I expect I'll get some nasty responses with this, so let me state up front that I want a public option. And I have been calling my representatives and my senators, as well as the White House comment line to encourage one.

However, there are a lot of misconceptions about it and I think there needs to be some real discussion about what the public option is, as structured in the House and Senate HELP Committee bills, and what its relationship is to the overall reform effort.

For decades, Democrats (and liberals in general) have been divided over the best way to reform the American health care system. Many liberal Democrats and health policy reformers advocated a single-payer approach. The problem with single-payer, however, was that having adopted an employer-based system by accident, polls showed majorities of Americans wanted to keep their private coverage. So others advocated trying to build off of that structure or implement a "pay-or-play" scheme, whereby employers either had to provide coverage or pay into a fund that could then provide health care to those without it (either through a public plan or through subsidies for private insurance.) In 2004, all the major Democratic candidates for president, including Howard Dean, proposed incremental bills that would expand coverage and introduce insurance company regulations but largely preserve the employer-based system. Both Dean and Kerry proposed letting people buy into an insurance exchange modeled on the Federal Employees Health Benefits Plan (FEHBP), but neither proposed a public option.

In 2006, political scientist Jacob Hacker of U.C. Berkeley came up with the idea of combining these two approaches. Keep the employer system, he said, but create a regulated marketplace - an "exchange" - for those who didn't get insurance through work or didn't like the insurance they were offered at work. And, he said, include a publicly-administered plan modeled on Medicare. By linking with Medicare, such a plan could quickly acquire tens of millions of customers and exercise strong cost controls. Its size would allow it to negotiate low prices for drugs and medical procedures, and by linking it with Medicare (which already did that for medical procedures), it could accomplish dramatic savings.

The plan proved popular and the Hacker plan came to form the basis for the health care proposals of all three major Democratic presidential candidates. John Edwards, Hillary Clinton, and Barack Obama all proposed basically similar plans, the chief difference being Clinton and Edwards supported an individual mandate while Obama did not. In Congress, the Hacker plan proved popular as well, and even Max Baucus included a strong public option in his initial health care proposals last November.

Flash forward to today and the public plan has become probably the biggest controversy among Democrats. Republicans proved completely hostile to the idea and conservative Democrats, especially in the Senate, have been unwilling to support it. The White House has given hints it may drop the plan or implement it only with a "trigger," which has prompted howls that Obama has sold us out and that no reform that passes will be worth it without a public option.

What is the White House doing? I don't think they quite know. They may drop the public plan. They may not. It looks like there are some internal divisions and trial balloons galore. While I hardly think they're playing some genius 100-dimensional chess game, it could be that they're simply trying to get a bill off the Senate floor and to conference committee, where a public plan could be reinserted if it passes the House.

But is dropping the public plan at this point make-or-break when it comes to reform? Maybe not. Here's why.

The problem is that the public plans that have been included in the House and HELP Committee bills have already been watered down so much as to make them relatively insignificant. President Obama got in trouble a few weeks ago for calling the public option only a "small part" of health care reform, but at this point, he's arguably correct. A public plan as proposed by the Hacker plan would have been revolutionary. The public plan that survives (so far) is not. Since the House bill is more generous than the Senate HELP Committee bill, let's look at what the House bill's public plan looks like.

* Not available until 2013

* Not open to everyone - it would only be open to the long-term unemployed, the self-employed, and employees of small businesses. These are the people eligible to purchase plans on the insurance exchange, where the public plan would sit as an option. The CBO estimates that the whole exchange would only have 20 million members by 2019, with about 1/3 choosing the public option. If you got insurance through your employer, you could not join the public plan or any plan in the exchange, even out of your own pocket.

* Not centrally-funded; it would sit within the exchange, which would have a national administrator overseeing all the plans (including the private ones), but though it would get startup funds from the government, it would have to be self-supporting, meaning it would need to fund itself via premiums. And it would need to advertise.

* Does not use Medicare rates; the House bill would let the public plan use Medicare rates at the outset and would have access to providers in the Medicare network, although providers could opt out. After the initial years, however, the public plan would need to negotiate its own rates, as other private insurers do.

This plan is a worthy feature, but given how limited it is, its effects are fairly small. Yes, it could provide somewhat lower prices. But not dramatically so compared to other plans on the exchange, because it would have to be entirely self-funded and would have to negotiate its own prices after the initial period. And because it wouldn't be open to everyone, it would not have substantial market power; the CBO estimates it would have 9-10 million members nationwide by 2019.

This public plan does set a benchmark that other plans have to match. However, the exchange would already have a basic standard benefits package that every insurer would have to meet. And the private plans on the exchange have some cost controls as well, due to their oversight by a central administrator. (Theoretically that could be expanded in the future too, such that the exchange administrator could negotiate prices for drugs and procedures for even the private plans.)

The result is that we're now in a pitched battle that to me seems more about symbolism at this point. The public plan as structured in the House bill really is a fairly minor part of the reform. Most of us on this board would be ineligible for it. The expansion of Medicaid, the insurance company regulations, the subsidies, the exchange, and the basic benefits package are all arguably more significant and would impact most of us far more than the weak public plan envisioned by the House bill. The true "strong" public option as envisioned in the Hacker plan died long ago.

The reason many progressive members of Congress are fighting so hard to include it is because they hope that both the insurance exchange and the public plan can be expanded such that everyone can buy into them (see below). And that exposes the fact that nearly everyone believes that even if the best possible bill is passed, it will need to be revisited in coming years to exert greater cost controls and build on the structure established in this round. However, if we have to revisit the bill in 3-4 years anyway, and if the public plan won't be open to everyone without another round of legislation, then what's the point of establishing it? It is argued that it's easier to expand an existing program than create a new one, but if you're going to wait to do that anyway, then why not just open up existing plans like Medicare or the VA at that point?

If you truly believe that there is no meaningful health care reform without a strong, Medicare-like public option (something I personally don't believe is true*), then the battle is already lost. At this stage, the difference between a bill with a public plan and without one is very small.

(* Universal health care systems come in vastly different shapes. Canada, Scandinavian countries, and some Asian countries use a single-payer system. Britain uses a nationalized, single-payer/single-provider system. Germany and France use heavily-regulated, nominally independent sickness funds to provide basic care. Some countries used mixed public/private systems. Both The Netherlands and Switzerland use entirely private systems. Singapore doesn't use insurance at all, requiring mandatory savings and universal health savings accounts with government-funded catastrophic care.

Now, the Dutch and the Swiss have very different systems than the U.S. The government negotiates prices for drugs and services and dictates a strong basic standard package that each insurer much provide. Though the insurers fought these systems tooth-and-nail, they've adapted, such that they now provide basic services as non-profits and make money off supplemental coverage.

That's why, in theory, you could achieve the features of the public plan through other means. You could, for example, strengthen the basic minimum package offered through the exchange, such that its pricing and premiums are set by the government and it becomes a government-directed benchmark that is merely administered by the private insurers, who would function as contract administrators.

Now, even with the public option intact, neither the House nor HELP bills envision anything this comprehensive. Which is why, public plan or no public plan, they would need to be expanded down the road. I still think they're worth passing, public plan or no public plan, because of the fact that they would provide coverage to everyone and end insurance company abuses such as rescission and discrimination against people with preexisting conditions, etc., and because, with the exchange, they provide a structure than could be molded into a coherent system)

Also, added on update...

(** My sense behind the Progressive Caucus in the House' line of thinking is that (a) they feel they've compromised so much already that they can't stomach losing the public plan as it currently stands, even if it's relatively limited. Plus, they may be planning to offer amendments on the House floor to strengthen it, although how those would fare in House-Senate negotiations is anyone's guess.)

I admit that I watched the collective freakout over the President's "backing away" from the public option with some confusion. Though some are dismissing it as spin, it really did not seem as though they were saying anything new. Obama has repeatedly refused to draw a line in the sand over the public option, and Sebelius has said before that they will "consider" Kent Conrad's "co-op" proposal.

Whether it's a good idea or not to be noncommittal is another issue entirely. Personally, I think they should draw a line in the sand over the public option, or at least be stronger in their advocacy. But I can see the other side of the argument. And that may simply be that the administration does not want to kill the bill and is just trying to get something first, out of the Finance committee and second, out of the Senate.

It is very clear that it is going to be very difficult for the Senate to pass a bill with a public option. According to DFA, only 37 senators are on record in support. The Republicans are unanimously opposed, and several Democrats have expressed hostility to it, including Blanche Lincoln, Kent Conrad, and Ben Nelson. Joe Lieberman has outright opposed it. Will it be Obama's fault if they defeat a public option in the Senate? In part - the bully pulpit is not insignificant. But let's also face the fact that senators are often, frankly, egotistical brats, who don't like to be pushed around and often like expressly to defy their leaders. (For some reason, Senate Democrats are notorious at this, far worse than their Republican cohorts, who are willing to vote for what their president pushes, lockstep; we can see both their successes - getting Bush's domestic and foreign policy agendas passed - and its failures - the fact they got... Bush's domestic and foreign policy agendas passed.) While people often cite Lyndon Johnson as an example of a president who knew how to bully the Senate, keep in mind he had over 70+ senators on his side, including liberal Republicans, and even he didn't try to attain universal coverage, settling for Medicare and Medicaid.

While some argue that the Senate should pass a bill through the reconciliation process, any bill sent through reconciliation would likely not include a public option, as the reconciliation process depends on the Senate parliamentarian's judgment and cannot usually be used to create new programs.

What does this mean? I think the odds are very high that the Senate will not pass a bill with a public option. However, it looks as though the House likely will include a public option. If the White House is truly committed to a public option, then conference committee is where pressure would - and should - be applied. If the bill coming out of conference includes a public option AND passes the House, it becomes very difficult for the Senate to reject it. Bills coming out of conference cannot be amended. They are not subject to the normal rules of debate. While they can be filibustered, it is difficult to do so for the very reason that they cannot be amended, meaning that ultimately they have to come down to an up-or-down vote. And do Evan Bayh and Kent Conrad really want to go down in history for killing universal health care? Especially since no universal health care bill has ever passed the House and all that would stand in the way of universal coverage would be a handful of conservative Democratic senators? (For more explanation on the conference process, click here.)

What's the evidence that the administration is just trying to get to conference? There are a few indications. In a conference call with liberal bloggers about a month back, President Obama himself made clear that conference is where the Administration plans to apply major pressure:



Moreover, Rahm Emanuel in the NYT seemed to acknowledge that they expect both that the Senate will not include a public option and that the House cannot support a bill without a public option:



Now, does that mean people should simply role over and have faith in Obama to do push a public option in conference? I'm a defender of his, but I'd still say no. Ultimately, if we get to the point where a public option depends on the conference committee - and that looks very likely right now - it becomes a matter of which House of Congress is willing to blink first. And the calculations of the conference committee negotiators will hinge on which body is more likely to do so. That in turn will depend on the ground and the general mood. If progressives push hard for the public option, urging supporters in Congress to not support a final bill without it and making the White House know that they will not consider health care reform without a public option to be true reform, then the incentives shift such that conference will be more likely to support a public option. If, however, public option advocates lay down their guard, liberals in the House may signal they'll support reform without a public option, and conservative Senate Democrats will think they can oppose it with impunity, then it's unlikely the conference committee will include a public option.

And let's face it: there's a reason liberals want this. Many health policy analysts are correct in saying that, as structured in the House and HELP committee bills, the public option really isn't going to be that important at the outset (meaning that Obama's statement that it is only a "small part" of the bill is quite true, as a literal matter). It will have to be self-supporting, and will be limited to the exchange, which will itself be limited to only the self-employed and those employed by small businesses. It won't have significant market power to drive down costs. But I think it's obvious why liberals still want it. It's far easier to expand programs than create new ones, and by establishing a "beachhead" public option (not just a carved out one for the poor and the elderly, ala Medicaid and Medicare), it can be expanded to the whole population, such that we could eventually get a de facto single-payer system or at least a mixed system with significant economies of scale associated with a single-payer system.

So by all means, fight for a public option. But be aware of the legislative process, and don't get discouraged if the Senate won't pass a bill with a public option in their first try. If the environment favors a public option, then a public option coming out of conference will be very difficult to stop.

I figured DU'ers who aren't familiar with South Asia might appreciate a brief rundown of the political history of South Asia. My profile is this: Indian-American and Hindu. I consider myself proudly Indian and proudly Hindu, though a cultural sense (like secular Jews). I'm also very interested in Indian history. One of Hinduism's best tenets is the belief in universalism -- I believe very firmly in tolerance and the essential goodness of the vast majority of human beings. Hence I strongly recoil from simplistic attempts to label any group enemies, something that needs to be stressed in this kind of Islamophobic climate.

In any event, here goes:

The Creation of Pakistan

Prior to 1947, under British rule, India, Pakistan and Bangladesh were all under British administration. 3/5 of the subcontinent was ruled directly by the British and divided into various provinces (Punjab, Sindh, Northwest Frontier, United Provinces, Central Provinces, Bengal, Assam, Madras, Bombay, etc.). The other 2/5 of the subcontinent were ruled indirectly through various Indian princes whose ancestors had cut deals with the British.

Pakistan arose due to the agitation of the Muslim League, lead by Muhammad Ali Jinnah. Jinnah had been an Indian Nationalist at one point, but he came to embrace the "Two Nation Theory" -- the idea that Hindus and Muslims constituted two separate nations within India and required equal political representation. People still debate whether Jinnah's actions were merely opportunistic or heartfelt (you can often tell who's Pakistani and whose Indian based on their assessments). Nevertheless, I won't delve into Jinnah's motivations. What IS true is that for a significant body of Muslims, there was fear that their religious rights would be curtailed under Hindu-majority rule.

Hindu nationalists also came to embrace the Two Nation Theory, and activists from the Hindu Mahasabha Party promoted the idea that Islam and Hinduism were incompatible; though some opposed the partition of India, they weren't all that upset by the outcome -- an overwhelmingly "Hindu" India.

The Muslim League was actually dominated by landowners who largely came from what is now Northern India. The demand for Pakistan was not particularly widespread prior to 1946 (a year before independence). In fact, the areas that currently MAKE UP Pakistan were largely resistant to the idea -- in those provinces, Muslims constituted a majority, so the local Muslims didn't really feel any sense of oppression. The Northwest Frontier Province -- the Pashtun region that is now the source of most of the terrorism -- was actually dominated by the secular Indian National Congress and their provincial leader, Khan Abdul Ghaffar Khan, was a close disciple of Gandhi who vehemently rejected the idea of partition. The Punjab was ruled by a regionalist party that also eschewed partition.

Part of the Muslim League's rise to power actually came in response to WWII. The Indian National Congress, which was secular but Hindu-dominated, had been running a devolved government under British rule. They opposed Britain's declaring war on behalf of India, however, and boycotted the government and were arrested. Since the Muslim League had supported Britain's war efforts, the Brits put the Muslim League in charge of the Indian Administration -- the move vastly increased their visibility and gave them crucial space. In the previous elections, after all, the Muslim League had actually vastly underpolled the Congress and numerous regional parties.

When the war ended and the Congress members were released, the Muslim League's new power allowed it to agitate more strenuously for Pakistan. Due to their increased visibility, the call for Pakistan this time began to resonate, especially once communal violence broke out in several Indian cities.

In the 1946 election, the Muslim League vote surged, and the League swept the races for the Muslim seats (the British had divided seats in the Indian proto-parliament along religious lines -- Muslims could only vote for Muslim candidates, Hindus for Hindu candidates). At this stage, the demand for Pakistan remained quite vague, and there's reason to believe that Jinnah was actually agitating for a pan-Indian Confederation with Pakistan as a component unit. (After all, much of the Muslim League's core support came OUTSIDE the areas that would become Pakistan -- a completely independent Pakistan would leave those people outside its jurisdiction unless they moved.)

This was actually proposed in 1946 as a power-sharing deal (the 1946 Cabinet Mission Plan). The Muslim League actually accepted it -- however, the Indian National Congress, after initially accepting it, changed their minds and turned it down. Basically, at this point, the Congress had little desire to compromise with the Muslim League, especially when they felt they could obtain unchallenged political power in a slightly smaller India.

Partition came extremely rapidly. The demand had seen very little public support just two years earlier, yet in June of 1947, amidst rising communal tensions and following severe riots in major cities, the Brits -- who were hell bent on getting out -- announced that in two months they would leave and that the country would be divided. The borders weren't even announced until the day AFTER independence. They were drawn by a civil servant from England who had never been to India and never would.

Few on either side expected partition to be particularly traumatic. The expectation from both the Muslim League and the INC was that most Hindus and Sikhs in Pakistan would stay in Pakistan and most Muslims in India would stay in India. Jinnah himself never sold his Indian property. The expectation was that BOTH states would be secular (as Jinnah himself desired).

Yet as soon as independence for both countries was declared, there was mass chaos. The British refused to enforce order, arguing their mandate had expired. As cities devolved into massive killing zones, millions of Hindus and Muslims abruptly fled -- many with almost no planning, having anticipated staying in their homes until just days earlier. 10-20 million people crossed the borders in those days, and millions were killed in an undeclared civil war.

The Partition permanently poisoned relationships between India and Pakistan thereafter. It radicalized an entire generation on both sides to think of "the other" as a would-be killer.

The Kashmir Dispute

The Kashmir Conflict is fairly complicated. At the time of partition, Kashmir as a princely state -- the princely states were not subject to the British and were technically independent when the British ended their administration. The princely states were theoretically free to join either India or Pakistan or remain independent. Except for Kashmir, however, all the others either joined India or Pakistan (based on the wishes of the local population) or were forced to join either India or Pakistan by force.

Kashmir was an interesting place. It had a multethnic and multireligious character, but had an overall Muslim majority of about 65%. Nevertheless, it was ruled by a Hindu king. The chief political party -- the democratic opposition to the Maharajah -- was the National Conference, a Muslim political party based in the Kashmiri valley (the region of the state where the bulk of the state's Muslims lived).

At the time of the partition, the general sentiment in Kashmir from both the king and most of the Kashmiris (at least among residents of the Valley) was for Kashmir to remain independent. Both India and Pakistan coveted the region, however. Pakistan coveted it because it was a Muslim-majority region and India coveted it for strategic reasons and more sentimental ones: the family of Nehru, India's first Prime Minister, was Kashmiri in origin.

When, months after independence, Kashmir had yet to accede to either state, Pakistan sent tribal elements to invade and jumpstart what they hoped would be a pro-Pakistan uprising. Things did not quite turn out that way. The tribal warriors would up getting diverted and preoccupied themselves with looting, which gave the Maharajah enough time to ask for Indian assistance to repel the invaders. India consented on the condition that the Maharajah accede to India.

At the time, the evidence actually indicates that most Kashmiris supported the decision to accede to India. Though the king was hated, Sheikh Abdullah, the popular leader of the National Conference had openly denounced the partition of India and was a close friend of Nehru. India troops were welcomed by the local population, who also feted Gandhi when he had visited earlier. India managed to turn back the Pakistani irregular forces, but only pushed them back until they were left with about one-third of the state -- these were mainly tribal regions in the north where India had little popular support. Nehru called for a cease-fire and went to the UN, who asked that both states withdraw and hold a plebescite.

Both sides ignored that call. India simply admitted Kashmir as a state, albeit one with a special autonomous status -- Kashmir was to be largely self-governing, with its own flag and constitution (something other Indian states don't have), and it would have the right to nullify federal laws. Furthermore, Kashmir could set its own immigration policies (to prevent large-scale Hindu transfers into Kashmir).

For the next ten years, there were no protests against Indian rule in Kashmir. However, the central government began to violate the terms of Kashmir's accession, stripping the state slowly of its autonomy. When Sheikh Abdullah protested and publicly flirted with the idea of independence, India responded by throwing him in jail on charges of sedition, which lead to the first large-scale protests against Indian rule.

Over the next several decades, successive Indian governments, attempting to stifle rising separatist sentiment, would jail Kashmiri politicians and blatantly rig elections in order to promote friendly politicians. The modern troubles date to 1988, when the brutal suppression of protests following another rigged election lead to sustained militancy.

Thereafter, Pakistan's intelligence services essentially grabbed onto Kashmir as a proxy conflict. They began funding anti-India groups that quickly took on a deeply fundamentalist bent. (The movement had started out largely Muslim but secular.) This was ironic, since Kashmir had historically been one of the most tolerant places in India -- the local Muslim customs were highly universalist and the Sufi saints were honored jointly by Hindus AND Muslims in Kashmir. The Islamicization of the Kashmir conflict lead to attacks on local Hindus and their large-scale emigration to other parts of India.

These days, most of the militants in Kashmir are foreign fighters. That isn't to say Kashmiris themselves are any happier with the situation -- most of them still desire independence. Independence is complicated by the fact that its opposed by the Hindu minority and by majorities in the regions of the state abutting the Kashmir valley. The Jammu region of the state is majority-Hindu and would like to remain part of India - Jammu lies to the south of the Kashmir Valley and the Valley is economically-dependent on Jammu. To the east of the Valley are the regions of Kargil and Ladakh, which have a mixed Muslim/Buddhist population -- that region too wants to stay part of India but can only be accessed through the Kashmir Valley.

Moreover, India fears that independence in Kashmir would lead to a small, unstable state on its northern border and that it would threaten India's unity, since India is a multiethnic, multireligious country with several dozens of languages and other non-Hindu majority states. (Indian Punjab has a Sikh majority and several tribal states in the Northeast have Christian majorities.)

Pakistan and Islamic Militancy

Pakistan entered independence in a very weak state. India had obtained most of the civic infrastructure and the bulk of the British-Indian military. Moreover, the Indian National Congress had more developed plans for government. The Muslim League had mainly been a pressure group for agitating for Pakistan -- once that demand was granted, the party had little in the way of a policy platform.

Moreover, the state was a geographic monstrosity, consisting of two wings -- East Pakistan and West Pakistan -- that were separated by nearly 2000 miles of Indian territory. Culturally, the Bengalis of East Pakistan and the Punjabis, Pashtuns, Sindhis, and Urdu-speakers of West Pakistan were completely different. There was nothing in common between them except for their Islamic faith. (Imagine creating a "Catholic" nation that consisted only of Spain and Poland -- that's what Pakistan was like at birth.)

Jinnah's hope was to create a secular homeland for Muslims on the subcontinent -- in theory, the closest analogue would actually be Israel. (It was for this reason that the Indian National Congress opposed the division of Palestine or the creation of Israel, viewing it as the exact same principle.)

Yet that distinction between a homeland for Muslims and a Muslim state was lost on many. Certainly, the more politicized members of the Muslim clerical establishment saw Pakistan as an endorsement of an Islamic state.

Jinnah may have been able to prevent that from happening, but he died very shortly after independence. His successor, the like-minded secularist Liaquat Ali Khan was assassinated in 1950 under mysterious circumstances.

The result is that Pakistan drifted for nearly a decade without a formal constitution, being governed under an amended form of the Government of India Act of 1937. No elections were held and the civilian president, Ghulam Muhammad, basically ruled as a civilian-autocrat until the army stepped in and placed Gen. Ayub Khan in power in the late 1950s.

The country drifted in and out of military rule for the next several decades. In 1971, the country split apart, with Pakistan's eastern wing, the province of East Bengal, becoming the independent state of Bangladesh in an extremely bloody civil war that saw Indian intervention.

In 1977, the civilian Prime Minister Zulfiker Bhutto was overthrown by Gen. Zia ul-Haq, who was responsible for the large-scale Islamicization of Pakistan. Although Pakistan had trappings of Islamic rule up till that point, it had largely been secular and most Pakistani law was British in origin.

Zia used Islam as a tool to justify his rule and curry favor with the conservative clerics. He also became a key U.S. Cold War ally and both the Carter and Reagan Administrations showered his regime with arms and funding in order to arm the Afghan Mujihadeen who were fighting the Soviets. It was Zia who also began funding militant groups in both Indian Punjab (Sikh separatists) and Kashmir.

He also put in place sharia law in civil cases and cracked down harshly on the Ahmadiyyas, a heterodox Muslim sect. Zia died in a mysterious plane crash in 1988, but the legacy of his rule is the rise of radical political Islam in Pakistan, something which had barely existed prior to his patronage.

Throughout the 1990s, Pakistan was ruled by weak and corrupt civilian leaders -- Benazir Bhutto and Nawaz Sharif. The country's economy was entirely stagnant during this period and Islamic political parties began to exercise a great deal of political power through brute force -- though they still didn't win many votes, they became expert agitators.

After Sharif was overthrown by Musharraf in 1999, Musharraf again, like Zia, used religious parties as cover for his policies. Though, post-9/11, he pledged to withdraw financing and funding of terror groups operating in Kashmir and Afghanistan, this didn't happen, whether by intent or design -- much of the Pakistan security and military establishment is essentially rogue.

***

In the end, this has wound up FAR longer than I anticipated. I expect this will drop like a rock, but I'm posting it anyway. I hope at least a few of you find this informative.