The Public Option Scam

So far in the Democratic primary campaign, the most common criticism of a single-payer healthcare system, or Medicare for All, seems to be that it deprives recipients of "choice." Because everyone would be put into a single national plan, critics say, those who actually like their already-existing private insurance would be unjustly stripped of the ability to stick with that plan, mercilessly "kicked  off" of it by an intrusive nanny state that would force them onto a less-preferred government plan. But they have a solution: the public option. This is a government-run plan that, unlike in the case of Medicare for All, consumers would have the option to buy into (and, perhaps, automatically be enrolled in if they lack private insurance). This way, these anti-single payer politicians claim, we could have our cake and eat it too: we would be increasing, rather than decreasing, consumer choice and offering those who want government-run healthcare a la Medicare for All the opportunity to have it. Everyone gets what they wants.

It's a superficially persuasive argument, which is perhaps why a single payer Medicare for All plan has apparently been declining in public popularity at the same time that a public option has become a more attractive choice in the eyes of the electorate. One might also fault the two main presidential contenders who support Medicare for All—Bernie Sanders and Elizabeth Warren—for doing an inadequate job of rebutting this argument. After all, it appeals to both the all-American notions of freedom and personal choice on the one hand and the left/liberal desire to help the unfortunate on the other. What could be better?

The only small problem (hardly a meaningful one in political campaigns) is that the argument is fraudulent. A public option would not carry the same advantages as Medicare for All, and at the expense of letting people keep their beloved private health insurance plans (rather than cruelly forcing them onto a public plan that would have no copays or deductibles and would cover vision and dental care) would keep the American healthcare system overcomplicated, needlessly expensive, and unequal in fundamentally immoral ways.

Let's examine, for example, Pete Buttigieg's clunkily named "Medicare for All Who Want It." As his campaign website promises, "everyone will be able to opt in to an affordable, comprehensive public alternative." Note the word "affordable," i.e., not free. This already presents a contrast with Medicare for All. Under a single payer plan, getting medical care could become the equivalent of driving on a public road or visiting a public library: no need to worry about picking out a plan that will give you the coverage you need at an affordable price, just take advantage of a service that's free at point of use whenever you need it; all you need to do is pay your taxes. Not so under Medicare of All Who Want It, or public option plans in general. As under the current system, the burden would be on consumers to pick the plan—public or private—that they believe is the most affordable given their circumstances.

This is not the only difference. For instance, as Dylan Scott of Vox notes, "The government plan would cover the same essential health benefits as private plans sold under Obamacare, though the details are left vague on what patients would pay out of pocket." This detail stands in contrast to Medicare for All, which, with its lack of copays and deductibles, "almost eliminates [out-of-pocket spending] entirely."

And what of those who are unable to afford private insurance? Buttigieg's website explains as follows:

The plan will automatically enroll individuals in affordable coverage if they are eligible for it, while those eligible for subsidized coverage will have a simple enrollment option. A backstop fund will reimburse health care providers for unpaid care to patients who are uninsured. Individuals who fall through the cracks will be retroactively enrolled in the public option.

So, from the sound of it, those who do not enroll in private insurance (including those who fail to do so for financial reasons) will be "automatically enroll[ed]" in the public option, even "retroactively enrolled" should they "fall through the cracks." Nothing on the website page indicates that private insurance will be made equally as "affordable" as the public plan, meaning that some will, presumably, be forced by their own circumstances to rely on the public option; the sacrosanct ideal of choice will apply only to those who are able to afford private insurance, while those unable to do so will be automatically enrolled in the public alternative (again, going by the sound of it). Details in this regard are scant, however.

Lest I appear to be singling out only Buttigieg's plan, we should also examine another public option-based healthcare proposal. Let's also take Joe Biden's. Biden's own website is only able to promise that his plan would insure "more than an estimated 97% of Americans"—leaving millions uninsured, in other words. The poor and sick will, apparently, be awarded with the "choice" to remain uninsured, with predictable consequences: People's Policy Project Matt Bruenig estimates that, even assuming the uninsured rate does fall to approximately 3% under Biden's healthcare plan, this could still mean the preventable deaths of 125,000 people in the first ten years after the plan's implementation—deaths that could be avoided under a genuinely universal healthcare plan, such as Medicare for All.

Whatever specific, avoidable flaws the Biden and Buttigieg plans may have, the reality is that all public option plans are doomed to run into the same problems. As George Bohmfalk writes in The Charlotte Observer, a public option "will likely become the insurer of last resort to the sickest and oldest among us. The insurance playing field will be anything but level. As deficient as they are, for-profit insurers will cleverly market themselves to the young and healthy, leaving those who use more healthcare to the public option. Its costs will balloon, dooming it to fail, to the delight of for-profit companies." To be sure, as long as private health insurance companies exist and are forced to compete with a public health insurance, they will use their considerable lobbying influence to weaken and undermine said public option. One can imagine the fate of those forced to rely on a public option as it's progressively slashed and weakened by Republicans (and, in all probability, centrist Democrats) in Congress, under pressure of the private health insurance lobby.

A public option also fails to offer the savings that a single payer plan would. Benjamin Studebaker and Nathan J. Robinson elaborate on this point in an article for Current Affairs:

Single payer systems control costs by giving the health service a monopoly on access to patients, preventing providers from exploiting desperate patients for profit. If instead there are a large number of insurance companies, providers can play those insurance companies off each other. Right now, we have a two-tier system, in which the best doctors and hospitals refuse to provide coverage unless your insurer offers them exorbitantly high rents. To support that cost while still making a profit, your insurer has to subject you to higher premiums, higher co-pays, and higher deductibles. Poor Americans with poor-quality insurance are stuck with providers who don’t provide high enough quality care to make these demands. The best providers keep charging ever higher rents, and the gap between the care they offer and the care the poor receive just keeps growing. Poor Americans are now seeing a decline in life expectancy, in part because they cannot afford to buy insurance that would give them access to the best doctors and hospitals. Costs balloon for rich Americans while the quality of care stagnates for the poor. 

The bloat doesn’t just come from providers. Because insurance works on a profit incentive, the insurance companies must extract rents as well. So the patient is paying to ensure not only that their doctor or hospital is highly-compensated, but that the insurance company generates profit too. Each insurance company has its own managers—its own CEO, its own human resources department, and so on. We have to pay all of these people, and because there are so many private insurance companies, there are so many middle managers to pay.

In a time where urgent (and necessarily costly) action is required on climate change, allowing vast sums of money to be wasted on bureaucracy and exorbitantly high rates for medical care is particularly obscene. 

To be sure, Medicare for All would significantly expand federal spending and require new taxes—as did its namesake Medicare, and Social Security before that. Those two government programs, of course, enjoy overwhelming popularity. According to a study from the libertarian Mercatus Institute, Medicare for All would significantly reduce national spending on healthcare, meaning we would pay less in new taxes than we are currently paying in private insurance premiums, co-pays, deductibles, etc. Those new taxes, furthermore, could be more fairly distributed than private insurance premiums, which (unlike income and payroll taxes) do not take into account the income of the person paying. The end result is that the vast majority of the population would surely end up saving money as a result of single payer healthcare funded by a progressive tax system, even taking into account whatever new taxes it required. The current system distributes costs in a highly regressive fashion. People in the 50th income percentile—squarely in the "middle class," with an annual income around $48,000—pay a total tax rate of 24.7%; the 400 richest people in the country pay a rate of just 23.1%. But if employee contributions to health insurance plans are treated as another form of taxation, the 50th percentile tax rate jumps to 37.6%, while the rate for the top 400 remains effectively unchanged. This doesn't even take into account out-of-pocket costs.

It should be clear, then, that any attempt to present the public option as a plan that would offer the same benefits as Medicare for All, while preserving "choice," is simply dishonest. Fearmongering against single payer healthcare plans by claiming that they would "kick 149 million people off their current health insurance," as Amy Klobuchar recently did, is something even lower. One can, of course, argue that Medicare for All would be virtually impossible to get through Congress. True, but by all indications a public option plan would run into similar opposition from the health insurance lobby. It is not at all clear how settling for a half-measure before any negotiations have even begun—and a half-measure that is still highly unlikely to make it through Congress, at that—is better than pushing for a plan that is both fair and cost-effective. As Libby Watson wrote for Splinter (RIP):

[A public option plan] would obviously be better than what we have now, since what we have now is lethal, toxic sludge. The questions that matter for politicians and advocates when it comes to choosing between a policy that’s merely better and one that’s actually good is whether the good policy is truly out of reach, and whether the worse policy would prevent reaching a better policy goal. 

As she correctly concludes, a public option would hardly be easier to pass through Congress, and could, if anything, "take[] the wind out of the sails of reform" if passed, making it less likely we would ever have a single-payer plan. 

Healthcare is a complicated matter, and one can hardly fault average Americans who are more attracted to a public option and fail to see, at first blush, why it's necessary to for many millions to be "kicked off" of their private insurance plans. In all likelihood, many haven't devoted the time to learn why a public option is a wildly inadequate alternative, and the debates among the Democratic primary candidates have surely done little to illuminate the subject. As for politicians who run for office proposing public option plans over Medicare for All, and using dishonest arguments to support their position, an altogether different—and far less generous—judgment is in order.

From Tragedy to Farce: Watergate and the Trump-Ukraine Scandal

(Trump photo: Jason Szenes/EPA-EFE/Shutterstock via Deadline. Nixon photo: AP Photo via Politico)

In his The Eighteenth Brumaire of Louis Napoleon, Karl Marx wrote a brief passage that has perhaps become something of a cliché to reference, but which current circumstances demand be quoted:

Hegel remarks somewhere that all great world-historic facts and personages appear, so to speak, twice. He forgot to add: the first time as tragedy, the second time as farce.

When we apply this principle to the current situation with Donald Trump, another unavoidable cliché emerges: the comparison of the Trump-Ukraine scandal to the Watergate scandal under Richard Nixon. While it has become trite to analogize scandals, particularly political scandals, to Watergate, the similarities here are too obvious to ignore. In both cases, a president engaged in blatantly corrupt actions to try to give himself a leg up against the opposition party in his bid for reelection; both scandals were compounded by (alleged) attempts to cover up the initial wrongdoing; and both resulted in the opening of an impeachment inquiry into the president (it remains to be seen how far the parallels will go, particularly in this respect).

The first level on which we have progressed from tragedy to farce is obvious. In Watergate, we had a popular president brought down by his cronies' (unnecessary) attempts to sabotage the Democratic party. To use the term first introduced by Aristotle, Nixon's corruption and his paranoia were his hamartia, or tragic flaw. Here we had a very capable president with the potential to go down in history as perhaps one of the greatest of the 20th century—having reestablished relations with China, achieved a détente with the Soviet Union, presided over the (eventual) drawing down of US involvement in the disastrous Vietnam War as well as the establishment of important regulatory agencies such as the EPA and OSHA—instead turned into a national pariah due to his own unforced errors, and those of the people around him. To add insult to injury, there is every reason to think Nixon could have been reelected without any of the "dirty tricks" the Committee to Re-Elect the President resorted to: Nixon was a popular incumbent, and George McGovern (the eventual Democratic nominee, who lost in a landslide to Nixon) might still have gotten the nomination even without the sabotage directed at one-time frontrunner Edmund Muskie. While Nixon was no doubt a gifted politician, his proclivity for dishonesty and playing dirty was consistent through his career—and with Watergate, it finally caught up to him in a fashion that must have seemed, for him and his supporters, reminiscent of the tragic downfall of an Othello or an Oedipus Rex.

While the similarities between "Ukrainegate" and Watergate are obvious, the backdrop of the current scandal is an almost complete inversion of that of its "tragic" predecessor: we now have a president who has never been popular, whose blatant stupidity and ineptitude are so extreme that he has already been ranked as one of the worst to ever hold his office, and whose entire presidency has so far been overshadowed by scandal. There is none of the drama of Watergate because Trump, unlike Nixon, has no public image to tarnish, no popularity to lose, and the details of the Ukraine scandal come as no surprise or shock, in contrast to the details of Nixon's treachery. Appropriately, then, there is little of the suspense there was with Watergate, as Trump has already casually admitted his attempt to persuade the Ukrainian government. When confronted with the situation, the relevant maxim seems to be one recently offered by philosopher Slavoj Žižek, paraphrasing the Marx brothers: "Trump acts and looks like a shamelessly obscene politician, but this should not deceive us – he really is a shamelessly obscene politician."

Just as the "tragedy" of Nixon's predicament is exacerbated by how unnecessary his actions were, the farce here is compounded by the sheer stupidity of Trump's: in an attempt to dig up dirt on a Democratic candidate who seems to perhaps be imploding all on his own, Trump relied not only on his suspicion of Biden's corruption but also his incomprehensible misconception that someone in Ukraine is in possession of one the DNC servers the company CrowdStrike had examined in 2016. The farcicality of it all increases when we actually look at the story of how Hunter Biden, in an apparent act of (legal) corruption all its own, came to sit on the board of a Ukrainian natural gas company for apparently no reason other than his relation to then-Vice President Joe Biden—despite having been kicked out of the Navy Reserve for cocaine use earlier the same year, and having little relevant experience.  In contrast to the Nixon saga's evocation of classical or especially Shakespearean tragedies, the Trump-Ukraine story is in some ways reminiscent of the work of the Coen brothers: for instance, the film Burn After Reading, in which a draft of an alcoholic ex-CIA analyst's memoirs ends up in the hands of two dim-witted gym employees, who attempt to sell it to the Russian embassy after they mistake it for sensitive intelligence and the analyst spurns their attempts to extract a reward from him for the memoir's safe return. Just as this cast of oafish characters careens toward disaster through a combination of bad judgment, incompetence and random chance, Trump et al. have perhaps charted their own downfall in a remarkably similar fashion.

But there is another, more important way in which the tragedy-to-farce arc has materialized. The real tragedy of Nixon's presidency—not from the perspective of him or his supporters, to be sure, but from the perspective of any moral person concerned with the general well-being of humanity—is not that his paranoia and corruption caught up with him, or even that he was paranoid and corrupt. Rather, it is that the Watergate scandal has overshadowed the many other, more grievous crimes of the Nixon administration (the bombing of Cambodia, COINTELPRO, the installation of Pinochet in Chile, etc.). Noam Chomsky was correct when he wrote that Watergate is "analogous to the discovery that the directors of Murder, Inc. were also cheating on their income tax. Reprehensible, to be sure, but hardly the main point." The authentic tragedy of the Nixon years is that after continuing the Vietnam War and even expanding it into Cambodia, he was resoundingly reelected over a candidate who was committed to ending the war—and that the public only turned against him over something as comparatively minor as Watergate, because the victim was the Democratic Party rather than a bunch of Indochinese peasants. To add insult to injury, it is the Watergate scandal, rather than the vast number of those killed by Nixon's policies, that is generally remembered as the "black spot" on his legacy.

This same dynamic is replicated in the case of Trump: it wasn't the family separation policy, or the Muslim ban, or the catastrophic environmental policies or any of the other blatantly destructive acts of the Trump administration that led to an impeachment inquiry finally being opened—it was an attempt to dig up dirt on Joe Biden and his son Hunter which, although flagrantly corrupt, is nonetheless almost comically insignificant in the harm it caused when compared to that which resulted from many of Trump's other actions. When the victims are migrant children separated from their parents, or refugees, or transgender people, the Democratic leadership couldn't be moved to open an impeachment inquiry—but only once the victim was Joe Biden were they finally swayed. What makes this aspect of the impeachment farcical rather than tragic (though perhaps it's both) is not that Trump's crimes are so much worse than Nixon's (they aren't) but rather that their corrupt and diabolical nature is so much more flagrant. Only the barest pretense is made by Trump and those around him that his actions are motivated by anything other than cruelty, bigotry and egotism. Yet despite this transparency, we have had to deal with months of Nancy Pelosi dismissing notion of impeachment with arguments that are in themselves farcical—that Trump is "almost self-impeaching," for instance. And now, even after the impeachment dam has broken, Pelosi and the Democratic leadership still want us to have a narrow impeachment inquiry focused on the Ukraine revelations.

This tragedy-to-farce dynamic is reflected in public opinion and treatment of the two presidents: while, pre-Watergate, Nixon had enjoyed a "traditional" relationship with the public (high approval ratings early on that remained at least middling until 1973, being named Gallup's "most admired man" for every year of his first term) and even, as noted, won a landslide reelection (carrying every state but Massachusetts), Trump has been an object of mockery and derision throughout his time in office—not only among "coastal elites" and the media, but among great swaths of the population even in the "heartland" (as a resident of a Midwestern state—one that Trump carried handily in 2016, even—I can personally testify that I have seen Trump mocked and derided by those around me far more than I have seen him defended). Accordingly, while the Watergate scandal marked a sort of collective trauma for much of the public (a "long national nightmare" in the words of Nixon's successor Gerald Ford), the Trump impeachment inquiry has so far appeared to produce far more ridicule on social media (in response to Trump's melodramatic reactions) than trauma of any sort.

We know the resolution of the Watergate scandal: the "tragic" downfall of Nixon and the genuinely tragic overshadowing of Nixon's vastly more grievous crimes in the public memory by Watergate. Can we therefore make any prediction on how the current scandal will play out? Well, from a comic perspective I can think of one perfect sequence of events: that Trump will be impeached by the House just to be inevitably acquitted by the Senate, and then will be defeated in the 2020 election immediately afterward. Were that to happen, Trump would likely be remembered as a disastrous president whose general buffoonery, incompetence and unpopularity—rather than simply any one act of corruption—were his great downfall. The comedy of that, of course, would be that after all is said and done, no lesson is learned and nothing has changed: Trump's public image is no different fundamentally than it was before impeachment, the Ukraine scandal, or even on the day of his inauguration. Obviously, the fact that this is perhaps the best option from a comedic perspective does not make it the likeliest; making any prediction about what will happen is a futile endeavor in a situation as outlandish as this one, just as, in a farce, one never knows what might come next.

So what should we take from this? That we are simply doomed to relive some absurd version of history, whatever we do? In one of Karl Marx's other most famous quotations, he writes:

Philosophers have hitherto only interpreted the world in various ways; the point is to change it. [emphasis in original]

Surely, then, we are not in some sort of Groundhog Day scenario, condemned to repeat the same cycle with no ability to fundamentally alter it. There are, I think, actions that can and should be taken. For Trump's opponents, the right approach is not to try to disrupt the farcical nature of it all—anyone in a farce who tries to proclaim themselves as the "serious person" in the room only makes themselves that much more of a laughingstock—but to lean into it. We should not, as Pelosi and the leadership want, have a "narrow impeachment" designed to take full advantage of the scandal du jour; rather, the impeachment investigation should be made as wide and as public as possible, probing into every conceivable instance of corruption or abuse of power that has happened under Trump: the abuse of migrants, the spending at Trump's properties by federal employees, the enabling of the assault on Yemen, even the stupid Tweets inciting racial hatred and attempting to mislead the public.

The hearings should become a national spectacle, like the Watergate hearings became, but unlike the Watergate hearings they should be spectacle for spectacle's sake. Trump has already been lashing out and digging himself in deeper just at the opening of an inquiry—the goal should be to provoke him as much as possible. Trump has a been a master of farce, making his opponents appear ridiculous in the Republican primary and reducing the country's most sacred rituals into an absurd spectacle that excites his supporters and infuriates his critics. But as soon as he becomes the target of ridicule, he is incapable of responding productively. Every time he tries to strike back, he simply makes himself more clownish. To actually impeach him is to send the case to the senate, where Trump is certain to be acquitted and claim vindication—for this reason, the point of the impeachment inquiry should not be to actually impeach Trump, but only to draw attention to his many wrongdoings and to further enrage him, leading to more wrongdoings which can further be litigated—creating a vicious circle and taking the absurdity of it all to a whole new level.

Obviously, there are objections one could raise to this strategy. One could say that it trivializes and politicizes the impeachment process, for instance. I believe that to make this objection, though, means one fundamentally misunderstands our predicament. The impeachment process is already politicized, first of all because impeachment is a doomed endeavor as noted—not because there are no grounds for Trump's impeachment and removal (as I've made clear, there are many) but because it stands no chance of winning enough Republican support in the senate for the necessary two-thirds supermajority required to convict. The reason the Republicans will not convict Trump is for purely political reasons: because to do so would be to alienate their base, to probably doom their chances in 2020, etc. But also, to only have a narrow focus on Ukraine and the like is just as politicized as what I have proposed, because it implicitly accepts the other wrongdoings of the Trump administration on the grounds that it is not politically worthwhile to prosecute them. As for trivializing, it is far too late to worry about such things: as I have argued, we are in the midst of a political farce, and to refuse to acknowledge this and make the best of it is to make oneself the butt of the joke.

One could also object that to turn the impeachment proceedings into a circus will mean the Democrats are seen as just as clownish as Trump. Perhaps, but so what? Nancy Pelosi and the congressional Democrats are already unpopular, and their public image matters little. The 2020 election will be greatly influenced by the presidential candidate the Democrats put forward and how this person performs against Trump; as long of the public sees Trump as a buffoon, whatever their view of Pelosi and the House Democrats, the Democratic nominee has an opportunity to position themselves as the one who can end the circus and shift the focus back to solving the many real  problems we face.

Of course, Pelosi and the Democratic leadership are highly unlikely to take this route, perhaps because truly examining all of the Trump administration's crimes would force us to confront his administration's continuity with those of his predecessors—including Obama—when it comes to treatment of undocumented immigrants, war crimes in the Middle East and in other respects. It is up to the Left, then, to remain consistent critics not only of Trump but of any impeachment process which fails to emphasize the full scope of his criminality, corruption, and idiocy; if such an investigation requires the Democrats to reckon with their own similarities to Trump, all the better. As long as the impeachment inquiry attempts to be "serious," it can be nothing more than one more piece of the tragicomic spectacle American politics have become—and, paradoxically, only by embracing its place in our political farce and making the most of would it deserve to be taken seriously.

CORRECTION: Previously this post alluded to Trump having relied on a discredited right-wing conspiracy theory; however, evidence I have seen then leaves me less confident that the theory of Biden acting to protect Burisma is completely discredited. I have updated accordingly and apologize for any error.