Jacob S. Hacker is the Stanley B. Resor Professor of Political Science at Yale University. An expert on the politics of U.S. health and social policy, he is author, coauthor, or editor of numerous books and articles, both scholarly and popular, including The Great Risk Shift: The New Economic Insecurity and the Decline of the American Dream (2006; paperback, January 2008) and Health At Risk: America’s Ailing Health System and How to Heal It (2008).

Now that the core demand of progressives has been removed from the Senate health care bill--namely, the public health insurance option--should progressives continue to support the effort?

For me, the question is particularly difficult. I have been the thinker most associated with the public option, which I’ve long argued is essential to ensuring accountability from private insurers and long-term cost control. I was devastated when it was killed at the hands of Senator Joe Lieberman, not least because of what it said about our democracy -- that a policy consistently supported by a strong majority of Americans could be brought down by a recalcitrant Senate minority.

It would therefore be tempting for me to side with Howard Dean and other progressive critics who say that health care reform should now be killed.

It would be tempting, but it would be wrong.

Since the first campaign for publicly guaranteed health insurance in the early twentieth century, opportunities for serious health reform have come only rarely and fleetingly. If this opportunity passes, it will be very long before the chance arrives again. Many Americans will be gravely hurt by the delay. The most progressive president of my generation--the generation that came of age in the anti-government shadow of Ronald Reagan--will be handed a crippling loss. The party he leads will be branded as unable to govern.

The public option was always a means to an end: real competition for insurers, an alternative for consumers to existing private plans that does not deny needed care or shift risks onto the vulnerable, the ability to provide affordable coverage over time. I thought it was the best means within our political grasp. It lay just beyond that grasp. Yet its demise--in this round--does not diminish the immediate necessity of those larger aims. And even without the public option, the bill that Congress passes and the President signs could move us substantially toward those goals.

As weak as it is in numerous areas, the Senate bill contains three vital reforms.  First, it creates a new framework, the “exchange,” through which people who lack secure workplace coverage can obtain the same kind of group health insurance that workers in large companies take for granted.  Second, it makes available hundreds of billions in federal help to allow people to buy coverage through the exchanges and through an expanded Medicaid program. Third, it places new regulations on private insurers that, if properly enforced, will reduce insurers’ ability to discriminate against the sick and to undermine the health security of Americans.

These are signal achievements, and they all would have been politically unthinkable just a few years ago.

To be sure, the bill also contains a requirement on individuals to have coverage, which has become the main target of criticism from the left. Without the public option, this mandate amounts to forcing people to buy private insurance without creating an affordable public alternative with which insurers must compete.

But the correct response to this critique is to make the requirement less necessary by providing greater assistance with the cost of premiums and by facilitating enrollment in the exchange--in other words, by making coverage more attractive and easier to obtain. 

The lack of a public option also makes even more imperative tough requirements on insurers to make them live up to their stated commitment to change their business model and slow the spiraling cost of coverage. The most important way to do this is to move away from the Senate bill’s state exchanges and toward a national exchange such as that contained in the House bill. The federal government needs to be directly involved in implementing and enforcing strong national regulations of insurers and creating the new exchange. Otherwise, the effort for reform might fail at the hands of hostile governors.

The federal government is the only entity big enough and powerful enough to ensure a highly consolidated private insurance industry follows the law.  It can and must demand transparency and obedience to the new rules. Insurers must open their books, and subject their rates, administrative costs, and profits to federal review. These new rules must apply to all plans, not just those within the exchange. And states should have authority not only to enforce these rules, but to innovate beyond them as well.

These are not politically unrealistic goals. Most are already embodied in the House bill. In bridging the differences between the two bills, Democratic leaders and the President must insist on a final bill that delivers on these fundamentals.  

If it does not deliver--if the new options offered through the exchange do not attract broad enrollment, if insurers continue to undermine health security with impunity--then the worst fears of progressives will come true. Coverage will be too expensive because only those with the highest health costs will sign up. Fewer Americans will obtain insurance than expected. Small employers won’t want to take advantage of their ability to buy insurance through the exchange. And Americans will become increasingly disillusioned with the promise of reform.

Progressives have good reason to be angry. Yet we should harness our anger to fix the bill--now and every year from now. The current bills in Congress do too little to help Americans immediately; their main actions are delayed for years. If and when legislation passes, progressives should demand immediate concrete actions to make the promise of a reform a reality more quickly and more effectively.

So a bill must pass. Yet it must be a better bill that passes. And  it must be understood by the President, the Congress and every American as only a step--an important but ultimately incomplete step--toward the vital goal that the campaign for the public option embodied: good affordable health care for every American.

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