I think I agree with you. But I also suspect that another political reality is that those to whom a public option has such great meaning have to go through a period of learning how a public option isn't a magic pony? But yeah, it's a pity that it has basically firmed up to an ideological argument about public/private sucking up all the oxygen.

AdAbsurdum, legislating genuinely strong and effective regulation will be just as difficult and politically daunting as legislating a substantial and broad public option with effective market power.

That's because the underlying political problem isn't with the form of the policies involved; it's with the inherently uphill and game-changing nature of the agenda itself. No matter how you slice it, progressive health care reform comes down to this: To deliver better health care to more people for lower average cost means taking something of value from some people and transferring that value to others. There is no way around this, and no politically pain-free way to avoid the bitter fight that will be required in order to succeed.

There is an existing health-industrial complex, composed of some very wealthy people - but also lots of ordinary managers, service-providers and laboring wage-earners - and that vast industry depends on the preservation of the status quo to hang onto the mountains of wealth created and reaped by their industry, and on which their accustomed livelihoods depend. They will fight like wolves to preserve what they have now, no matter how we endeavor to take it away from them, and the supporters of progressive health care reform need to be prepared to fight back just as hard, and compete unsentimentally for a larger piece of the economic pie.

People sometimes talk about high and unnecessary "costs" and "waste" in health care as though they are talking about money that is literally being burned in wood stoves or flushed down toilets. But that's not how waste occurs. Everywhere money moves, it moves out of one pocket and into another. If the expenditure is deemed wasteful, then that means you have a situation in which goods and service that are currently being exchanged for a certain quantity of money either don't need to be provided at all, or are being provided by suppliers who are vulnerable to being hard-bargained into providing those goods and services at a lower cost. In either case, the elimination of that waste means that that supplier gets less and the customer gets more.

For any instance of waste you care to identify in the health care industry, eliminating that waste means imposing a financial hit on somebody, somewhere: some medical supplier who is getting away with charging one price for supplies when he could be squeezed into charging much less; some doctor who is making $500,000 a year when he and his peers could be squeezed into accepting $200,000; some CEO who is making $10 million a year who could be replaced with one making $1.5 million; some medical insurance salesman who is making one level of commission who could be forced to accept a lower one. If progressive health care succeeds, many of these people are going to be hurt economically. That's a clod, unavoidable fact.

The system is indeed full of fat, waste and exploitation; and as a result most of us get worse, less reliable and more expensive health care than we might otherwise have with a leaner and more efficient system. To serve the broadest public interest, we the members of that public are going to have to put our hands around the necks of the people who are profiting most handsomely from the current system, and wring more out of them. We need to push them up against a wall, turn them upside down and shake the loose change out of their pockets. The public has to begin to deal with this massive complex the way a large wholesaler deals with its vendors: by banging their estimable market power and market share down on the table to demand the most goods and services at the lowest possible price, and by creating, or threatening to create, nonprofit government alternatives when private industry won't play ball.

But if the health-care consuming public continues to be divided and fragmented into millions of little customers, their potential market power and leverage will remain diluted, and the health biz will remain a sellers' market.

You are going to get the same fight if you go the purely regulatory route. If you regulate the policies insurers can offer, the prices they can charge, the restrictions they can impose, the risky customers they must accept, the deductibles they can require, the salaries they can pay, the minimal levels of service they are responsible to provide, then you are going to have the same fight all over again, even if the whole system remains "private". In the end, the powerful beneficiaries of a system that is working for those people are going to fight to oppose changes that make the system worse for them so it can be better for others. It doesn't matter whether the threat to their interests comes in the form of a new government-operated competitor, or a whole bunch of government legal rules that grab hold of the market and direct it away from laissez faire market decisions into publicly-mandated ends.

We can succeed in getting more for less. We this all the time in the business world. Industries slim down, smarten up, work harder and reorganize their work forces when they are forced to do so by the competitive environment. To succeed, we the health-care consuming public have to build ourselves into an awesome competitive force to get a better deal for ourselves. But if we and our legislators are afraid to play hardball, we will lose.

I believe a public option is vital, because it gets the public's very large foot in the door, wearing the heavy shoes of the United States Government. Once that foot is in the door, even if only a little bit initially, we can pry it open wider and wider. We can adjust and augment the public option in future legislative sessions, and threaten to make it bigger, more comprehensive and more muscular if private industry doesn't deliver more on their own. We need to get our hands on that hammer.

Allowing states to opt out of the public option will allow insurance companies strikes me as very risky business. Insurance companies might be able to target opt-out states and sell insurance at cut rates there as a "loss leader". Then they can say, "Look at how much better health insurance is in Alabama than Oregon! That's because Oregon employs that damn public option!" They can conspire to kill the option with games of this sort if all of our states aren't required to opt in.

Winning a better and fairer economic outcome for ourselves and our posterity is going to be a sometimes ugly, painful and ruthless competitive business. We need to be prepared to go up against ruthless, serious people who fight these kinds of business battles every day. But the American public is throwing fortunes away on health care costs - fortunes they can save if they get their act together to pool their market power and throw their weight around. So let's stop pussy-footing around, and let's get on with it. Americans have to turn themselves into a large 10,000 pound gorilla, and start sitting on people to get what we want.

Your idea would require a system of regulation that actually had government regulating industry, which in turn requires some professional integrity and a committment to do the job. We have seen how that system, while good if you can get it, rarely works in America because the system has become so corrupt. It didn't workon Wall Street. It won't work for health insurance. But it's a good idea in other countries where they implement regulatory programs with integrity and don't allow the regulators to be captured by the regulated industries.

That's an excellent point except that the same forces that are arrayed against Medicare for all are also not going to accept that level of regulation. I think the frustration here is that the insurance companies are really going for something like the status quo with the added benefit that the currently uninsured Americans will be forced by law to become customers (a prize so valuable that they were willing to trade rescission rights and pre-existing conditions exemptions to get it).

I always advocated for cost controls of some sort. Some sort of regulation on premiums.

I also joined Obama's "once upon a time" idea of a public option.

You guys own this now.

The constant omision from this discussion of the success of entirely private-insurance-based systems in Switzerland, the Netherlands, and Germany smacks of ideological bias.

Hmmmmm.....

According to T.R. Reid, from his book The Healing of America, and excerpted at WGBH Frontline [paragraphs reordered and emphasis added to make my point clearer],

The Bismarck Model

Named for the Prussian Chancellor Otto von Bismarck, who invented the welfare state as part of the unification of Germany in the 19th century. Despite its European heritage, this system of providing health care would look fairly familiar to Americans. It uses an insurance system -- the insurers are called "sickness funds" -- usually financed jointly by employers and employees through payroll deduction.

The Bismarck model is found in Germany, of course, and France, Belgium, the Netherlands, Japan, Switzerland, and, to a degree, in Latin America.

Unlike the U.S. insurance industry, though, Bismarck-type health insurance plans have to cover everybody, and they don't make a profit. Doctors and hospitals tend to be private in Bismarck countries; Japan has more private hospitals than the U.S. Although this is a multi-payer model -- Germany has about 240 different funds -- tight regulation gives government much of the cost-control clout that the single-payer Beveridge Model provides.

Oh, snap!

Omitting the "and they don't make a profit" part of the "entirely entirely private-insurance-based systems" in the countries you mention... smacks of ideological bias, if not outright misrepresentation.

I'd be fine with a Bismarck system under those parameters. Unfortunately, that too is "not on the table" here in our bought and paid for Congress.

More from Reid here, among other places. Google away.

In Germany, health care is based on private insurance BUT the insurance MUST BE non-profit.

Take the profit motive out of the health insurance industry and you'll see health care costs go down immediately.

But you're living in cloud cuckoo land if you think this would make it past our Senators (D and R) from Corporatist Insurance-Co.

Sorry, can't tell you that. Wish I could.