Health care looks like it will be a big issue next year, during the 2018 congressional campaigns. If Democrats are to have any real hope of flipping the House of Representatives, or the Senate, we need to make it a really big issue by focusing on a small number of ideas that can make a big difference.

As I write, it’s not certain that the Dems will be able to stop the Republicans in their effort to repeal Obamacare. The R’s constantly bring up the loss of participating insurers at many of the exchanges across the country. Loss of insurance plans, and increasing out-of-pocket expenses herald the “implosion” of Obamacare, according to Republicans. This, say the R’s, makes “repeal and replace” an urgent necessity. If repeal actually happens, we’ll be faced with an entirely changed political landscape around the health care issue. New, but not necessarily unfavorable for Dems.

I’m betting that repeal will not succeed. As imperfect as it is, the Affordable Care Act (ACA or Obamacare) has opened the eyes of many, many people to the possibility of extending a “right to health care” to all Americans. It’s still only a possibility. In order to make this vital “right” happen, Obamacare needs to be improved.

But then, some of our friends urge us to quit worrying about Obamacare and work instead for a single payer government health insurance system, like the one in Canada.

I have a bunch of relatives in Canada and I’ve talked to them about their health insurance system. Nobody has to convince me that single payer is a great way to go. My Canadian family loves their government health insurance. The problem is, I really doubt that we would ever be able organize enough support here in the U.S. to overcome the deadly opposition that our private insurance companies would mount against us. . Canadians established their system a long time ago, under Tommy Douglas. Private Canadian insurance companies didn’t have anything like the power and resources that U.S. insurance companies have today.

There are several more issues to consider.  Most Americans still get their health insurance through their jobs and many of these people would be resistant to a new system out of concern that the benefits would not be equal to what they already receive. Another related problem is that the money employers put out for health insurance is considered part of workers wages. Many workers would be justifiably skeptical that their employers would shift money from health insurance and place it directly into the employees’ checks to help cover the large tax increases that would come with a new single payer system.

A big reason most labor unions are reluctant to support single payer is that it would mean the end of a large reason workers have for joining a union. Health care would no longer be negotiated as part of union contracts.

Then there is the large tax increase that would have everybody worried, no matter how much single payer advocates claimed that most people would wind up paying less total for health care, if we switched to single payer.

I might be wrong about the small likelihood of getting single payer, and if so, that will be great for all of us. Just in case I’m right, I think it would be a good idea to support ways of improving Obamacare, so it can work even better than it does now.

The first thing I’d suggest is to add a public option to the ACA. There was a lot of interest in public option (PO) back in 2009, when Obamacare was working its’ way through Congress. PO set off a lot of opposition from insurance companies and was eventually killed, before the bill passed. I’ve often wondered what would have happened if Single Payer advocates had spoken up for PO like they did for SP. Maybe Obama would have pursued the PO a little more with public support to lean on. Maybe it would have been passed with the rest of the ACA.

What is a public option? It would simply be a government run health insurance plan made available on the exchanges along with all the private plans. PO would compete with the private plans and by doing so would control costs and also establish a minimum standard for generosity of benefits. PO would be regulation through competition. A particularly attractive aspect of having a PO would be making sure there were no places in America where all the insurance plans had pulled out. PO would still be there. By driving costs down through competition, PO would make more health care available to more people, which would make the ACA stronger than ever.

An interesting comparison between SP and PO should be considered. PO will face opposition from the private insurance industry, no doubt about it. But it won’t be the kind of gut level, no prisoners position SP attracts. SP would close down the entire private insurance industry. If SP succeeds, private health insurance is dead. PO takes on private insurance, but it also leaves the door open for those who want to compete. PO doesn’t take them on all at once in a life and death struggle.

There are a number of ways a PO could be instituted. The first most people think of when they hear the term “public option” is a Federal Government insurance plan where people could purchase insurance, just like a private plan. This plan would be self-sustaining, not requiring government support, except for the same subsidies that are given to people for the private plans.

Nevada has come up with a clever way of possibly doing a PO. Simply allow people to buy into Medicaid, using the same subsidies they would get for private plans. The Nevada plan appears to have a good chance of passing and signed by the governor. This will be very interesting to follow.

Another idea I’ve heard kicked around is to have the Federal Government partner with a large company like Kaiser, or group of companies to offer a public/private insurance plan. Working for a PO should in no way mean that we are against single payer. Actually, I think that a PO could easily turn into a single payer system. PO and single payer should not be enemies.

Another way of improving the ACA that I’m attracted to is to establish a federal government agency that is responsible for buying large amounts of drugs from the pharmaceutical companies, large enough to negotiate lower prices for the medicines, and pass along the savings to individual Americans who need the drugs. This is commonly referred to a “bulk buying” and is the reason drugs in places like Canada and Australia cost less than half of what they do here, for the exact same medicines. Like PO this would make more money available for better health care and to drive down the cost of premiums and other out-of-pockets.

We should fight to save Obamacare, and also to make it stronger

Brian King