Program for the Big Night

President Obama's speech to Congress is coming up tomorrow night (Wednesday). There are many ways he could play this critical public appearance, but I think the following is what he will say, and then what I think he should add:

Obama can not threaten to veto a bill that does not have a public option in it. That will reinforce the stalemate that has already developed. Instead, he will praise the concept of the public option, but emphasize all the other worthy aspects of a potential bill, many of which are essentially agreed upon.

He will not ask for much from Republicans, except to contribute any ideas to achieve the goals he will describe. The bipartisan effort of the Gang of Six Finance Committee Senators is fizzling out, without any real agreement, and with a draft bill that's a non-starter: a mandate to buy, no mandate for employers to provide insurance, and no public option. That draft does have money for health co-ops, which I see as another useful alternative, but no substitute for a properly-constructed public option. He will implicitly endorse the legislative strategy of using the budget reconciliation waiver to the 60 vote requirement in the Senate, which at this point looks like the only way anything real can be accomplished. And, it seems, a lot can be accomplished that way.

I would add one note: Candidate Obama was not in favor of requiring all--by law--to take insurance. I don't think he will support the concept now, either, opting for cleverly-designed incentives (such as reduced prices for pharmaceuticals, tax credits conditioned on taking, and keeping, catastrophic care insurance) rather than coercion. People tend to forget his stance--which was quite distinct from Candidate Hillary Clinton's--in their analysis of the issue and what Obama will require in the health care legislation.

What he should do is insist that such a public option--I would suggest one that is designed to be mildly profitable (the profits going toward Mediare/Medicaid), one that is allowed to negotiate better rates with hospitals, doctors, and pharmaceuticals (just as private insurers can do), one that is available to all Americans, one that does not penalize for pre-existing conditions but rewards individuals for specific healthful behaviors, one that scales premiums for the size of deductible, so that it can be a catastrophic-illness only policy or something much more expensive and providing fuller coverage, and finally I recommend that the captive insurer AIG be enlisted to provide distribution support for it--such an option needs to be brought to the Senate floor for an up-or-down vote at some stage in the legislative process.

Nothing less would be a change to business as usual; a floor vote for a public option is a requirement for us to believe in this change--even if it loses. Then we'll know which Senators deserve our support--and which deserve to get their support from the insurance lobby.