Between the Waves: Building Power for a Public Option.

Given the close division of power in Washington, DC, how might health reformers pursue their bolder aims? In particular, how might they pursue the robust public option that was a centerpiece of Joe Biden's health plan during the campaign? This new iteration of the public option-far more ambitious than anything seriously considered during the debate over the ACA-is not in the cards right now. But instead of giving up on it, advocates should recast it in an inspiring vision that can structure immediate initiatives designed to make its achievement more feasible. This strategy, which might be called "building power through policy," would involve using the openings for policy change that are likely to exist in the near term to reshape the political landscape for the long term. Three interim steps in particular could advance the public option's prospects: (1) pursuing immediate improvements in the ACA that are tangible and traceable yet do not work against the eventual creation of a public option, (2) building the necessary foundations for a public option within Medicare while encouraging progressive states to experiment with state public plan models, and (3) seeding and strengthening movements to press for more fundamental reform.

Putting politics first.

The greatest lesson of the failure of comprehensive health reform in the early 1990s is that politics comes first. Even the best-laid policy plans are worthless if they lack the political support to pass. Putting politics first means avoiding the overarching mistake of the Clinton reformers: envisioning a grand policy compromise rather than hammering out a real political compromise. It also means addressing the inevitable fears of those who believe that they are well protected by our eroding employment-based system. And it means formulating political strategies that are premised on the contemporary realities of the hyperpolarized U.S. political environment, rather than wistfully recalled images of the bipartisan politics of old.

Secret weapon: the "new" Medicare as a route to health security.

Over the past twenty years, Medicare has been transformed from a single-payer insurer into a hybrid of complementary public and private insurance arrangements. Despite creating ongoing controversy, these changes have resulted in an ironic and largely overlooked strategic potential: Medicare's evolving hybrid form makes it the most promising vehicle for overcoming the historical obstacles to universal health insurance in the United States. To make this surprising case, we first explore the distinctive political dynamics of programs that, like today's Medicare, are hybrids of public and private arrangements. We then consider how these political dynamics might circumvent past barriers to universal health insurance. Finally, we discuss the strengths and weaknesses of alternative pathways through which Medicare could be expanded to promote health security.