The best reason to create a public health insurance option is to increase competition in the health insurance market and thereby lower premiums. No one can know how much money a public option would save, but the idea seems worth trying as an efficiency measure.
It is being treated as much more than that–as the central battle of the summer and perhaps of the whole 111th Congress. Some liberals (an explicit example is Paul Krugman) want to show that assertive governments can do good–thereby debunking modern conservatism, which holds that governments are the problem. Passing a public option would demonstrate that a ruling majority in America today supports activist government; the success of the new policy would then increase support for such activism. As Mark Schmitt observes, the origin of the public option was not research into which policy would cut costs, but rather a political strategy to get a victory for expansionist liberalism.
For that very reason, conservatives want to defeat the proposal. Defeat would demonstrate that there is no pro-government ruling majority in America today; it would also allow opponents to argue against the evils of the public plan without the risk that it might work in practice.
This kind of proxy battle is common today. For example, charter schools are promoted by libertarians, who want to demonstrate that choice can improve quality even in an area traditionally run by the state, and by moderate liberals, who want to show that the public sector can innovate and therefore doesn’t deserve to be cut. Charter schools are opposed by some traditional liberals who think that market-type competition is overrated and who want to draw the line at the schoolhouse. The decision whether to turn a given school into a charter thus becomes an ideological proxy battle rather than a rather complex, nuanced, fundamentally local question about which governance structure would work best in each situation. (See my analysis here.)
There are advantages to ideological politics. We must simplify by applying broad principles, or else the complexity, variety, and nuance of the world is overwhelming and we cannot act at all. Voter turnout rises when there is more ideological conflict because it is easier to engage when the lines are sharply and simply drawn. Ideological strategists, such as the libertarians of Victorian England and the activist liberals of the New Deal, have sometimes achieved great things.
But the drawbacks of ideological politics are obvious: oversimplification, suppression of worthy alternatives, manipulation of voters who aren’t attuned to the ideological game, and a tendency to confuse means with ends. We see these problems in today’s health care debate. The true goal for progressives is to provide all Americans with affordable health insurance. There are crucial provisions in the main Congressional bills for that purpose–notably, subsidies for low-income Americans and regulations to protect people who have pre-existing conditions. The details of these provisions are essential. Who is eligible for how much financial support are the most important questions for poor people. They are not, however, the focus of the great national debate–for two reasons. First, poor people are not organized or influential. Second, subsidies are not an ideological proxy issue. We already subsidize health care–it’s unexciting (but very important) to propose spending more.
The public option should be a means (a mechanism to cut costs and therefore make it easier to insure everyone), but it is becoming the end because of its symbolic role in ideological politics.
Meanwhile, liberals don’t seem interested in the potential of private co-ops, if appropriately designed and funded. That’s because co-ops have been portrayed simply as a compromise between liberals and conservatives, and therefore as a disappointing outcome for those–on both sides–who want an ideological “win.”
I suspect that the health care debate is less engaging for average Americans than it should be because it has turned into an ideological proxy debate that makes most sense to the “base” on both sides. By the way, the conservative ideological base is usually about twice as big as the liberal ideological base–26% called themselves conservatives versus 15% who identified as liberals in the 2004 American National Election Survey.
I noted above that ideologies can encourage participation by providing comprehensive worldviews that make decisions easier. But only certain kinds of ideologies work for that purpose. A vital ideology needs an impressive story arc, beloved and talented current leaders, moving examples, strong networks and organized backers, opportunities for grassroots engagement, and a coherent theory. New Deal liberalism had all those, at its peak. Paul Krugman’s ambition is to resurrect statist liberalism as a movement. Maybe that’s possible, but it certainly hasn’t happened yet. Thus I am not at all surprised that most people feel left out of the ideological proxy war that is taking place among political elites and strong partisans. I am also not surprised that conservatives are winning the health care debate–it is a proxy battle, and they have more true believers. If it could be about how to provide the best possible health care for all Americans, it would be a different story.