For some time now, I’ve been hearing what Kip Sullivan calls the “yes, but” position on health care reform. That position says roughly that yes, Medicare for All, is the best available solution for the problems besetting our health insurance system; but, unfortunately, Medicare for All is not “on the table” right now, so we have to push for the public option. I’m afraid I think that as a basis for a strategy of engagement with Congress, both in and outside of town hall venues, this position is very ill-considered.

I don’t think it matters whether someone actually prefers Medicare for All, or a strong public option, or whether someone actually thinks that Medicare for All is “unfeasible” right now, and that the best progressives can possibly get in the current political environment is a strong public option. In all these instances, the best thing to do, and this is especially true in town hall contexts, is to talk about Medicare for All, to push for Medicare for All, and never, never, try to push for a strong, or any kind of public option. Why not?

The answer is multifaceted. The case for Medicare for All is much simpler to make than the case for a public option, and the objections to Medicare for All are well-known, and can be easily refuted by you. In addition, systems similar to Medicare for All, exist in most advanced countries, and have worked in these countries in a much more cost effective fashion than our private health insurance system works here. In other words, there is a factual basis for thinking that Medicare for All will work. First, similar systems work in other nations. And second, Medicare for Seniors works here.

On the other hand, the term “public option” is vague, and there are many possible variations of the public option. None have been shown to work. The public option idea is experimental. And, in particular, the proposal included in HR 3200 for a public option is both experimental and implausible, and we have little reason to believe that it will work given its intended small scale and very slow development. Apart from these considerations, however, the public option/exchange idea in HR 3200 is hard to explain in such a way that people can be persuaded that it will perform its tasks of lowering costs and also developing a provider network that will supply good services for public plan subscribers. In other words it is a hard sell to “regular” people because it is hard for them to understand.

One of the most important reasons why a proposal with a public option should never be pushed is because you can’t gain anything politically by advocating it, rather than Medicare for All, and you are likely to lose a great deal. Let’s say one advocates for Medicare for All, and that then you find that there is large number of votes for it, but not a majority. Then you have a bloc of Congresspeople on record as supporting Medicare for All. If that bloc is large, and if its members are willing to stand firm against any other reform proposals, others who want reform badly will have to offer something significant. The more stubborn the Medicare for All bloc is, the more likely it is that a strong public option will be offered as a compromise.

Alternatively, however, if one advocates a “robust” public option bill to begin with, and if, as is now apparent, one lacks a heavy majority for it, the bloc supporting it will be offered a compromise of either a weak or no public option at all. So, you have gained nothing and lost much by going the public option, rather than the Medicare for All route.

To put a somewhat finer point on this view, what kind of strategy of negotiation is it to begin negotiations with the position that you want to end up at? What kind of boneheaded play is that? If you were selling a house and you wanted $185K for it, would you start out by asking 185K for it or would you ask 205K? What the public option folks have done, and are still doing is like asking for 185K when they want 185k, a sure recipe for having to settle for 175k or 165k depending on the market.

Supporters of the public option have been very concerned about spreading the word about it and “selling it” to people, and they often say that this is the key to success. “If only people understood the benefits they will get out of the public option.” But the funny part of this whole process is that there’s no need to explain the public option to people right now at all. All you really have to do is to work as hard as you can to explain Medicare for All and get it passed. If you get close enough to passage or get enough votes to block anything else, the strong public option alternative that is likely to emerge from this conflict situation can be explained to people as a compromise that you had to settle for, but that can be transformed to Medicare for All later if the compromise doesn’t work.

So, in short, progressives should forget about the public option and push Medicare for All for all we’re worth at town halls, and in other venues over the coming months. For both Medicare for All and “Yes, but . . . “ progressives this is the best thing we can do. So let’s do it, forget about pre-judgments of what’s on or off the table, and let the chips fall where they may.



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.