One of the difficulties with writing about the health care debate in this country is figuring out what scale you want to use to examine it. A lot of people are looking at the art of negotiation. For example, it’s pretty standard to ask for something more than what you are willing to settle for. It’s entirely reasonable to criticize Obama for running on the health care plan he hoped to pass rather than one that was a little more ambitious. Obama’s campaign health care plan was well thought-out and articulated, and it was designed to be realistic. He wasn’t promising anything that was clearly beyond his (or anybody else’s) ability to deliver. But, that might be the heart of the problem here. Obama asked for exactly what he wanted, and no more. Therefore, if he makes a concession here or there, suddenly the whole logic and effectiveness of the plan comes into question. It’s somewhat difficult to be angry with someone for honest campaigning, but the result isn’t anything to praise.

The first hint of a major concession came from Rahm Emanuel floating a trigger mechanism. Essentially, this would have created a public option, but only if certain cost savings were not realized over the first few years of the health care reform. That concession was defeated in the mark-ups of the House and Senate HELP bills, but it was sitting there as a potential concession in passing the Senate Finance Committee’s bill. Here’s how Mark Ambinder describes this:

The White House — and Democrats — messed this up. Maybe it was inevitable. Somehow, and maybe I’ll write this article for a magazine, the idea of the public plan became the sine qua non of meaningful reform for a very vocal portion of the Democratic intellectual elite. House Democrats embraced the idea. If you equate health care reform with a public option, then, well, health care reform is dead to you. There are a lot of angry liberals tonight. They are within their rights to feel aggrieved.

The White House DID play up the potential cost-cutting that a public plan might, sometime down the road, produce. Afterall, given the political environment at the time they first started to argue about health care, they had no choice: the public, Democrats in Congress were mouths-agape about the deficit. In polling and focus groups, cost works well. And the public option — combined with the handy-dandy IMAC price commission proposal — are curve-benders.

Before the health care debate began in earnest, I can tell you that very senior White House officials believed that some form of public plan was absolutely necessary to ensure that the overall bill would be seen as a cost-cutter. That opinion changed roundabout three months ago when it became clear that even a public plan with a trigger mechanism — Rahm Emanuel’s preferred option — just didn’t have the votes.

What happened is that even the concession (a trigger mechanism) became incapable of achieving cloture in the Senate because the Republicans remained united in opposition and there were a few key Democratic defections. Some of the Democrats have been vocal and up front about their desire to protect the profits of the health insurance industry. Their argument (coming from people like Blanche Lincoln, Kent Conrad, Byron Dorgan, and Ben Nelson) has been that people will really like the public option because it will be cheaper, and that will destroy the private market for health insurance. Of course, one of the key things we’re trying to accomplish here is to drive down the cost of insurance. So, it’s odd to complain about a health care reform plan that drives down costs. But these senators are concerned that costs will be driven down so low that there won’t be any profit left available to the insurance industry. Over time, their argument goes, everyone who isn’t already eligible for government-run health care like Medicare or Medicaid or the Veteran’s hospitals, will sign up for the public option. And that will leave giant insurance corporations in places like Nebraska without any customers at all.

Now, you and I don’t give a rat’s ass if that happens. I suspect we would all welcome that outcome. But these corporations carry a lot of water in the small states where they are incorporated. It would be hard to find senators (from either party) representing, for example, Nebraska who would want to see their insurance corporations lose out on a ton of business. The situation reminds me quite a bit of the way the defense industry protects its big contracts by subcontracting out bits and pieces of the work to as many states and congressional districts as possible. Only, in this case, the corporations are taking advantage of the tendency of small states like Delaware and South Dakota to create extremely corporate-friendly laws and regulations as a way of creating jobs for their citizens. Companies tend to incorporate in those states, and then they become the biggest employers and can influence electoral outcomes for a mere pittance of what it would take in big states like New York, Illinois, or California.

The result is that a handful of Democratic senators who collectively represent less people than live in Los Angeles can bring down any effort to create a public option that would eat away at corporate profits.

It’s pretty sick, but it isn’t the fault of any one president or even their strategists that we are facing these obstacles. The way the Constitution grants so much power to small population states in the Senate, combined with savvy strategizing by the insurance corporations, makes it very, very difficult to get 60 votes for health reform regardless of who is in technical control of the Senate. We have similar problems with agricultural and defense-spending policy.

In the meantime, a sincere effort is being made to convince progressives, who mainly come from large states and safe districts, to vote against any health care plan that doesn’t really stick it to the insurance industry. The idea is not to kill health care, but to convince the Obama administration that they have an even bigger problem with progressives than they do with small-state Democratic senators. The potential flaw in this strategy, however, is that it isn’t the Obama administration who needs to be convinced. We still need Lincoln and Nelson and Pryor and Johnson and Dorgan and Baucus and Carper and Conrad to at least vote for cloture. And they aren’t going to do it. Part of the reason they are less likely to fold than the progressives is simple. Their seats are vulnerable and they’re afraid that no bill is safer than a bill that will hurt their biggest employers. The progressives may passionately want health care reform, but they’re not likely to lose their jobs no matter what happens. Given those dynamics, who do you think is going to blink first?

Now, I’ve just been describing in a bit of a simplistic way why we’re having these problems passing health care reform. But a more important question is whether or not we might still succeed even if we don’t get a public option in the bill. In other words, are we better off passing something, however flawed, or in killing health care reform off completely if the bill is inadequate?

Let me just say something here about single-payer health care. As our current situation more than adequately demonstrates, we’re not getting single-payer through Congress any time soon. But we might pass it in Pennsylvania. And that is how Canada wound up with a national single-payer system. One province adopted it, and it worked so well that the logic of a national system became inescapable. Most people who I respect on these issues have moved their single-payer advocacy to the states. And I think that is the correct approach. In the meantime, we want to get as many people covered as possible, especially people who are priced out or who have preexisting conditions. We want to do this for humanitarian reasons, even if there could be potential long-term strategic issues with how it is done.

Having started writing on these issues, I realize I could go on forever and in a number of different directions, and this article is already getting long for a blog-post. So, let me wrap this up for now.

My basic take on this is that we are better off passing whatever it is that can pass. If we get more people covered and eliminate rescissions and preexisting conditions preclusions, then we’ll have helped a lot of people. My best guess is that the primary problem with the health care bill that does pass will be that it does not do enough to create cost savings. What will happen then is that Congress will have created a semi-entitlement (which they’ll never take away) that they cannot afford. The reasons that they will not be able to afford it will be because of all the things (particularly the public option) that are not in the bill. And they’ll wind up fixing the problem down the road.

While all that is going on, we should give up on HR 676 and put all that effort into passing single-payer in Pennsylvania (and other states where it is remotely feasible). My advice is based on my best assessment of the political landscape. If Obama fails to pass any health care reform at all because progressives join small-state Democratic senators in killing all efforts at compromise, then the cause of health care will be set back sharply and the potential for a return to power of the Republicans will be boosted to an unacceptable level.