The single-payer option was quickly dropped by the Democrats in Congress. Their sponsors (the health-"care" industry) did not like it.

Joe Lieberman single-handedly killed the public option. He was able to do so because he was the 60th vote the Democrats needed.

Source: http://voices.washingtonpost.com/ezra-klein/2009/12/the_deat...

There are far less than 50 votes from either party to suspend the 60-vote filibuster rule because it gives more power to each individual senator.

By contrast, Lieberman single-handedly killed the public option.

> But that's not always the case - Neil Gorsuch was confirmed by a vote to suspend the 60 vote rule

No, as your source accurately states, he was confirmed after a vote to abolish the rule for Supreme Court nominations.

It's a perfectly reasonable question to ask whether the 60 vote threshold can survive for any kind of legislation in the future. In particular, here is an argument that American democracy is doomed because of the way partisanship ratchets towards more extreme mechanics over time: https://www.vox.com/2015/3/2/8120063/american-democracy-doom...

However, it remains the case that in 2009, 59 senators were ready to vote for a public option, but there was no 60th. By contrast, there were nowhere close to even 50 votes for removing the filibuster and changing to a 50 vote threshold.

Please do not miss the fact that Lieberman had no rational justification for opposing the public option and that one of the keenest observers at the time accused him of being "driven more by a pathological dislike of the liberals who dogged him in 2006 than by any remotely rational policy judgment." http://voices.washingtonpost.com/ezra-klein/2009/12/lieberma...

Sure, 59 People were ready to vote but not so ready they'd take the action to remove the limit.

Those are the facts. You are laying emphasis on the one person who wouldn't vote and I'm laying emphasis on the 51+ wouldn't take take stronger action.

I think it's reasonable to give my emphasis given the way the Democratic Party has behaved over time.

And we reached agreement! I thought that can never happen on discussion boards.

On the other hand, if they had removed the limit, (a) there would have been an even bigger Republican backlash against "Obamacare" (if that's possible), and (b) the precedent would have emboldened Republicans to suspend the filibuster for their priorities as well. Result? In 2017, the Senate would have more motivation to repeal Obamacare and fewer limitations: they wouldn't have to shoehorn the repeal bill into the reconciliation process to avoid the filibuster, as they're currently trying, which (among other effects) limits the provisions they can include. And so they'd probably have passed their bill, and the public option would have died in 2017, just a few years after its creation.

I suppose that voters could have hypothetically had a positive reaction to the public option once actually set up, and rewarded Democrats for it in subsequent elections. But I doubt it. Although Medicare already exists, the public option would represent a significant expansion which would probably come with serious growing pains - plenty of material for Republicans to make horror stories out of. Probably fewer actual cases of huge premiums (which are already not that common), but it's not like statistics have ever been much barrier to politicians and their preconceived narratives. I guess the GOP wouldn't have been able to weaken the law through a constitutional challenge, as they did with Medicaid expansion - after all, the public option can't be unconstitutional unless Medicare is. But the Supreme Court is highly political, and I wouldn't be surprised if the law ended up being weakened some other way by a 5-4 majority...

But politically, Republicans would have a stronger alternative to offer: ACA without the public option. Y'know, the thing they currently portray as the root of all evil; I think they'd have ended up seeing it as a good conservative compromise, that preserved universal coverage availability without requiring the government to be involved directly. Arch-conservatives might not like that outcome (then again, they might) - but they'd likely accept it as an intermediate step, that still accomplished the substantive change of repealing a huge government program (the public option). It would be much easier to get consensus on than the repeal-in-name-only bills they're tossing around in the real world.

I suppose I'm getting way too speculative; the last two paragraphs aren't even directly related to the nuclear option, although they're meant to question the upside of Democrats hypothetically having deployed it. There would've been serious downsides, not just in health care; it's quite possible the 60 vote rule would end up being killed entirely rather than only for 'special' bills, so Republicans in the current Congress would've been able to pass a wide variety of their priorities, and repeal a wide variety of Democrats'. (For all I know you might support the Republicans on their other priorities, but the Democrats whose votes we're talking about certainly didn't.)

> I think that's quibbling. If votes to abolish the rule for a case are available, it's reasonable for a single suspension vote to be possible to.

A suspension is both procedurally (or textually) more complicated (it either requires changing the rules twice, changing the rules to add a suspension provision and then acting separately to exercise it, or changing the rules to include a tailored exception that applied only to the case at issue) and more politically fraught (rather than publicly defending the case that the general rule is outdated, it requires legislators to defend that the rule is generally valid but should not be applied to the immediate case.) It's very much not the same thing as abolishing the filibuster for a well-defined class of cases.

This is particularly true in the Gorsuch case where the recent Democratic action to remove the filibuster from other Presidential appointees made applying the “nuclear option” to Supreme Court justices much less “nuclear” than it had seemed previously when it been considered.

It was dropped because it was politically impossible and it wasn't worth burning political capital on it. Even just the public option wasn't able to gain traction; single payer was never going to happen in 2009.

I would just note that "...it was politically impossible" and "the Democrats were never serious in saying they wanted it" are two ways to frame the same reality. Both are true. Take your pick.

I'm not saying any democrats at the time were willing to go all in on it, but the two statements would only be two ways to frame the same reality if democrats had the ability to make unilateral decisions in the senate. They never did.

The nuclear option - changing the rules to allow majority votes to override a filibuster - has existed in potentia for a long time. The republicans have used it lately for things they consider crucial to their agenda. If the democrats wanted single payer and considered it crucial to their agenda, they could have done that. Of course neither of those "ifs" are true and we can use the lack of action to judge this.

> If the democrats wanted single payer and considered it crucial to their agenda, they could have done that.

And then watched it get blown away by next congress as soon as the GOP gained 51 seats to do whatever they want. Blowing away the fillibuster is an awful, terrible, no good idea and there is almost no legislative agenda which would validate it.

And to be clear, the GOP senators were and still are slimey bastards for basically everything they did leading up to Gorsuch. It should have never been done. They will almost certainly regret it as soon as they lose the senate.

As I recall, the rough idea was to adopt a Republican plan (RomneyCare) in order to achieve bipartisan support (and "stake holder" support). And then it became the evil spawn of the Democrats...

Strictly speaking, it was politically possible - the Democrats had majority in both the Congress and the Senate.

Public option is a great solution, because it does not prevent the people who prefer (and can afford) to pay for private services from doing so.

Not really, they only had a filibuster proof majority for a very short period of time -- http://www.outsidethebeltway.com/did-the-democrats-ever-real....

And that is counting Lieberman as a D; a person who backed McCain for president and who later personally killed the public option.

I do think we will get to the public option at some point. It just makes too much sense not to and would strengthen the healthcare as a whole while allowing people more choice.

Public option is unlikely to happen in the near future. Too many people start frothing at the mouth and yelling "socialism!" every time it is proposed.

> which would eliminate abuse on the billing side, at least to the insured

How does single payer fix that? If the hospital gives you a bill and won't negotiate down, how does the government "fix" this? Which is kind of what my question is: were specifics given in the ACA on how that problem will be fixed?

A single buyer negotiating with multiple sellers can force prices down to cost. Whether it actually does so is a public choice problem.

Well since single payer typically refers to the government being the single payer, the bill goes to the government because you the insured are not the payer of the bill.

The bill goes to the government, who gets its funding from the people. This in no way stops any systemic over-billing that may be occuring.

Well, in my country, the government would laugh, and then only pay a standard amount.

I thought that was what medic(aid/are) in the US already pretty much did.

And unless they pay enough no providers will do the procedure unless you somehow force them.

Yes, which is why single-payer systems generally do a tiny bit of research, pick a reasonable amount, and pay that.

Sure, but if you're the single possible payer, you can push that number down quite low.

At the end of the day their revenue is dependent on throughput of people for their facility. If they gain a poor reputation relative to other providers they will lose. Quality of care would be the only thing they could compete on.

See: Japan where the government decides the price of procedures.

On national health insurance (monthly cost depends on your salary but for an average person it is a few hundred bucks per month) the hospital pays 70% and patient pays 30%.

It means basic visits to the doctor or dentist are very cheap here. Like $20 for consultation + medicine. ER+X-rays and MRI (appendicitis, sigh) was a little bit over $100.