Of course, all of us have heard about one of the President’s favorite maxims, “the perfect is the enemy of the good,” with its implication that practicality most often calls for us to forego our attempts to reach a hard to achieve or impossible ideal, in favor of acting to achieve a good result that, while not ideal; certainly represents an improvement in our current situation. It’s very hard to disagree with a proposition like that; but while there’s nothing wrong with the idea behind it; the devil is in the details of how you apply it.

For example, in the present health case reform context, the President evidently thinks that “Medicare for All” is the “perfect,” while a “public option,” or perhaps some compromise, still to be worked out, is “the good.” But such a view is both highly simplistic and problematic, and seems more like a device for labeling a view one doesn’t like, then a maxim that can really serve as a guide to action on health care reform. First, by no stretch of the imagination could “Medicare for All,” or its current embodiment in HR 676, be mistaken for “the perfect.” Medicare for seniors, even though most seniors are happy with it, has serious cost control problems, and, of course, health care in the United States has serious quality problems whether it’s funded by Medicare or not. Second, while “Medicare for All” would certainly not be “perfect,” it’s also not true that other alternatives on the table such as “the public option” are necessarily “the good.” The term “public option” is systematically vague. As the old saying goes, it covers a multitude of sins. It can refer to a Government-run entity equipped with the ready-made provider network of Medicare, and reimbursement rates that are as the same as Medicare’s, along with the authority to contract with anyone for health insurance; and it can also refer to a Government entity that begins with no provider network, that is constrained to charge prices that are no different from the prevailing rates of private insurance companies, and that has the authority to contract only with individuals who have no access to other health insurance; or it can refer to anything in between. A “public option” bill can be set in the context of a public health care exchange, or not. It can be offered in the context of universal mandates for individuals to acquire health insurance, or not. It can be offered in the context of subsidies for lower income individuals who cannot afford to comply with such mandates or not. It can be offered in the context of elimination of discrimination based on preconditions and rescissions, or not. Depending on various combinations of these conditions, many variations of “public option systems are possible, and not all of them are equally, “the good.” So, the question immediately arises; if “Medicare for All” is “the perfect,” and “public option” is “the good,” then which “public option” is “the good?” How do we tell if a particular variation of the public option is “good?”

A variant of this problem also besets a column offered by Paul Begala at WaPo this morning, called “Progress Over Perfection.” Begala expresses the following sentiments:

”Progressive politics is, in my view, a movement, not a monument. We cannot achieve perfection in this life, and if that is our goal we will always be frustrated. . . . “

”. . . I’ve never seen the Republican right oppose a tax cut for the rich because it wasn’t generous enough; I’ve never seen them oppose a set of loopholes for corporate lobbyists because one industry or another wasn’t included. The left, on the other hand, too often prefers a glorious defeat to an incremental victory. . . .”

”. . . The question is not whether I or other progressives will support a health-reform bill that includes everything we want but, rather, whether we will support a bill that doesn’t. . ."

”. . . I am trying to find the right blend of principle and pragmatism — ever mindful that, aside from race, health care is the most difficult domestic issue of the past century. FDR couldn’t pass it. Nor could Truman, nor Nixon nor Carter nor Clinton. Lesser presidents like George W. Bush didn’t even try. . . . “

”The Founders gave us a standard: "a more perfect Union." It’s an odd phrase; we don’t generally speak of something becoming "more perfect." I believe it means that we have a duty, every generation, to make progress. For a dozen generations we have done that, in our imperfect way. Let’s hope those writing the new health-reform bill can give us something that represents historic progress — and that those of us most passionately committed to fundamental reform can celebrate progress, not lament a lack of perfection.”

I couldn’t agree more with these sentiments. But the same problem that besets Obama’s maxim, besets this advice also, because just as there is always difficulty in deciding whether a particular health care reform bill is really “the good,” we have pretty much the same difficulty in evaluating whether a particular health care reform bill is an instance of “progress” or not.

Put simply, most of us might agree that a public option fulfilling Jacob Hacker’s original specification, might be an instance of progress. On the other hand, to consider a “public option” bill such as the ones we see coming out of the Senate HELP committee, or HR 3200, “progress,” might be stretching that term a bit. Both these bills put the “public option” in effect in 2013, and both only make a small percentage of the population eligible for the public option. Both deny the public option a ready-made provider network, and rates at the level of Medicare. And both provide individual mandates for health insurance and mandates for businesses, greatly expanding the private insurance market without doing much to regulate costs. Considering that the public option in these bills covers only a small proportion of the population, and that the bills are designed to constrain the public plan from competing too vigorously with the private insurance companies, and also that the mandates and subsidies specified in these bills are likely to provide a $1 trillion revenue increase for insurance companies over 10 years, are these bills really an improvement over the status quo?

Well, certainly they provide progress by banning exclusions based on preconditions and rescissions, and if these bills provided only for these things, they might well be instances of progress though surely only incremental. However, given the narrow scope and likely ineffectiveness of the public option in both bills, and also the great cost involved in subsidizing private insurance, I seriously question whether this could be called progress. Moreover, if the public option is replaced with Kent Conrad’s co-ops, and there is no public option in the final bill at all, it will be even harder to claim that we have achieved either “the good” rather than “the perfect,” or “progress” rather than “perfection.”

In short, I think that both the President’s maxim and Begala’s slogan are not much help as guides to action. In the end, even if we’re determined not to privilege the “perfect” over “the good,” or “perfection” over “progress,” we still have to determine whether any particular health care reform bill really does constitute “progress” before we decide to support it. And from my point of view, spending $1.5 trillion on a health care reform bill that won’t really cope with the problem of accelerating insurance costs is not progress even if it abolishes denials of insurance based on preconditions and also rescissions. It seems to me that it is a lot easier and cheaper for the taxpayer, for Congress just to pass an incremental bill that will outlaw denying insurance coverage based on preconditions and rescissions, and also discrimination in premium pricing against those who have such preconditions.

Why don’t we do that until the insurance companies are ready to support at least a robust public option along the lines originally proposed by Jacob Hacker; if not “Medicare for All,” itself? Can the Blue Dogs really oppose this? On what grounds, that it will make the insurance companies unprofitable? Who cares? After all, it won’t cost the taxpayers anything at all, will it? And it can also be implemented immediately, rather than waiting until 2013. Now that’s incremental progress I, a Medicare for All advocate, can get behind. I understand why the Republicans in Congress with their great sympathy for health insurance companies might have a problem with it? But why would any Democratic Administration or Congressperson?



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 www.dkms.com, www.kmci.org, www.adaptivemetricscenter.com, and the blog “All Life is Problem Solving” at http://radio.weblogs.com/0135950, and http://www.kmci.org/alllifeisproblemsolving. 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.