Dear Karen

Dear Karen:

You've navigated a lot of tricky territory in your health care career. You've outlasted your old bosses Chris Dodd and Lane Kirkland, and made room for Chip Kahn - somewhere else. You watched states fail to rein in health care costs in the 1980s, as the hospital industry (then as now a real driver of exorbitant health care expenditures) captured the Certificate of Need programs that were supposed to regulate them. You encouraged unions to turn to second opinions and managed care as a consumer-driven effort to control costs. No luck there. After Clinton care fell apart, you and the nation's employers turned to the insurance industry to hold down rates - a buck would be turned, but it would have to be better than the systems they all knew worked perfectly well in Canada and Europe. (They use their national and state budgets to set a limit on costs. Works like a dream: health care is affordable, health outcomes are pretty good, and politics focuses on, well, whatever it is Foreigners talk about.)

The Bush years were lots of fun for the insurance industry. Yes, employers were increasingly strained by premiums, but they had outs - they could pass on costs to employees, or just drop coverage. And since finance capital increasingly controlled U.S. businesses and the media, the last thing they wanted to do was call down government regulation on you. Or on anybody. Then came the global economic meltdown.

Now we have the Obama era reform. All ready to pass, with one major sticking point: the public option. Your members insisted on universal buy-in, in exchange for ending the egregious abuses commited on the patients of America, pre-existing condition exclusions and rescissions. Got that. The public, being no dope, wanted an escape hatch. You said from day one, no way. An ambitious but pragmatic new Administration, having read up on Harry and Louise, was strategically cordial. Both sides knew it would take a mass uprising or a miracle to overcome your opposition. And here's what happened:

The masses didn't rise up. Trying to figure out how not to get foreclosed, while staying employed and keeping their kids safe, they consistently told pollsters they wanted health reform but they wanted a public option, too. They didn't think highly of governmenrt but liked the insurance industry even less. But rising up, no. About 100 of them tried to get arrested at insurance offices around the country. You told Joe and Ben to lift their little fingers to stop the public option, the civilized way, in the Senate, where it's always done discreetly.

Then we had elections in Virginia, New Jersey and Massachusetts. Turns out the masses just threw up their hands in disgust. Suddenly it was maybe no health reform at all. Your stocks went up. But your press statements expressed alarm.

Some say you can't survive long without the government subsidies you were anticipating from the reform proposals, clear evidence that the whole thing is fatally flawed.

I say it's a game of chicken. And you should call it off.

I'd rather you disappeared. That isn't happening this year. Your interest is perpetual life and wealth. That isn't happening this year either.

We can get legislation that keeps the insurance industry on life support. The trade off is that you bow to the inevitable, with plenty of estate planning and golden parachutes and whatever else you've figured out after all these years about opening the next chapter. Tell Fox News, the White House and the Senatte that you've recalculated. You can manage with a national exchange and a public option, after all. Warn the hospitals and the drug industry. They'll understand. (They'll be soaking up lots of the same gravy as AHIP members. And they'll be around a lot longer, in any case.)

It's good negotiating. You walk away with a bundle and your power just tarnished. There's always tomorrow. But like another famous scrappy survivor, you can decide you'll think about that, tomorrow.