Is the public option that some have deemed the sword we should all fall on in the healthcare debate little more than fool’s gold?

In the wake of the now widely touted New York Times poll this weekend that showed 85 percent of Americans believe our health care system should be fundamentally changed or completely rebuilt and that people are even willing to pay more in taxes to get that kind of system,  the next question ought to be why are Democrats and some liberal constituency groups willing to settle for so little?

From the news pages to the blogs, some progressive activists are counting up the votes and what can be done to persuade 12 recalcitrant Senators and a number of insurance industry fans in the House to vote for a “robust” public option.  

But is this really where we should be drawing the line?

One of those not willing to enlist apparently is Robert Kuttner, co-editor of the American Prospect, who wrote Monday

The public option is a not-very-good second best–because our leading liberal politicians lack the nerve to embrace the one reform that simultaneously solves the problem of cost, quality, and universal inclusion. The policy that dare not speak its name is of course comprehensive national health insurance, or Medicare-for-All.

Kuttner also identifies the central problems with the public option that its most passionate advocates have yet to explain how they will avoid:

Basically, it leaves the two worst aspects of the system intact. First, private insurers will continue to dominate. Second, most people will continue to get their insurance through their employers. Given these two bedrock realities, there is no way that the bill can make serious inroads on cost without cutting back on care.

and further:

a mixed system with a public option effectively invites the most expensive and hard-to-treat people to opt for the public plan, while private insurers will seek to insure the young and the healthy. This is a familiar problem known as adverse selection. The private insurers will then smugly point out that the public plan is less “efficient,” when in fact it simply will have a more costly population. The only way to avoid this problem is to have everyone in the same universal plan–what’s otherwise known as a single-payer plan.

Even the “robust” public option, assuming it is not gutted in the heated rush to accommodate the healthcare industry and pass a “bipartisan” bill, will almost certainly be burdened by these shortcomings.

Will the availability of a public plan genuinely stop private insurers from engaging in adverse selection?

Anyone familiar with the marketing techniques the insurers use now will know they have a hundred ways and more to weed out sicker, more costly customers, even with the toughest requirements prohibiting exclusion of patients with pre-existing conditions.

Nothing now proposed in Congress is likely to change these marketing practices.

Will the public option really stop insurance companies from price gouging? The theory we’re told is that the cheaper public plan will force the private companies to lower costs to compete. The reality is likely to be far different.

With the added requirement of an individual mandate, forcing everyone not covered now to buy insurance, many, especially those who are younger, and healthier, will opt for the barebones minimum plans the insurers will be sure to offer as a lure.

But without effective cost controls, the huge out of pocket costs will discourage even the healthiest people from actually using their insurance. And, in the event of an accident or unexpected illness, even greater financial distress looms when they find out all the services their skeletal plans don’t cover or the limitations in the fine print.

Meanwhile, the public plan likely to have a disproportionate number of sicker enrollees and unable to compete in market costs with the multi-billion dollar private corporations could easily face the choice of bankruptcy or, as Kuttner suggests, massive cost cutting in the form of rationing care. To see the future of the public plan, look at what is happening with many public hospitals and clinics today.

Finally, there’s the issue almost no one talks about. Insurance companies denying medical treatment, referrals to specialists, or diagnostic procedures they don’t want to pay for. Will the availability of a public plan prompt the private insurers to start authorizing claims they now deny?

If there’s a message to be drawn from the Times‘ poll, it is that Americans know our system is broken, and they want real change. They want reform that solves the crisis. They want a healthcare system that doesn’t leave them at the mercy of the private insurers, being forced to choose between house payments or going to the doctor. They want to be able to choose their care provider, or keep the one they have. They want coverage they won’t lose if they are unemployed.

And they won’t get that with any of the plans now being touted as politically viable.

One other lesson of the Times‘ poll. If President Obama, who once famously identified himself as an advocate of single payer, and the Democratic leadership were fighting for single payer as hard as they are for limited reform, they would have the overwhelming support of the public.

What’s the alternative for progressives? How about, let’s fight for the reform we need, not just one that might pass, no matter how ineffective the solution it offers.