Scenes from the ‘Opt-Out’ Craze


Having taken the read of some of the shrewder health care policy nerds, it seems that the Carper/Schumer Public Option ‘opt-out’ compromise may really be a winner in policy terms. As I tentatively argued this morning, it would seem to get you a sufficiently large and nationally based plan that would provide the negotiating leverage that is the key to a successful public option. And, again, assuming the plan worked as advertised in the ‘in’ states, there’d be growing political pressure for the hold out states to come on board.

That’s the policy side of the equation. For the political calculus, the ability for states to opt out would deflate some of the 10th Amendment/government take over/death panel freak show and give conservative Democrats enough breathing room to come on board. And a number of key conservative Dems as well as liberals seemed to warm to the idea.

Over the course of the day though it became clear that none of the key power centers — not the White House or the Dem leadership in either chamber — seemed at all interested. From some of the leadership sources we spoke to, the idea seemed to be: ‘Sure, interesting idea. And a lot of people are talking about it. But it’s just not on the radar for the leadership. So why are we talking about this?’I confess that something did sound a little off to me about the proposition that differing factions agreeing on one palatable policy option was irrelevant since it’s not what the leadership is focused on. Especially because I’m not sure the leadership has inspired a great deal of confidence in their ability to pilot this ship to port. But that’s one clear part of the equation.

Another issue is just what votes such a compromise would secure. If 3/4 loaf doesn’t secure more votes or enough votes more, you might as well stick with a whole loaf. And this issue just isn’t clear yet. Republicans have made clear that they’ll oppose any form of public option, indeed likely any reform bill at all. So you’re still working with 60 Democrats and potentially Olympia Snowe to get to 60. Some seem to think you still can’t get to 60 with this. But that’s their line.

Then there’s the issue of people in opting-out states — a point about which we’ve received many emails today.

The general assumption is that the opt-out states would be heavily red, disproportionately small in population and centered in the Mountain West and the South. And a number of people from these states wrote in today saying, Why is this such a great idea if it leaves me high and dry? It’s a good question. And I think there’s a decent issue of principle at stake in reform being national. We didn’t do opt-outs for Medicare or Civil Rights (we’ll okay, for a while, but not eventually) or Social Security (labor laws provide something of a counter-example). So why now? 10th Amendment gonzos notwithstanding, we are a national community, one people. So if reform is needed it should be for everyone.

I get that point and in many ways agree with it. But I don’t find it sufficient in this case. As I suggested earlier, an opt-out would create an interesting and somewhat controlled experiment. We’d get to see how a public option and the lack thereof affected insurance markets in different states. If the public option really is a good idea and it works to lower prices and foster competition, I think you’d in short order have a lot of political pressure on Republican opt-out governors to let their citizens have access to lower costs too.

So the assumption I’m operating on is that an opt-out regime would nevertheless create real momentum for adoption nationwide. Second, getting something good for most people in the country simply shouldn’t be hostage to a limited number of hold out states. It would be national in as much as it would be available to every state — sort of a public option option, you might say. And at the end of the day the citizens of opt-out states need to and I think should be able to force the matter through their own state governments if it becomes clear that the public option is improving costs and access in other parts of the country.

All that said, it’s important to emphasize that for now this does seem like the outside-the-box thinking of a couple Democratic senators, not the state of play for key leaders in Congress or the White House. Just speaking for myself, though, it’s the one ‘compromise’ I’ve heard of that sounds like it might be the way to thread the needle.


Josh Marshall is editor and publisher of