. In my interview with Hacker, I asked whether he thinks there is a possibility that state-based public option programs might serve as a model for a national public option.
Hacker told me that if this kind of upstream policy diffusion occurred, it would most likely be because a Democratic presidential candidate chose to adopt a state-based public option as part of their platform. As an example of how this might work, Hacker pointed to Joe Biden’s adoption of the climate platform Jay Inslee implemented as governor in the state of Washington and ran on in Inslee’s 2020 presidential campaign.
“Jay Inslee runs for president, is not a successful candidate, but he brought his climate polices onto the national agenda. Biden ended up adopting a lot of the Inslee program,” said Hacker. “You could see that happening with a public option as well… it's going to have to work through some national political mechanism like a presidential race.”
Though I interviewed Hacker before Biden signed the Inflation Reduction Act into law, the fact that the Inflation Reduction Act included the largest investment in clean energy in U.S. history and was heavily influenced by Inslee’s blueprint only validated Hacker’s point.
There have been some promising signs that Colorado’s public option has led to a decrease in annual premiums for state residents. Colorado governor Jared Polis, who signed the public option into law and won re-election by 19 points in 2022, has not ruled out a bid for the White House in 2028. Polis or another would-be presidential candidate could point to the successes the public option has had in their state, the ways a national public option could do what a state-based public option could not, and bring the public option back onto Democrats’ national agenda.
Agenda Prioritization
Speaking of the IRA, this brings me to the second reason for optimism about the public option’s future. For the first seven years after its passage, the Affordable Care Act was more of a liability than an asset for Democrats politically—Republicans crushed Democrats in the 2010 midterm elections and made their promise to repeal the ACA a central piece of their platform.
But once Republicans were actually in a position to repeal the ACA following Donald Trump’s election in 2017, they blinked. There was an intense grassroots revolt against repealing the ACA, and none of the “repeal and replace” bills (regardless of whether the repeal was “skinny” or “thick”) was able to get 51 votes in the US Senate. In the 2018 midterm elections, political failure followed legislative failure, with Democrats’ retaking of the House of Representatives fueled by a strong backlash to Republicans’ attempts to repeal the ACA.
With health care finally a winning issue for Democrats, expanding the ACA became a top priority of Biden and the Democrats in 2021, especially given the focus COVID-19 put on the importance of quality, affordable health care coverage. The American Rescue Plan Act expanded the reach and generosity of the ACA’s subsidies until 2023. The Inflation Reduction Act extended those subsidy expansions until 2025 and allowed Medicare to negotiate the price of prescription drugs for the first time.
While the public option did not make it onto the agenda in the 2021-2022 Democratic Congress, when Democrats next have control of Congress, health care will continue to be a top priority. The public option may have another day in the sun as part of a prioritized health care reform package.
A Gaps-Focused Approach
The foremost reason reforming the U.S. health care system is so difficult is because of the complex web of stakeholders in the health care industry, which includes (but is not limited to) hospitals, pharmaceutical companies, insurance companies, doctors, and nurses. In 1993, Bill Clinton’s health care reform proposal floundered because of intense industry opposition.
In 2009 and 2010, Obama avoided Clinton’s mistakes by working with and accommodating the health care industry’s wishes on the Affordable Care Act. One of the insurance industry’s most important priorities was to leave employer-provided insurance intact. Obama and the Democrats complied, focusing on providing coverage for the uninsured rather than meddling with the plans of those who already had coverage.
A public option could emulate the ACA’s recipe for political success by limiting itself to a group of individuals without a comprehensive framework of public coverage: seniors in need of long-term care. Currently, the Medicaid program is the largest public funding source for long-term care in the United States. As a result, many seniors face long waiting lists to receive Medicaid funding for their long-term care needs.
“We have a system that is jury-rigged around Medicaid for nursing-home care,” said Hacker. “There are more and more elderly folks who are going to reach retirement without coverage, because Medicare doesn’t cover most kinds of long-term care. Every year, somebody issues a report saying, ‘we’ve got to do something about long-term care,’ and every year, nobody does anything. One of the things I tried to do in my last efforts on the public option [through the Build Back Better legislation] was to really say, ‘Look, we could do a public option with a really strong emphasis on long-term care services.’”
When the Build Back Better Act was shelved at the end of 2021 due to the opposition of West Virginia Senator Joe Manchin, immediate hopes for bolstering America’s long-term care system went down with it. However, other proposals could still function as a kind of public option for long-term care. One approach, the WISH Act, has proposed using a voluntary payroll tax to replace Medicaid as the primary source of public funding for long-term care. While this payroll tax is voluntary, it is an opt-out rather than an opt-in program, meaning that workers are automatically enrolled in the program until they deliberately go through the process of unenrolling.
By establishing a steady stream of funding for long-term care patients, the WISH Act or another similar proposal could reduce the stark inequities in America’s long-term care system. As it would not affect existing employer-provided coverage, a public option for long-term care would not encounter the level of hostility among the health insurance lobby or existing beneficiaries.
Suffice it to say that options for the public option still exist. With the right presidential candidate, the right timing, and the right design, the public option still has promise as a way to bring the United States of America closer to high-quality, universal health care coverage. ♦
Thanksgiving Table Takedown
'Sharing Lies': Russia Continues to Influence US Elections with GOP Aid
By Jack Carter Benjamin
Ah, C-SPAN. The butt of the joke every year at the White House Correspondents Dinner.
Cecily Strong, 2015: “This event is being broadcast on C-SPAN, so to some viewers watching at home on C-SPAN, hello. But to most viewers watching at home on C-SPAN, meow.”
Al Franken, 1996: “Now ordinarily I’m not one to engage in self-promotion, but this is C-SPAN and there are literally hundreds of people watching, so…”
Seth Meyers, 2011: “I am also honored to be performing for those of you here tonight, as well as the handful of people watching at home on C-SPAN. […] People think Bin Laden is hiding in the Hindu Kush, but did you know that every day from four to five he hosts a show on C-SPAN?”
Conan O’Brien, 1995: “Finally, I have an announcement for those of you watching tonight’s event live on C-SPAN: for God’s sake, it’s a Saturday night.”
Beltway humor aside, C-SPAN gives a just-the-facts version of the circus that is Congress, particularly the House of Representatives under Republican leadership. And there has perhaps been no greater circus than the Republicans’ impeachment inquiry in search of dirt on Joe Biden.
Launched last September and led by Kentucky congressman James Comer, the inquiry progressed despite no evidence of wrongdoing by President Biden before or during the impeachment. Rather, Comer is using a sham Biden impeachment inquiry to undermine the gravity of former President Trump’s two impeachments and sully Biden’s respected name.
The inquiry isn’t without its silver linings, however small they are compared to the “but her emails” redux regarding Hunter Biden’s laptop. Case in point: Lev Parnas’s testimony on March 20.
For those who may have forgotten amid the sheer number of depraved and criminal former Trump associates, Parnas was an accomplice of Trump attorney Rudy Giuliani in his attempts to dig up dirt on then-candidate Joe Biden. The broader scope of the efforts led to Trump’s first impeachment, as he was found to have pressured Ukrainian president Volodymyr Zelensky to launch an investigation into the Bidens on the false grounds (floated by Giuliani, Parnas, et al.) about Hunter Biden’s work for Ukrainian energy firm Burisma in return for $400 million in congressionally approved military aid.
On March 20, Parnas gave damning testimony against Trump and his Republican colleagues for continuing to knowingly lie about the Biden family for political gain. In doing so, Parnas said, Republicans and their friendly media apparatus, particularly on Fox News, were knowingly spreading false propaganda originating from the Kremlin.
“Everyone involved knew they were sharing lies,” he stated. “From Trump and Giuliani’s shadow diplomacy, to my missions to Ukraine and elsewhere […] everything was for the ultimate benefit of Donald Trump and thereby Vladimir Putin.”
In a notable exchange with Maryland Democrat Jamie Raskin, Parnas admitted the Trump team’s willingness to accept Russian disinformation.
Raskin: Were you aware, was Mr. Giuliani aware, that these people were basically just doing the bidding of Vladimir Putin?
Parnas: Absolutely.
Raskin: So he had no hesitation about spreading lies that were concocted by Russian agents?
Parnas: As long as it fit the narrative, absolutely not.
Parnas went on to call out specific Republican members of Congress for contributing to the Russian disinformation campaign. “There were also other people doing the bidding for the Russians,” he continued. “People in Congress, like Senator Ron Johnson, like Congressman Pete Sessions, who sits here right now, [and] was with me from the very beginning of this journey into digging dirt on Joe Biden.”
Parnas’s declaration of broader Republican ratfuckery is further backed by the fact that ex-FBI informant Alexander Smirnov, whose claim the Bidens were bribed through Hunter via Burisma was the core allegation underpinning the Republicans’ impeachment efforts, was charged with lying to the FBI. In fact, Smirnov’s lie was found to be “linked with Russian intelligence.”
It is deliciously ironic that the impeachment inquiry into President Biden has accomplished nothing other than to provide more evidence to impeach former President Trump again.
But Russia’s attempts to influence US elections have become a boogeyman, garnering less attention than they deserve. It is reminiscent of Brexit: a problem everyone recognizes to be actively harmful, and yet no one wants to actively tackle.
The Mueller report “did not establish that members of the Trump campaign conspired or coordinated with the Russian government in its election interference activities,” despite widespread obstruction efforts on behalf of the Trump campaign to conceal their activities. Consequently, the story of the Trump campaign welcoming Russian efforts to influence the 2016 election has fallen out of the broader context around ongoing Russian efforts to aid Donald Trump and destabilize American democracy as it wages a war against Ukraine and the West.
But that context is important. As military aid to Ukraine, a key ally, is once again held up (this time, in Congress thanks to pressure by Donald Trump and far-right Republicans), it’s important to remember the coordinated effort, dating back over seven years, to use Russian disinformation against Democrats.
As Parnas testified, such efforts are ongoing. Republicans are continuing to schlep lies concocted by a hostile foreign adversary that the US is currently waging a proxy war with. Such actions are craven and treasonous.
While you don’t have to have watched hours upon hours of C-SPAN to see how politicians have so blatantly betrayed their country without consequence, voters should pay closer attention to the MAGA movement’s reciprocal relationship with our enemies.
It is outrageous. Voters should be outraged. They should also be constantly reminded of how all the pieces of this multi-year disinformation effort fit together. And while I greatly appreciate C-SPAN’s work and wish it had a longer wingspan, the channel of political junkies and lethargic cats cannot be the only one bringing Donald Trump’s long and disgraceful rap sheet into the light. ♦