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What Might Have Been; What Still Might Be

Many progressives, even though they’ve been working for a PO-based health care reform bill, have 1) never given up Medicare for All as the goal of their activity, and 2) decided, in the first quarter of 2009, that Medicare for All could not pass the new Congress. They then reacted to their realization by concluding that since Medicare for All couldn’t pass, they would not advocate for it anymore politically, but would transfer their activist commitment to getting a strong public option. Last Spring, they had in mind a Jacob Hacker-type PO, which they saw as the road to Medicare for All. So, in short, they took Medicare for All off the table as something to push for, and they did so because they thought the impossibility of its passing was "reality."

In my other life, in the field of Knowledge Management, I sometimes work on the idea of reflexivity, a favorite notion of George Soros’s, and also on complex systems, a field having to do with the rise, maintenance, and fall of various types of systems, including human organizations of various kinds. Both of these notions are closely related to the idea that to some degree at least we make our own realities, or, as some in systems theory put it, we constantly "bring forth our world."

One of the things we mean by this, is that, to some degree, and especially in social contexts, we and others help to make our own reality. Social reality is not given to us, so much as we contribute to making it ourselves. In turn, this means that our futures are not pre-determined for us, and that, in particular, there is no pre-set future social reality, but rather there is only the reality that we, in concert with our fellow humans, make.

Now, getting back to the thinking pattern of a lot of progressives in the Winter and Spring quarters of 2009, we can see that they decided that a social reality in which Medicare for All was feasible by the Summer or Fall of 2009 would never occur, and as a result of that prediction, they decided not to advocate for it anymore in this round of reform, but to advocate, in just as determined a way, for Public Option-based legislation, because they thought that it was the best that progressives could possibly hope for in the short run, and, many of them, thought, it might lead to single-payer over 5 – 10 years anyway. They set about creating, in other words, a social reality of reform with a robust PO.

They may well have been right about their prediction of the fate of Medicare for All, but I think they made a mistake when they concluded, further, that just because Medicare for All was unlikely to happen in the short run, they ought to give up pushing for it, and instead concentrate their political activity on pushing for a “robust” PO. I think this because, in deciding to take Medicare for All off the table, and working for a PO instead, they have brought forth a world in which the robust PO that was their pre-compromise position proved hard to communicate, became the left wing of the political spectrum of recognized possibilities, and the focus of attacks from the insurance industry, and so gave way in the legislative/lobbying process to what is likely to be at best a reform with a very, very weak PO, or even a “trigger,” that they must really bite their tongues to continue to support.

By committing to tactics of explicit advocacy of a robust PO, aimed at bringing about legislation, they set themselves on a path where the judgment that they needed as robust a PO as possible, always implied continued explicit advocacy of a robust PO at every stage of the legislative/lobbying process, regardless of the degree of defeat suffered at the preceding stage. When the most liberal House and Senate committees came out with disappointing bills that were quite far from the original idea of a robust PO, and had a completely unacceptable band-aid period, during which the majority of the deaths, bankruptcies, and foreclosures due to lack of health insurance would continue, they believed that they had to react with support of the best of those bills, because they offered the best available PO on the continuum of robustness. When the committees merged their bills, and even though the result fell far short of their original pre-compromise, there was nothing to do, they thought, but support and redouble efforts to prevent further erosion in the PO.

When similar things happened in the Senate, progressives had similar reactions when it came to lobbying activity. In each case where there was disappointment, the progressives revised downward their notions of what was possible, and prepared to bring forth a world with a weaker PO-based reform. Each time they did that, they took action that was part of a more global process that led to an even weaker PO. This process is a classic example of reflexivity: one’s judgment of what is possible leads to one’s choice of action, which impacts a later judgment of what’s possible, which impacts one’s choice of a similar action as before, and so one goes round and round in a deflationary cycle that ends with action defending a PO-based reform that is only a shadow of what one started out to support.

But, going back to the first step, why did progressives conclude that since Medicare wasn’t possible in the short-run, but the public option was, that, in this round of reform, at least, they ought to advocate for the PO explicitly and directly, and push as hard as they can to get as robust a PO as possible? This certainly seems like the commonsensical, and straightforwardly rational thing to do, but it clearly wasn’t, because it drew them into a reflexive downward spiral of decreasing PO robustness within every stage of the legislative process, until now they are facing a PO predicted to enroll only 3 million people, or perhaps even “triggers,” which won’t be operative until 2014, which may allow state opt-outs before the exchange and the PO are operative, and which may even contain the Stupak anti-choice language.

What progressives could have and should have done instead, regardless of what they believed about the ultimate feasibility of getting it passed, was to have taken the seemingly completely irrational course of refusing to take Medicare for All off the table, mobilized the 87 co-sponsors of HR 676, and insisted that they would defeat any reform bill that wasn’t HR 676. Had all progressive movement groups held to that position, and all progressive legislators too, and loudly announced that they would oppose, and vote against, all committee bills that weren’t HR 676, and loudly announced, as well, that Nancy Pelosi’s synthesis bill had better be HR 676 if she wanted their votes. they would have brought forth a completely different world, an entirely different reality this Fall.

Imagine if, at the first stage of this process, the progressives had not agreed to take HR 676 off the table in the House and S 703 in the Senate. The first thing that would have happened is that the MSM and cable news would have talked about Obama’s rebellious Party ideologues who were contradicting all the tenets of pragmatism, who were allowing the perfect to be the enemy of the good, who were insisting on single-payer, and who were refusing to accept his leadership and undermining his newly-elected authority. Since this opposition in the ranks would have been big news back in January and February, the progressives would have gotten interviews. Single-payer, enhanced Medicare for All, would have been presented to the broader public back then. It, and not the PO, would have been touted as one of the main reform policy positions, even while it was also characterized as the ideologue position. The support for Medicare for All in Congress, however, whether ideological or not, would have connected to a popular movement for Medicare for All, very early on, and enabled that movement. To avoid a fight with the progressives and lots of press articles about how ineffective he was being as a leader, President Obama might have concluded that the best way to go was to feed this popular movement, to find its leaders, to get them into the White House, and to help them to mobilize the public in favor of Medicare for All.

Why would he do that? Because every good politician knows that when the crowd starts to move, you need to get out in front of it, if you expect to have any control over it at all. The crowd needs to trust you as one of its leaders. And after all, any health care reform bill is a great victory for his Administration, even if it destroys the insurance companies as a viable political force that can’t provide campaign contributions either to Democrats or anyone else.

The insurance companies would have fired on Medicare for All very early, of course, and the pharmaceutical industry too. Both would have attacked it as “socialized medicine.” But everyone knows about Medicare because their grandparents and parents have it, and 86% of them like it. People know that it’s not socialized medicine; but only Government-funded insurance. It can be easily communicated to them that if Medicare for All is enacted, they won’t lose their providers, but only their insurance companies, which a heavy majority of them hate and mistrust anyway.

What about the polls? Well once the MSM had made the very early progressive insistence on Medicare for All, a popular narrative, they would have included Medicare for All in their polling. In fact, there’s a good chance that their framing would have suppressed polling of the PO entirely, because the progressives would not have had it on the table, as something they were pushing. Even if that had not happened however, both Medicare for All and a “Medicare-like PO” would most probably have polled 75% together, with Medicare for All itself at around 55-60%. That support probably would have been maintained throughout the Summer, because the tea bag movement would have had a lot more difficult time tagging Medicare with “death panels” and “Government takeover of medical care,” than they had doing that with PO-based bills that no one understood.

What about the blue dog and ConservaDem opposition in the House? With 55-60% supporting Medicare for All and 15-20% supporting the PO, the blue dogs and ConservDems would have had a hard time, proposing anything in opposition to Medicare for All, other than a Jacob Hacker-type PO. How many votes would they have had. Well, that would have depended on the President.

If early progressive stubbornness and the appearance of a popular movement had persuaded him to be friendly to Medicare for All, and get out in front of the movement, then the whole group of Congresspeople who routinely support a president of their own Party would have come over to Medicare for All. Adding that group to the 87 progressive co-sponsors of HR 676, one would probably have been looking at 200 votes in the House. Not enough to pass Medicare for All, but getting close.

In a situation like this, and assuming the same “no” behavior we see now from the Republicans, the result, with some leadership and heavy presidential pressure, would be that either Medicare for All would have passed the House in a close vote, or a compromise with the blue dogs on a strong Hacker-type PO would have emerged behind closed doors as a compromise. In this scenario progressives would have had to compromise only once, at the end of the process, and there would have been no need to sell the PO idea to the public, except as the best alternative possible to Medicare for All itself.

What if the President wouldn’t back Medicare for All, but maintained neutrality from the House proceedings, while saying, in typical Obama fashion, that, in principle, he agreed with it, but . . . . That would still leave the Presidential Party in the House as the arbiter between the blue dogs and the more numerous co-sponsors of HR 676. If the partisans of HR 676 stood very firm, the most likely outcome would again be a very strong PO, much superior to what we have now.

How about the Senate? Well to reasonably project what might have happened there, I think we first have to forget about the political landscape we see now, because an alternative landscape in which the House progressives insisted on HR 676 until the very end of the process, would have been very different from what we see today. One difference would have been that progressives in the Senate would have seen many representatives in the House standing up for Medicare for All, and also an external movement, good polling for Medicare for All, and much better press coverage for it than we see now. Cable news commentators like Chris Mathews, Ed Schultz, Keith, Olbermann, Rachel Maddow, and Dylan Ratigan would be covering it far more than they are now, as would various commentators on CNN, and Fox, though in a much less complimentary way.Finally, netroots commentary would have been much more frequent and much more complimentary than it has been.

If the President aligned with the House progressives and the movement, then Senate progressives, and presidential followers in the Senate would have been much emboldened to follow the House progressives, and most probably more than 40 Senators would have fallen in line in back of Medicare for All; not enough to pass the bill, even through reconciliation, or through using the nuclear option. Nevertheless, those votes would have been enough to guarantee a much better compromise bill emerging from Senate negotiations, especially if Harry Reid made it clear that health care reform would not be subject to the regular order in the Senate, and that extraordinary measures would be used to pass a reform bill. With only 10 Senators, none of whom were the most extreme blue dogs and Conservadems left to bring over, I think the likelihood would have been very good, if the progressives held very firm, that a compromise on a Jacob Hacker-type PO would have been negotiated in the Senate too, and one without a band-aid period before implementation.

What if Obama stayed above the fray, beyond endorsing Medicare for All in principle, to accommodate the movement? In that case, there would still be roughly 20 votes for Medicare for All. With the House progressives standing firm for HR 676, and a Medicare for All movement ongoing, these Senators would have done the same, and no health care reform bill could pass without accommodating them. On the other hand, their hand would be weaker than in the first scenario, because the Senators who primarily support the President, would be less supportive, more neutral to Medicare for All, and more interested brokering a compromise deal with the remaining Senators needed to get to 50 votes so that reconciliation, or the nuclear option, could be used to pass a health care reform bill.

Nevertheless, stubbornness, on the part of Medicare for All supporters would still have worked to get other Democrats to move toward at least a strong PO-based bill, without a band-aid period, because the alternative is no bill at all, and blue dogs and the White House cannot abide that. The result would have been a much stronger PO-based bill coming out of the Senate. With a Jacob Hacker-type PO bill coming out of the House and a weaker, but still very strong PO, coming out of the Senate, the Conference Committee would have produced a bill very close to Jacob Hacker’s original design. That’s still not Medicare for All, and progressives whose goal is such legislation would still have had work to do in the future. But the result would have been far better than we are looking at now; both for those who prefer Medicare for All, and for those relatively few who prefer the PO in principle.

Finally, why have I constructed this narrative of what might have been, if only the progressives had concluded that the likely eventual defeat of Medicare for All, did not entail that they should stop advocating for it, and pressure only for a public option based reform?

First, because I wanted to make it clear that whether or not Medicare for All is possible to pass in a given legislative session, doesn’t determine whether we ought to do all we can to advocate for it or seek it. What does determine that, or at least should, is an accurate assessment of what the consequences of continued advocacy and pressuring for it are likely to be. Nor, is the seeking in such a situation merely just symbolic. It can have a variety of practical effects including: a) educating people about what Medicare for All might mean; b) influencing the context of the legislative process producing health care reform; and c) influencing and shaping the actual negotiations affecting that process.

Second, I wanted to sketch out the reflexivity trap progressives had gotten themselves into when they adopted the PO-based strategy for getting health care reform. Since a PO-based reform is a vague and ambiguous concept, that represents a moving target for reform, many different positions on the continuum of robustness of PO – based plans exist, and this reality of many choices that might fit the idea of the PO, fits perfectly with the many stages a bill goes through in our legislative system, to produce a de-generative spiral of gradual weakening of the PO as the process moves through its successive stages. The PO concept was tailor-made for gradual watering down in the crucible of legislative conflict, and commitment to it in the abstract by progressives, condemned them to a reflexive process that resulted in this gradual weakening of the PO, until the possibilities we see today were created by the progressives’ own PO advocacy-guided interaction with other parties in the process.

Third, I wanted to make it clear that progressives contributed vitally to the outcome we have now, by their choice to enter the reflexive process of getting the PO through the legislative process, while accepting as their goal trying to get the best PO-based plan they could at each stage of the process. As soon as they committed themselves in this way, they committed themselves to defeat and failure. They could have created a different social reality by just insisting on Medicare for All and refusing to enter negotiations on the type of PO that would be accepted as a compromise until the very last stages of the process. But they didn’t try this, because they were afraid of working against their new President, or of being marginalized as ideologues, or of engaging in a protracted conflict with their fellow Democrats.

And fourth, and last, of course, I wanted to try to prevent the lesson of the process we are currently still engaged in from being misconstrued. That lesson is not that the United States is not ready for a robust PO-based plan right now, and that we must keep trying to fight for one in the coming years and educating the public about what the PO is. That is the wrong lesson because it is a trap. It is a trap that results in 2000 page compromises full of loopholes. It is a trap because it involves endless negotiations about the precise variation of the PO idea that will be enacted. It is a trap because it opens legislation up to band-aid periods in which we fail to ends deaths, bankruptcies, and foreclosures due to lack of insurance coverage, and to endless negotiations about which parts of the population can enter the exchange and have access to the PO, and which cannot. It is a trap for countless other reasons as well.

The right lesson for progressives to learn now is that the present bill must be killed, because it is a terrible bill which makes the future worse, as I’ve argued here, here, here, and here. And, once it is killed, progressives also need to forget about advocating for the PO. The PO is not a goal, it is not something that can stand alone as an ideal that will excite people. It is a second-best tactical solution that we can accept only as an outcome that emerges at the end point of the legislative process, and only if Medicare for All, after all of our most intense efforts, can’t get through that process.

We cannot seek the PO in the context of an incremental legislative process, and expect to be successful. We must seek and work for, and move heaven and earth for, only Medicare for All, whether we believe we can pass it or not, and then, if we do fail to pass it, we must be prepared to use the desire of others for any reform bill, to compromise just once on a Jacob Hacker-type public option, without entering a multi-stage de-generative reflexive process that will kill the PO as an instrument for getting to Medicare for All.

(Also posted at the Alllifeisproblemsolving blog where there may be more comments)

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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.