Pelosi's Public Option a Nod to Moderates

Surrounded by colleagues last week in front of the Capitol, Rep. John Dingell, the 83-year-old Democrat from Michigan, helped unveil the House's healthcare bill, of which he was the lead author. The bill, he said, "meets the goals that our great President Obama has outlined" and expands insurance coverage to 96 percent of Americans. He added that the bill was "conceived" in the "greatest openness, frankness, and fairness."

But the conception was also rocky, with the status of the public option, a government-run plan, often in flux. Its fate, even now, is unsettled.

As Speaker Nancy Pelosi noted, the House bill, after much speculation outside Congress and much deliberation within, does include a public option. But it's different from what Democrats in the Senate are considering. So what the final plan looks like, assuming health reform passes, is now as much a political question as a philosophical one.

Pelosi, by her own admission, has been aggressively counting votes within her caucus. Her goal was always to produce the strongest public option possible, which basically meant trying to get colleagues to support a plan that would have the most power against the private sector. To keep spending down, liberals in her party wanted the plan to pay doctors and hospitals what Medicare pays. But more moderate members worried that such rates would force healthcare providers out of business.

Pelosi chose to appease the moderates. Under the House bill, doctors and hospitals can negotiate their payments with the government. Politically, this move should give Pelosi the support she needs, even though it doesn't come close to fulfilling liberal's expectations. According to the Congressional Budget Office, the public plan, as written by the House, would enroll only about 6 million people by 2019. Floor debate on the bill, House Majority Leader Steny Hoyer said Tuesday, will most likely begin by the end of the week, once some last-minute abortion and immigration issues are worked out. A final vote would then come next week.

But a fight still looms with the Senate. Senate Majority Leader Harry Reid, tasked with producing a merged bill from the work of two committees, surprised many last week by including a public option in his final product. But it came with a twist. States, he said, would be allowed to "opt out" of it.

At the time, Reid said a consensus had been reached among Democrats and the White House that letting states opt out would be the best way to move forward.

Yet talk of consensus may have been premature. Connecticut Sen. Joe Lieberman, an independent who caucuses with the Democrats, said later in the week that he would not support Reid's approach. Maine Sen. Olympia Snowe, the moderate Republican whose support Democrats have courted, also expressed her displeasure with Reid's decision.

Perhaps most important, many moderate Democrats are holding their tongues, because details about Reid's plan are still unclear. According to Reid's office, a state's decision to opt out of the public option would be made by state legislatures, not by a state governor. But many other parts of the proposal still need to be fleshed out.

Those details are expected sometime this week, once Reid's office receive cost estimates from the Congressional Budget Office. So as much as the public option is a matter of policy, its final design now seems to be up to politics.

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