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We are getting to that gritty grimy disgusting part of the legislative sausage making on health care where the fight is less about what shining principles we will achieve, and more about the best possible negotiating strategy for getting the best possible details in the bill. On a wide range of issues- including the public option, affordability for the middle class, who pays what in new taxes, how to lock in new cost savings, abortion, immigration- negotiators are still hammering out a wide range of details. Anyone who thinks either progressives or conservatives get a clean win on any of this is wrong, but anyone who writes the whole negotiation exercise as unimportant because we can't get clean wins is even more wrong. I have seen the effect of the details of public policy from both ends, as an organizer of poor and working class people and as a White House official, and I guarantee you that these details in real life.
We are now at a point where (a) the reconciliation option is virtually off the table for all kinds of political, timing, and procedural reasons (some of which I outlined a few days ago here); and (b) we are so close to getting a bill done that no one wants to be the person who stops it, making it likely to get passed. Where that leaves us is white knuckle negotiation time. The bill was never going to be everything progressives wanted: the question now is what percentage of what we wanted can we get.
Let's take the most publicized fight, the public option. We know for sure that it isn't going to look anything like Yale professor Jacob Hacker wrote up the public option idea a couple of years back, and all of us who have been fighting so hard for its enactment for the last 18 months are deeply troubled by that. But having fallen short of that, the details that are currently being discussed will matter enormously: will the new entity be national in scope or state by state? Will it be available from day one of a new system, or only if triggered? If there is a trigger, is it a trigger written never to trigger as the first Snowe trigger was, or is it a trigger that is more likely to be triggered, and triggered early on? Do anti-trust standards ever come into play in terms of the competitiveness of individual insurance markets? If the new entity is not exactly a public option, does it look more like the Tennesee Valley Authority in terms of its structure, or Fannie Mae (TVA is a whole lot better, because its board is appointed publicly and it is more accountable in general)? Are more people eligible for Medicare, Medicaid, and S-CHIP?
All of this matters a huge amount. These details have an enormous amount to say on whether there is any kind of real competition for private insurers, and on whether tens of millions have access to any kind of a decent public option, whatever it is called.
On every single issue, these kind of essential details are being worked through. It is essential that progressives negotiate together, and negotiate well, for us to end up with a decent bill. We can still make this a much better bill, but the process is as intense as it gets.
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