The Senate finance committee strangles health reform's best idea.

How to fix health policy.
Sept. 29 2009 6:38 PM

Public Enemy

The Senate finance committee strangles health reform's best idea.

Click here for a guide to following the health care reform story online.

The Senate Finance committee's vote not to include a "public option" (i.e., a government health insurance program) in its health reform bill came as no surprise, but it was baffling all the same. Chairman Max Baucus excluded it from his chairman's mark. Yet even as he voted against it Tuesday, he said, "There's a lot to like in a public option" and "A public option would help to hold insurance companies' feet to the fire." He was voting against it, Baucus explained, because it couldn't get 60 votes in the Senate.

Baucus is right that there are not 60 votes in support of the public option. (If health reform were brought up as a "reconciliation" bill, it would need only 50 votes, a goal more within reach. Unfortunately, Democrats have little stomach for this gambit at the moment.) The public option has no support among Senate Republicans and is even opposed by many Senate Democrats.

But this isn't an instance of politicians bowing to popular passions. As the liberal watchdog Media Matters pointed out, more Americans believe in the existence of UFOs (34 percent, according to a 2007 Associated Press poll) than oppose the public option (26 percent, according to a recent New York Times poll). Even among Republicans, opposition tothe public option (42 percent) is outweighed by support (47 percent). Polls consistently find that the public option is more popular than health reform itself.

Nor is this an instance of politicians bowing to the doctors' lobby. Support for the public option among physicians is even greater than it is among the public (63 percent), even though it's intended to curb their fees. Within the health care lobby, only health insurers are dead set against the public option, because it would shrink (and, eventually, if greatly expanded, could largely eliminate) their market share.


The strong public support for the public option has persuaded its chief supporters, Sen. Jay Rockefeller, D-W.Va., and Sen. Chuck Schumer, D-N.Y., that even if they're unable to get it into the health reform bill on the Senate floor, it will eventually become law. Balanced against this sunny view is the bleaker one (expressed by Rockefeller at the Tuesday markup) that health reform will put half a trillion dollars into private health insurers' hands over the next 10 years. As lobbies become wealthier, they tend to become more powerful, not less so.

The Senate markup was full of nonsensical moments. (A fuller account of the proceedings is available here.) Sen. Kent Conrad, D-N.D., who persuaded Baucus to substitute the public option with funding for nonprofit health care cooperatives, waxed rhapsodic about the health systems in France, Switzerland, Germany, and Japan, which provide benefits through "not-for-profit insurers" like his proposed co-ops. But he neglected to point out that these foreign nonprofits enjoy an advantage the Baucus plan doesn't deliver. In France, Switzerland, Germany, and Japan, it isin most instances against the law to provide basic health coverage on a for-profit basis.

Sen. Charles Grassley, R-Iowa, said he couldn't support the public option because the government had a history, in the Medicare program, of breaking initial promises not to limit physicians' fees. This was just moments after his fellow committee Republican, Sen. John Cornyn of Texas, had complained that the public option would lead to out-of-control entitlement spending. For the record, the public option is not an entitlement program. Entitlement programs involve automatic spending. Whatever Congress spent on a public option would have to be appropriated.

The public option failed not once but twice, first in a version proposed by Rockefeller and then in a compromise proposed by Schumer. Rockefeller's undiluted version failed 15-8, with five Democrats and all Republicans voting against. Schumer's failed 13-10, picking up two Democrats (Florida's Bill Nelson and Delaware's Tom Carper). * Public-option advocates will now try to shoehorn it into the bill that gets blended with the Senate Health committee's bill (which includes a public option); to pass it through amendment on the Senate floor; or to get House-Senate conferees to support it.

Success is possible but unlikely. Public support may need to rise to 90 percent before Congress is willing to concede that voters want it.

E-mail Timothy Noah at



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