a favored public plan would probably doom today’s private insurance. Although some congressional proposals limit enrollment eligibility in the public plan, pressures to liberalize would be overwhelming. Why should only some under-65 Americans enjoy lower premiums? In one study that assumed widespread eligibility, the Lewin Group estimated that 103 million people—half the number with private insurance—would switch to the public plan. Private insurance might become a specialty product.

Many would say: Whoopee! Get rid of the sinister insurers. Bring on a single-payer system. But if that’s the agenda, why not debate it directly? It’s not insurers that cause high health costs; they’re simply the middlemen. It’s the fragmented delivery system and open-ended reimbursement. Would strict regulation of doctors, hospitals and patients under a single-payer system provide control? Or would genuine competition among health plans over price and quality work better?

That’s the debate we need, but in truth, doctors, hospitals and patients don’t want to be limited, whether by government or markets. Congress reflects public opinion. Fearing a real debate, we fake it.