Because this post is running ridiculously long, I’m going to open with an Executive Summary:

By agreeing to speak no ill of the public option concept, the Congressional Progressive Caucus and likeminded others (categorized below as “public option pragmatists”) help ensure that the only critiques most Americans hear of this flawed idea come from corporatists and lunatics. In the process they facilitate the further marginalization of the solution they, and most Americans, support: profit-purged (aka single-payer) health care financing.

Instead of lashing out at single-payer advocates who criticize the public option concept, they would do better to incorporate those critiques into their core messaging. This would help them better communicate why they would prefer a single-payer system, if it were achievable, and it would in no way detract from their strategic advocacy for the least defective (ie, maximally single-payer-ready) public option possible. It would also open up space for positions such as the “single payer trigger” that could increase their negotiating leverage versus more capitulatory Democratic proposals.

The spectrum of politically engaged people and groups who agree that our nation would be best served by a single-payer health financing system subdivides broadly into three groups:

Public option boosters, who acknowledge the superiority of single payer in hushed tones, but who take most of their cues from the President and DNC. Like the President, they vehemently deny that a health reform system that incorporates a public option could, would, or should in any way serve as a transitional step toward single payer. Not only will they not lift a finger in support of single-payer advocacy, but they actively work to exclude single payer proponents and arguments from public discourse. The national leadership (as distinct from constituent groups and individuals) of Healthcare for America Now (HCAN) exemplifies this faction.

Public option pragmatists, who openly, even eloquently, declare their preference for single payer but have placed single-payer advocacy on hold in light of the crushing unlikelihood that it could pass this year. Instead, they work to ensure that any public option plan that does pass is as “robust” (ie, Medicare-like) as possible. Unlike the public option boosters, many public option pragmatists feel no compunction about expressing their desire to see a public option system ultimately transition to full single payer.

Although public option pragmatists may criticize weakened “compromise” public option formulations (such as that put forward by Senator Schumer), they join with the public option boosters in never publicly questioning the twin putative virtues of public option: 1) free “choice” of insurance plans and 2) the capacity of “competition” from a public plan to “keep private health insurers honest.” In fact, with surprising ferocity, they may attack more ardent single-payer advocates who publicly cast doubt on those virtues. The Congressional Progressive Caucus, or at least those working to enable them to speak with one voice, exemplifies this group, along with individual advocates such as the indefatigable (and IMHO, indispensable) Daily Kos diarist slinkerwink.

Single-payer stalwarts, who continue to push vociferously for single payer, as embodied in John Conyers’s HR 676, despite the dim odds of its passage this year. Many of these advocates have been on the case since the Clinton years or before. Far from monolithically “leftist” (not that there’s anything wrong with that), this group includes heavy representation among doctors and nurses, including at least two former editors of the New England Journal of Medicine. Core groups in this constituency include Physicians for a National Health Program (PNHP), the California Nurses Association/National Nurses Organizing Committee (CNA/NNOC), Healthcare Now! (older than, and decidedly unaffiliated with, HCAN), Progressive Democrats of America (PDA), and Single Payer Action.

Most single-payer stalwarts are furious at Obama and mainstream Democratic leaders for willfully excluding them from participation in forums and hearings on health care reform, especially considering that HR 676 has some 80 cosponsors and that poll data show 60% support for national health insurance among both physicians and the public at large. Most are also, if not furious at, at least disappointed in organizations such as moveon.org and Democracy for America for signing on early to the HCAN coalition and so abandoning strong single-payer advocacy before it could begin to gain traction in current deliberations.

Single payer stalwarts, unlike the public option pragmatists (much less the public option boosters), freely express grave misgivings about the viability of a public option plan, even if “robust.”

* They point out that even the strongest public option plan will preserve the structural defects – namely, the primacy of for-profit insurers and the infrastructures necessary to deal with them – responsible for so many of the medical and economic horrors highlighted in SickO and repeated many thousandfold each day.

* They note that the economies and social equities inherent in profit-purged systems have been demonstrated repeatedly in real-world examples outside the United States, whereas the benefits of a government/for-profit hybrid remain highly theoretical.

* Moreover, they worry that public disillusionment with a public option system, once its natural defects become manifest, will damage the credibility of government-based financing reform efforts generally, and so weaken rather than strengthen future prospects for a transition to single payer.

I’ve gone to the trouble of characterizing this taxonomy because I believe some interactions between the public option pragmatists and the single-payer stalwarts have become unnecessarily toxic and I think I may have some constructive suggestions in this regard. I do so transparently from my perspective as a single-payer stalwart, which is why when I call the above the “candor continuum,” you don’t need to guess which stretch of the spectrum I view as offering maximum candor.

All three factions make valuable contributions. You can link to this comment for much of what angers me about HCAN, but the organization has certainly done yeoman work in exposing and directing mainstream media attention toward health care swiftboating efforts, nouveau Harry and Louise campaigns, and Frank Luntz Rethug talk points.

Although the organization has generally tried to play nice with so-called centrist Democrats (earlier this year its web site contained a page allowing people to send “thank-you in advance” notes to Max Baucus for “taking on” health care; I can’t find it anymore), they have had no choice but to oppose Ben Nelson and his 7-year trigger and, more recently, Kent Conrad’s coop nonstarter. However, once a Democrat declares affinity with a public option scheme, even a crappy, capitulatory version like Chuck Schumer’s, they generally consider him or her safely within the fold.

Regarding the public-option pragmatists, let me stipulate that I loves me some Congressional Progressive Caucus, which represents the best we’ve got in the House. Most of the cosponsors of HR 676, after all, belong to the CPC. And I loves me some American Progressive Caucus Policy Foundation (APCPF), co-founded by Darcy Burner, who could not have chosen a more creative and constructive career alternative following her paper-thin loss in her recent run for Congress.

APCPF has been working with the CPC to help the caucus, which far outnumbers the disproportionately influential Blue Dogs, act more strategically as a bloc to exert meaningful leverage in Congress on a range of issues. My sense is that herding cats does not do justice to the difficulty of this effort, unless we’re talking about these bad boys.

The foundation has twice invited Intertube denizens to submit and proportionately weight questions to the CPC on health care reform. In both cases, a majority of questions, and votes for them, showed strong support for single payer and frustration at Obama and the Axis of Baucus having kept it off the table.

Given that this show has only just gotten on the road, it’s understandable that the process by which the CPC responds to such questions has been a little kerchunky. On May 21, and then on June 4, Rep Keith Ellison moderated hour-long discussions on the House floor in which three or four CPC members gave largely extemporaneous floor speeches about health care reform; Ellison would occasionally interject one of the questions from the Intertubes, which a CPC member would then answer, to a greater or lesser degree of responsiveness. Darcy then edited these sessions into 6-minute clips, linkable from her web site (currently the only one up is from the June 4 session, although I’m certain I saw one from May 21 as well).

Anyone who doubts the strength of CPC support for single payer should, as I have, slog through the full hour-long sessions (note: your right and left keyboard arrows allow fast-forwarding or rewinding in 1-minute increments). Your doubts will be allayed. Nonetheless, you will also observe a fairly strict message discipline with respect to the public option concept.

The CPC position, certainly more edifying than HCAN’s, is, We support single payer, but if we can’t get it, we want the most robust public option possible. They also appear unconstrained from expressing the hope (in defiance of Obama’s current position) that a robust public option will grind for-profit insurers into dust, and pave the way for single payer. But when it comes to directly acknowledging the deficiencies of a public option vs single payer, the clear instruction is, “Here Be Monsters.”

Regarding this message discipline, have a look at this article by Russ Mokhiber, or even better, this interview on which it’s based, regarding a June 4 presentation given by former PNHP analyst Nick Skala to the CPC (prior to the videotaped floor session). This brings some context to the curiously and uncharacteristically petulant tone of this post by Darcy Burner in DKos two days later. “[W]herever I go,” she wrote, “I see a small vocal group viciously attacking progressives for fighting for a public option – because they think it would be better if we utterly lost while chanting about single payer.”

The Skala interview also provides context to the exchange he had with Burner in the comment thread to her post, starting with this comment, to which Skala attaches the full text of his presentation to the CPC. I must say that I don’t see much evidence of “viciousness” on Skala’s part in his testimony, any more than I saw it in the critiques of public option plans voiced by Drs Himmelstein and Wolfe in this May 22 segment of Bill Moyers Journal.

Sharp critiques of the public option concept are not in themselves attacks on people trying to ensure passage of the least objectionable incarnation of this idea. If some single-payer stalwarts are viciously attacking the CPC, I’ve certainly seen no evidence of it. When I joined with single-payer activist groups to lobby Congress last month, we never received instructions to tell progressive Representatives to support HR 676 to the exclusion of attempting to achieve a robust public option.

Indeed, most single-payer stalwarts recognize the exemplary role of CPC members in finally getting a House hearing on single payer, on continuing to push for CBO scoring of single payer and/or of Pete Stark’s HR 193 “Public Option on Steroids” bill (not the official title). However, I do draw a sharp distinction between CPC members, who support single payer openly and vocally, and groups like HCAN, whose efforts to suppress discussion of single payer reach the laughable extreme of treating Bill Moyers (!!!) as a nonperson. In their case, it’s a little late to accuse detractors of viciousness when they’re responding to deliberate censorship and marginalization.

I promised (potentially) constructive suggestions, didn’t I? FWIW:

I would ask that public option pragmatists try to adopt – or at least stop going ballistic over – the candid and quite valid critiques of the public option concept coming from single-payer stalwarts.

I am not asking CPC members (or other public option pragmatists) to change their strategic advocacy, well articulated here, for a robust public option. But I would ask them to be a little less cheery about it and to couch that vigorous support as coming “more in sorrow than assent,” given the unquestionable inferiority of public option to single payer.

I would further suggest messaging along the following lines:

We take seriously the concerns of credible and authoritative analysts who predict that even the strongest public option will come nowhere near achieving the proven economies and social benefits seen with single-payer and related systems throughout the world.

We nonetheless will support our president, by trying to maximize the capability of a public plan to succeed, through competition, in making the for-profit insurance companies “honest.”

Given the high uncertainty of such an effort vs the proven benefits of single payer, we propose that any health reform package passed this year contain a single payer trigger (or single payer “sunrise”) provision, by which the failure to reach certain defined benchmarks (eg, full coverage, reductions in total median consumer expenditures on health care, number of medical bankruptcies, etc.) will initiate the provisions of HR 676 (or equivalent).

I know the argument that any criticism of the public option concept, even from the single-payer side of the spectrum, is functionally equivalent to a Republican attack. I believe proper messaging can prevent this. But I’m too bushed to pursue the question in depth. Perhaps this can be explored in the comment thread, if any.

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