What if Congress actually passes health care reform, and it includes an opt-out public (government-run) option for the states?

It would seem to be a question for the governor and the state legislature of each state.

After a year of acrimonious debate in congress, the take-no-prisoners debate would move to the 50 states. The public option would become the object of discussion in the various red and blue states. Lobbyists from Washington would probably have to fan out across the country. The public would hear the same arguments in state capitols, for and against, that it heard emanating from Washington. State decisions on the public option would become nearly an industry on to itself.

Fanciful as this scenario might seem, it does raise the question for North Dakotans. If this should come to pass, would the North Dakota legislature opt out or opt in?

The conventional wisdom is that a majority of North Dakotans oppose a public option. And given the predominately Republican majority in North Dakota, one would assume the state would opt out - state bank and state mill and elevator aside.

Or would we? Given the also overwhelming predominance of Blue Cross Blue Shield, and its current public relations problems, the people might be looking for options, including a public one. It would certainly depend upon what else might be in that reform package and how the government-run option would set up.

A trickle-down state decision like this would certainly give candidates for the 2010 Legislature something to talk about during their campaigns. It could heighten interest statewide in what might otherwise be a rather nominal election season. Unless, of course, existing lawmakers fear just that and ask the governor to call a special session to deal with the opt-out or opt-in question before the general election.

And say, what if North Dakota did opt out, what would that mean to people who might have qualified for a government-run option. Minnesota might opt in, Montana opt out, who knows about South Dakota. Would a patch work national map opting in and out be fair to the people who benefit from a public option but live in an opt-out state?

The more I think about it, the opt-in/opt-out option doesn't work, and it's not just the inherent unfairness to those who would or would not have access in the individual's states. Consider: Should the states be given the option of opting out of No Child Left Behind, cap-and-trade, federal crop supports, Social Security, Medicaid, Medicare and on and on.

Congress should not create national programs that are not inclusive.

We can take lessons in this going back to Reconstruction after the Civil War, which passed forward segregation to what became a bloody resolve in the 1960s. And today we have islands of pro-choice states offering abortion clinics among states with anti-abortion laws, or is it the other way around? We can see this pay out in the present inequities between states in terms of standards for No Child Left Behind.

Either a public option is good for all of us, or for none of us.

The truth: Proponents of the public option didn't have the votes and, having failed to find a workable compromise, they wanted to keep a public option alive for another day and another battle.

Another truth: If health care reform passes congress and it includes an opt-in/opt-out choice for states, it will create an incredibly divisive, hurtful debate, state by state, that will result in the collapse of health care as we know it.

(Ken Rogers' column appears each Saturday. Contact him at ken.rogers@bismarcktribune.com.)