The politics of health insurance reform is a great example of reflexivity. Reflexivity is the idea that acceptance and assertion of our beliefs about reality, has an effect on how we act, which, in turn, has an effect on reality, and to some extent creates it; and, equally, reality influences what we think about it and how we act, thus closing a reflexive circle. George Soros who has written a lot about reflexivity focuses on the idea of interference and specifically on the interaction of the cognitive and manipulative functions underlying human decision making and action.

In current health insurance reform politics, it was decided early on that America wasn’t ready for a Medicare for All, single payer program, and therefore that it was not feasible to try to pass such a program. This decision seems to have been made collectively by key members of the Obama Administration, including the President, as well as key members of Congress including the heads of important committees such as Teddy Kennedy, Charlie Rangel, George Miller and others, The Speaker of the House, and the Majority Leader of the Senate. Outside of the Government, progressive interest groups such as Move-on and Health Care for America Now (HCAN), also made that judgment early on, and have supported the Administration in taking “single payer off the table.” In addition, key influential individuals like John Podesta and George Soros have supported this view, with Soros becoming one of the major financial benefactors of HCAN.

Of course, when high-level political leaders and influential interest groups and individuals decide that Medicare for All isn’t feasible, and then act based on the basis of their conjecture to take it off the table in Congress, and marginalize people like John Conyers, Anthony Weiner, Dennis Kucinich, and Bernie Sanders who favor it, they don’t test their conjecture about its feasibility, they self-fulfill it, and provide a clear example of reflexivity, and of the unanticipated consequences often associated with it. And the irony of this example, is that George Soros, the long-time student of reflexivity is heavily involved in an operation where a commitment to a particular construction of reality has given rise to unanticipated consequences, that neither he nor his allies bargained for.

The decision to take single payer off the table in Congress and off the agenda of major interest groups contributing to the health care debate, has removed the awkwardness of having to entertain and give serious consideration to two progressive alternatives in Congress, but it has also deprived many in the progressive movement of the chance to support and work for their preferred health care solution, and it has done so in a way that Medicare for All supporters think is unfair, and frankly not very bright, if one’s objective is really to pass legislation with either Medicare for All, or at least a strong public option.

The impact on some single payer progressives of taking their favorite alternative off the table without a fair hearing, is to leave a residue of resentment and anger among these progressives, and also a feeling that the Administration can’t be counted on to support progressive legislation when it has the chance to so. These folks are disinclined to stay active in the health care debate, and therefore to respond to current appeals by the Administration and its supporters to join with them to fight for health insurance reform.

The impact on still other single payer progressives is confusion in their writings about health insurance reform. A good example of that is in Guy Saperstein’s post at Alternet entitled “The Only Option for Health Reform Is the Public Option.” Saperstein does a really good job in his post of rehearsing the reasons why health insurance reform is necessary, including a variety of well-known statistics showing how poorly performing our system is compared to systems in the rest of the developed world. He also covers cost issues well and points out that the US spends twice as much per person as our nearest competitor, Canada, and that the private insurance system spends $300 Billion per year in Administrative costs, and another 300 Billion in marketing costs and profits. But when it comes to talking about solutions, Saperstein adheres closely to public option supporter talking points. Specifically:

”The most logical correction to the costly inefficiencies of the American private health insurance system would be a single-payer system — like Medicare, a popular and successful single-payer system.”

An acknowledgment that the best solution is single-payer, a Medicare for All system. He continues:

”But single-payer has proved to be too radical a change for Congress even to consider this time around, so we are left with the possibility of a "public option," which would allow individuals and employer plans to buy into a public system modeled on Medicare.”

”Too radical” for Congress is it? Where are the quotes and references to back this statement? The House has 85 co-sponsors of HR 676, John Conyers’ single payer bill. Also, where’s the President in all of this. Didn’t Max Baucus claim that it was the President who took single payer off the table? Saperstein continues:

”While this "public option" may not be the perfect solution, the perfect should not be the enemy of the good. Moreover, if the public option is robust, over time it would outcompete the costly, inefficient private health insurance system, and you would find not only individuals choosing the public option, but also employer health plans concerned about costs.”

”The perfect should not be the enemy of the good” is one of those slogans that substitutes for argument and reason. First, because we very rarely have "the perfect" even as a possibility in politics. And in the case of health care insurance systems, Medicare for All is certainly far from perfect, and we can guarantee that even if we implemented that solution, it would have problems and we would have to have to be very active in creating and maintaining the affordability of good health care. What we do know from our own Medicare experience, and from the experiences of other single payer systems is that such a system works a lot better than our current one. But perfection is not something we are choosing when we decide on single payer. Second, not only is Medicare not perfect, but a public option plan is not necessarily "the good," either. Right now, the details of any public option that might go through Congress are vague. Some public options may be good in that they might have an effect on costs in the insurance market. But others may be useless in shaping that market and may even have difficulty in assembling a network of providers sufficient to provide good health care to the relatively small number of enrollees the system would have in the first few years.

Of course, as Saperstein says, over time, a public option might bring down the costs of private insurance. However, this is not enough to make the plan good, because the kinds of public options being considered in HR 3200 and the Senate HELP committee bill have no prospect of reducing insurance costs in the short run, which means that public option plans under consideration are not the good at all, but rather alternatives that will not rid the system of those $300 Billion per year Administrative Costs, nor would they help at all with the other $300 Billion in marketing costs or in lower profits. Nor would these bills lower costs below the $6001 per person we spend now, and they would be very likely to increase those costs by a substantial percentage each year without a constraint on cost inflation imposed by the final legislation.

In short, insofar, as a single payer solution can claim the advantage of eliminating hundreds of billions of dollars in private insurance company administrative, marketing, and profit costs, lowering pharmaceutical costs through bargaining with the drug companies, and removing the burden of health insurance from all of our businesses; these overwhelming advantages cannot be provided by a public option of the sort we find in HR 3200. At best, such a public option might begin a decade-long process that would finally have its intended effect. But in the meantime, the United States would still have the most bloated health insurance system in the world, and, unless other aspects of the Administration’s health care reform are effective, one of the worst performing health care systems among the wealthy nations of the world.

So, what Saperstein gives us is an argument for a single payer system, because of its anticipated effects in lowering costs. But then confused thinking sets in when the case for single payer is taken as justifying a public option as “the good” based on what it would accomplish if it ever did morph into a single payer system over a long period of time. The only problem with this argument is that the public option is not “the good” in any practical, political time horizon that will mean anything to ordinary people. A supposed solution that will solve a problem in ten years, is no solution for today that anyone ought to be interested in, since during that ten years the chances are overwhelming that someone will come up with a solution that works within a year or less. Especially if they become sufficiently fed up with the dysfunctional system we are living under to get out from under their ideological prejudices.

In addition to sowing anger, resentment, and confusion among progressives, the judgment that Medicare for All wasn’t feasible, also had the effect of shifting the spectrum of health care plans being considered over to the right. This has to have hurt the negotiating position of the public option. As many have remarked the public option no longer seems like a compromise position, and therefore it can easily be painted as an extreme left-wing solution. But if Medicare for All was on the menu, public option plans would be seen as compromises, and depending on how strong single payer was it may have had a much stronger position in negotiations than it has now.

So, finally, it seems that the strategy of the President and the interest groups and individuals to back a public option, and tell everyone that Medicare for All is off the table, has had the unintended effect of weakening the public option itself, so that what we now face are alternatives that are unlikely to be successful in solving the problem. This result was produced by reflexivity, by the vagueness and ambiguity of the public option idea, and by the failure to think through how others would react to taking single payer off the table. It has, finally left the Administration with a big problem; the problem of mobilizing support for a health care reform that no one understands or loves. And when the Administration appeals to progressives to get excited about such a plan, and to go out and fight for it, the progressives have no idea what they will be fighting for.



Joseph M. Firestone, Ph.D. is Managing Director, CEO of the Knowledge Management Consortium International (KMCI), and Director and co-Instructor of KMCI’s CKIM Certificate program, as well as Director of KMCI’s synchronous, real-time Distance Learning Program. He is also CKO of Executive Information Systems, Inc. a Knowledge and Information Management Consultancy.

Joe is author or co-author of more than 150 articles, white papers, and reports, as well as the following book-length publications: Knowledge Management and Risk Management; A Business Fable, UK: Ark Group, 2008, Risk Intelligence Metrics: An Adaptive Metrics Center Industry Report, Wilmington, DE: KMCI Online Press, 2006, “Has Knowledge management been Done,” Special Issue of The Learning Organization: An International Journal, 12, no. 2, April, 2005, Enterprise Information Portals and Knowledge Management, Burlington, MA: KMCI Press/Butterworth-Heinemann, 2003; Key Issues in The New Knowledge Management, Burlington, MA: KMCI Press/Butterworth-Heinemann, 2003, and Excerpt # 1 from The Open Enterprise, Wilmington, DE: KMCI Online Press, 2003.

Joe is also developer of the web sites,,, and the blog “All Life is Problem Solving” at, and He has taught Political Science at the Graduate and Undergraduate Levels, and has a BA from Cornell University in Government, and MA and Ph.D. degrees in Comparative Politics and International Relations from Michigan State University.